Independent Predictor Of Mortality Research Articles

Prognostic and therapeutic implications of low aortic valve calcium score in patients with low gradient aortic stenosis.

Low gradient (LG) aortic stenosis (AS) poses a diagnostic challenge. Aortic valve calcium score (AVCS) assessment has emerged as a complementary diagnostic method when echocardiography provides discordant results. However, the diagnostic and prognostic value of AVCS in LGAS has not been thoroughly studied. Our aims were to investigate the prognostic importance of AVCS in LGAS and to assess whether symptomatic patients with LGAS and low AVCS may benefit from aortic valve intervention (AVI). 327 symptomatic patients (78.5±7.3 years, 51% women) with severe AS defined by the aortic valve area who underwent computed tomography for transcatheter aortic valve intervention (TAVI) planning were enrolled. AVCS was measured. AVCS<2000 AU in men and<1200 AU in women was considered low AVCS. 243 patients had high gradient (HG) and 84 had LGAS. Low AVCS was present in 25(10%) of the HG and 34(40%) of the LGAS cases. Over a median follow-up period of 4.9 years, 194 deaths occurred. In multivariate analysis, AVCS was a significant independent predictor of all-cause mortality among HGAS (aHR:2.317; CI:1.104-4.861; p= 0.026), but not among LGAS (aHR:0.848; CI:0.434-1.658; p=0.630) patients. After propensity score matching between patients who underwent AVI and those who were medically treated, AVI (94% TAVI) was a significant and independent predictor of survival among LG AS patients with low AVCS even after adjustment for clinical variables (aHR:0.102, CI:0.028-0.369; p<0.001). The prevalence of low AVCS is much higher in LGAS than in HGAS. In symptomatic severe LGAS low AVCS did not entail a better prognosis. AVI is equally beneficial in LGAS patients with high or low AVCS, similarly to HGAS.

Left ventricular pressure-strain loops for the assessment of myocardial work in a low-risk community-based cohort: associations with long-term prognosis

Abstract Background Non-invasive left ventricular (LV) pressure-strain loop analysis is a novel technique for the evaluation of global myocardial work (GMW) that provides additional insights on LV contractility and energetics beyond traditional metrics, such as ejection fraction (EF) and global longitudinal strain (GLS). Despite its established value in numerous cardiac diseases, there remains limited data on its predictive power in a low-risk population. Purpose Our objective was to determine the long-term prognostic value of GMW in a population-based screening sample comprising low-risk adult individuals. Methods We retrospectively identified 1562 volunteers from a population-based screening program (mean age 54±15 years, 59% female), with a median follow-up time of 11 years. All subjects underwent 2D echocardiography to measure LV EF, GLS, peak atrial longitudinal strain (PALS), GMW index (GMWI), global wasted work (GWW), and GMW efficiency (GMWE). The primary endpoint was all-cause mortality. Results 191 subjects (12,2%) met the primary endpoint. Subjects who experienced adverse outcomes exhibited significantly lower LV EF (dead vs. alive; 49.7±8.3 vs. 52.7 ±6.4 %, p&amp;lt;0.001), GLS (-18.7±4.1 vs. -20.4±3.6 %, p&amp;lt;0.001), PALS (33.6±15.7 vs. 44.2±15.2 %, p&amp;lt;0.001), and GMWI (2181.7±591.3 vs. 2286.8±482.5 mmHg%, p=0.008). Furthermore, subjects with adverse outcomes had significantly higher GWW (132.6±249.4 vs 95.1±113.4 mmHg%, p&amp;lt;0.001) and, consequently, lower GMWE (0.95±0.05 vs. 0.96±0.03, p&amp;lt;0.001). Univariate Cox regression analysis revealed GMWI to be a significant predictor of mortality (hazard ratio for 100 units 0.957 [95% CI: 0.929-0.986], p=0.004), alongside GMWE (hazard ratio for 1 percent 0.940 [95% CI: 0.912-0.968], p&amp;lt;0.001), and GWW (hazard ratio for 100 units 1.124 [95% CI: 1.063-1.188], p&amp;lt;0.001). By multivariable Cox regression encompassing age, sex, GMWI, LVEF, GLS, PALS, and systolic blood pressure, GMWI remained an independent predictor of all-cause mortality (hazard ratio 0.932 [95% CI: 0.874-0.995], p=0.035), while GLS was not an independent predictor. Moreover, integrating the Atherosclerosis Risk in Communities (ARIC)-HF risk factors (age, sex, race, coronary artery disease, antihypertensive medication, blood pressure, diabetes mellitus, body mass index, heart rate, and smoking status), we constructed a multivariate model with GMWI. GMWI was still an independent predictor of mortality (hazard ratio for 100 units 0.941 [95% CI: 0.903-0.980], p=0.004). Using the GMWI cut-off value of 1576 mm Hg% (based on a large-scale healthy population study), the population was divided into 2 groups. Using Kaplan-Meier curves (Figure), the outcomes of the groups differed significantly (log-rank p&amp;lt;0.001). Conclusions GMW provides added value in clinical outcome prediction, even in low-risk individuals. Myocardial work analysis is a promising approach for a comprehensive evaluation of cardiac function and for cardiovascular risk stratification.

Safety and mid-term outcomes of impella compared to intra-aortic balloon pumping in patients who required mechanical cardiac support

Abstract Background Impella (Abiomed USA) is a promising alternative to improve prognosis in patients with cardiogenic shock requiring mechanical cardiac support (MCS). Despite of its advanced hemodynamic profile, its superiority regarding prognosis has not been established yet. Aims The aims of this study were to investigate safety and mid-term outcomes of Impella compared to IABP in patients who required MCS. Methods In this single-center study, consecutive 205 patients who required IABP or Impella from January 2017 to June 2023 were evaluated retrospectively. The primary outcome was 180-day mortality. Secondary outcomes were the rate of complications including hemolysis, thrombocytopenia, bleeding, limb ischemia, acute kidney impairment and stroke. Major complication was defined as major bleeding (BARC 3-5), limb ischemia and stroke. Results Of all patients, 62 (30.2%) received Impella and 143 (69.8%) IABP. The rate of patients required extracorporeal membrane oxygenation (ECMO) support was not significantly different between two groups (31.4 % vs 38.7%; p=0.34. There were no significant differences in 180-day mortality between two groups (36.2% vs 31.1%; p=0.55). Further investigation according to SCAI classification demonstrated that the mortality rate in SCAI C group was significantly lower in Impella than IABP group (34.1% vs 6.7%; p=0.02), whereas there were not significant differences in mortality between two groups in SCAI D and E groups (54.8% vs 61.4%; p=0.71). The rate of major complications was significantly higher in Impella group (54.4% vs 72.1%; p=0.02). The rate of hemolysis (19.6% vs. 58.1%, p&amp;lt;0.01), thrombocytopenia (19.6% vs. 58.1%, p&amp;lt;0.01), limb ischemia (4.3% vs. 17.7%, p&amp;lt;0.01), acute kidney impairment (37.7% vs 64.5%, p&amp;lt;0.01) and initiation of renal replacement therapy (13.8% vs 29%, p=0.02) were significantly higher in Impella group. Multivariate analysis adjusting for Impella use, out of hospital cardiopulmonary arrest (OHCPA), initial lactate ≥60 md/dL and major complication, revealed that age ≥70 (hazard ratio (HR): 3.1, 95%CI: 1.73-5.61) and use of ECMO (HR: 4.3, 95%CI: 2.54-7.31) were independent predictor of mortality. The mortality rate arose up to 83.3% in patients with age ≥70, OHCPA and use of ECMO (HR: 9.7, 95%CI: 4.07-23.02). Conclusion The mortality rate did not differ between Impella and IABP, however Impella was associated with improved mortality in patients with SCAI C group. The complications were high likely seen in patients with Impella compared to IABP. Our findings indicate that Impella results in better outcomes with careful selection of patients, defining its indication and appropriate care. A further investigation would be of value to elucidate whether Impella improve prognosis.

Coronary microvascular dysfunction as assessed by cardiac MRI and its association with aerobic exercise capacity in dilated cardiomyopathy

Abstract Background Dilated cardiomyopathy (DCM) has a poor prognosis. Aerobic exercise capacity (peak VO2) is an independent predictor of mortality but the central mechanisms contributing to exercise intolerance in DCM are unknown. Purpose To characterise myocardial perfusion reserve (MPR) and determine if cardiovascular magnetic resonance (CMR) measures of structure, function and microvascular function are associated with aerobic exercise capacity in DCM. Methods Single centre, prospective, case-control comparison of adults with DCM and matched controls. Adenosine-stress perfusion CMR to assess cardiac structure, function and quantitative perfusion, and cardiopulmonary exercise testing (CPET) to determine peak VO2, was performed. Controls were propensity matched based on age, sex, body mass index and diabetes status, and between group comparison was adjusted for other key clinical characteristics (CMR: ethnicity and systolic blood pressure; CPET: ethnicity, systolic blood pressure, smoking history and lung disease). Comparison of perfusion in segments with and without late gadolinium enhancement was performed using mixed effects linear regression taking into account individual patient segmental perfusion. Pre-specified multivariable linear regression, including key clinical and cardiac variables, was undertaken in patients with DCM to identify independent associations with percentage predicted peak VO2, which incorporates age, sex, height and weight. Results Sixty-six patients with DCM (median age 61 years, 71% male) were matched to 66 controls (median age 59 years, 71% male). The DCM group had greater left ventricular (LV) end-diastolic and end-systolic volumes, lower systolic and diastolic function, and had more focal and diffuse fibrosis compared to controls (Table 1). There was lower rest (0.58±0.14 versus 0.65±0.17 mL/min/g; P=0.033) and stress (1.53±0.49 versus 2.01±0.60 mL/g/min; P&amp;lt;0.001) myocardial blood flow, and lower MPR (2.69±0.84 versus 3.15±0.84 mL/g/min; P=0.002) in the DCM group. In DCM patients, mixed effects linear regression demonstrated lower rest (adjusted mean 0.54(95% CI 0.50-0.57) versus 0.58(0.55-0.62) mL/g/min; P&amp;lt;0.001) and stress MBF (1.38(1.25-1.51) versus 1.55(1.43-1.67) mL/g/min; P&amp;lt;0.001) in segments with LGE compared to segments without LGE, but there was no difference in MPR (2.71(2.47-2.96) versus 2.76(2.55-2.97) mL/g/min; P=0.496). DCM patients had markedly lower peak VO2 (19.8±5.5 versus 25.2±7.3 mL/kg/min; P&amp;lt;0.001). Multivariable linear regression demonstrated that LV ejection fraction, extracellular volume fraction and MPR, but not LV mass, were independently associated with percentage predicted peak VO2 in DCM (R squared=0.531, P&amp;lt;0.001; Table 2). Conclusions DCM patients have lower rest and stress myocardial blood flow and lower MPR compared to controls. In DCM, MPR, LV ejection fraction and fibrosis are independently associated with aerobic exercise capacity.

Right ventricular pulmonary artery uncoupling independently associated with 5 year outcome following AHF hospitalisation

Abstract Background Right ventricular pulmonary artery (RV-PA) uncoupling is associated with poor outcome across a range of conditions, but its role in acute heart failure (AHF) remains incompletely investigated. Purpose To investigate if RV-PA uncoupling is independently associated with mortality following hospitalisation for AHF. Methods 418 patients were recruited. 391/418 (93.5%) had measurable TAPSE and SPAP and were followed up for 5 years to assess for all-cause mortality. Patients were recruited if they displayed signs and symptoms of AHF, had point-of-care brain-natriuretic peptide &amp;gt;100pg/ml and had evidence of HF on TTE. We identified a study-specific cut-off for TAPSE/SPAP of 0.24mm/mmHg on ROC analysis and performed univariate analysis to assess for an association with outcome. 30 covariates encompassing comorbidities, medications, echo parameters and observations were assessed and logistic regression analysis performed including variables associated with outcome. Results Patient average age at presentation was 79 years, 53.3% were male, 55.5% had hypertension, 30.7% had diabetes and 36.8% had CAD with a mean LVEF of 42.6% and BNP of 1363pg/ml. The mean TAPSE was 15.6mm and SPAP of 52.5mmHg. The average TAPSE/SPAP was 0.34mm/mmHg. 252/391 (64.5%) presented with TAPSE/SPAP &amp;lt;0.24mm/mmHg. These individuals were at higher risk of 5-year mortality compared to &amp;gt;0.24mm/mmHg: HR 1.94 (95% CI 1.49-2.54 [p&amp;lt;0.0001]), which persisted when adjusted for significant covariates – HR 1.35 (95% CI 1.02-1.80 [p&amp;lt;0.0395]). Conclusion TAPSE/SPAP ratio is an independent predictor of mortality in patients admitted with AHF. Our cut-off, a lower value than others have suggested in the literature for chronic conditions such as pulmonary hypertension, could identify those at risk of poor outcome in the acute setting. This may offer an exciting therapeutic target and help risk stratify patients. These results should focus the attention of those managing AHF patients onto the RV, pulmonary pressures and their interrelationship. It is time we moved beyond the LVEF.

Incidence and predictors of 2-year mortality following percutaneous left atrial appendage occlusion in the EWOLUTION tria

Abstract Background and aims Sufficient survival time following left atrial appendage occlusion (LAAO) is essential for ensuring the efficacy and cost-effectiveness of this strategy for stroke prevention. Understanding prognostic factors for early mortality after LAAO could optimize patient selection. In the current study we perform an in-depth analysis of 2-year mortality after LAAO, focusing particularly on potential predictors. Methods The EWOLUTION registry is a real-world cohort comprising 1020 patients that underwent LAAO. Endpoint definitions were prespecified and death was categorized as cardiovascular, non-cardiovascular, or of unknown origin. Mortality rates were calculated from Kaplan-Meier estimates. Patient characteristics and event rates were compared between deceased and alive patients by unpaired T-tests or Chi-squared test, as appropriate. Baseline characteristics significantly associated with death in univariate Cox regression analysis were incorporated into the multivariate analysis. All multivariate predictors were included in a risk model. Results 2-year mortality rate was 16.4% (CI: 14.0-18.7%), with 50% of patients dying from a noncardiovascular cause. Deceased patients had more comorbities and more often had a major bleeding after LAAO (20.6% vs 3.3%, p&amp;lt;0.001). Multivariate baseline predictors of 2-year mortality included age (HR 1.05, CI: 1.03-1.08, per year increase), heart failure (HR 1.73, CI: 1.24-2.41), vascular disease(HR 1.47, CI: 1.05-2.05), valvular disease (HR 1.63 CI: 1.15-2.33), abnormal liver function (HR 1.80 CI: 1.02-3.17) and abnormal renal function (HR 1.58, CI: 1.10-2.27). Mortality rate exhibited a gradual rise as the number of risk factors increased, reaching 46.1% in patients presenting with five or six risk factors. Conclusion One in six patients died within 2 years after LAAO. We were able to identify six independent predictors of mortality. When combined, this model showed a gradual increase in mortality rate with a growing number of risk factors, which may guide appropriate patient selection for LAAO.

Clinical, echocardiographic and haemodynamic predictors of morbidity and mortality in pulmonary hypertension: a nation-wide registry

Abstract Background and aims In this retrospective analysis of a nation-wide registry on pulmonary arterial hypertension (PAH), group IV and V, we aimed to evaluate the clinical, echocardiographic,haemodynamic and neurohumoral predictors of morbidity and mortality. Methods This study included 903 patients enrolled from 24 cardiology centers participating in the RegiStry on clInical outcoMe and sUrvival in pulmonaRy hypertension Groups (SIMURG II). ESC/ERS 2022 risk scoring model was used for risk predictions at baseline assessment. Composite endpoint (CEP) definitions were adopted from the SERAPHIN and GRIPHON trials. Results Age was 51.27 + 21.37 years, and 72 % of patients were female. Incident cases were noted in 65.9 % of overall group. Idiopathic PAH (IPAH), PAH-associated with congenital heart diseases (CHD-PAH), PAH-associated with connective tissue diseases (CTD-PAH), porto-PAH, Group IV and V pulmonary hypertension (PH) were documented in 33 %, 33.5 %, 12 %, 1.6 %, 20 % and 1.7 % of overall patients, respectively. Background mono and dual targeted combinations, and sequential dual or triple combinations were noted in 17 %, 57 % and 26 % of patients, respectively. Baseline low-, intermediate- and high-risk were noted in 1.2 %, 14.1 %, and 84.7 %, respectively. Median follow-up time was 867 (412-1667) days. Overall rates of mortality and CEP were 26 % and 39%, respectively. Prevalent versus incident cases were associated signifinatly lower mortality and CEP rates (p=0.028 and p=0.024, respectively). Mortality and CEP rates were 31 % and 44 % in IPAH, 20 % and 39 % in CHD-PAH, 31 % and 43 % in CTD-PAH, and 25 % and 30 % in group IV patients, respectively. CHD-PAH compared with other groups was associated with a higher Kaplan-Meier (K-M) survival and CEP-free survival (p&amp;lt; 0.0001 and p=0.00023, respectively). Survival was associated with prevalent versus incident status, baseline functional class (FC) and six-minute walk distance (6MWD) in all subgroups (p&amp;lt;0.0001 for all), NT-brain natriuretic peptide and right atrial area in IPAH,CHD-PAH and CTD-PAH, and mixed venous O2 saturation % in IPAH and CHD-PAH (p varying from &amp;lt;0.0001 to 0.027). But, TAPSE / systolic pulmonary artery pressure ratio, right atrial-pulmonary capillary wedge pressure difference, pulmonary vascular resistance and its ratio to systemic vascular resistance, cardiac index were not related with survival. Baseline high versus intermediate /low risk was associated with a lower overall survival and CEP-free survival ( p=0.03 and p=0.003, respectively). Male sex [hazard ratio(HR):1.73;1.2-2,51,p = 0.004], 6MWD (p&amp;lt;0.001), FC III/IV (HR: 2.52;1.47-4.32, p&amp;lt;0.001) and baseline low-risk (HR:0.37;0.21-0.65, p&amp;lt;0.001) were independent predictors of mortality. Conclusions Our nation-wide data revealed current insights regarding the clinical, echocardiographic,haemodynamic and neurohumoral predictors of morbidity and mortality in PAH and group IV PH.

Isolation of Candida Species Is Associated with Comorbidities, Prolonged Mechanical Ventilation, and Treatment Outcomes in Surgical ICU Patients, a Cross-Sectional Study

The isolation of Candida may be related to comorbidity, prolonged mechanical ventilation, and survival during intensive care unit (ICU) stay, especially with non-albicans Candida (NAC). To examine the frequency of Candida isolation, associated comorbidities and outcomes in the surgical ICU in Osijek University Hospital, Croatia, the data from the electronic database from May 2016 to 30 June 2023 were analyzed. In a cross-sectional study examining 15,790 microbiological samples, different strains of Candida were observed in 581 samples from 236 patients. The control group (N = 261) was 130 consecutive patients from March to May 2019 and 131 in the same months in 2020 (pre- and post-COVID-19). Comorbidities, duration of mechanical ventilation, and survival were compared. Patients with isolated Candida were more often non-elective and had significantly more heart, kidney, and liver diseases and sepsis than the control group (p &lt; 0.001). The duration of mechanical ventilation was 9.2 [2.2–9.24], 96 [24–146], 160 [19.5–343], and 224 [73.5–510] hours in the controls, in patients with Candida albicans, in patients with NAC, and in patients with ≥2 Candida species isolated, respectively. The mortality was significantly higher (42%) in patients with isolated Candida than in the control group (19%, p &lt; 0.001). In a multivariate analysis adjusted for patients’ age, the Simplified Acute Physiology Score II, days of ICU, and type of admission, only sepsis on admission was an independent predictor of mortality (odds ratio = 2.27).

Adverse prognostic implications of increased left ventricular force in hypertrophic cardiomyopathy

Abstract Background The left ventricular (LV) force, also known as elastance, serves as a load-independent indicator of contractility and can be noninvasively assessed through echocardiography. In hypertrophic cardiomyopathy (HCM), the heightened presence of the active state of myosin heads results in an increased LV force. Purpose To assess the prognostic value of increased LV elastance at rest in patients with HCM. Methods We enrolled 1420 HCM patients (age 50±16 years, 907 males, 64%) with ejection fraction (EF) ≥50%, referred for rest transthoracic echocardiography (TTE) in 10 quality-controlled labs from 7 countries. TTE assessment included peak left ventricular outflow tract gradient (LVOTG), EF, and LV force (systolic blood pressure + LVOTG/LV end-systolic volume assessed with 2-D, mmHg/mL). All patients were followed up. All-cause death was the outcome measure. Results At a median follow-up of 83 months, 150 deaths occurred (Group 1). At study entry, Group 1 patients had the same ESC-Sudden cardiac death score compared to survivors (Group 2). In Group 1 compared to Group 2, TTE showed higher values of MR severity, E/e’ , left atrial volume index, estimated systolic pulmonary artery pressure, and force (see table). At multivariable Cox analysis, only age (HR =1.08, 95% CI=1.03-1.14, p=0.001) and force &amp;gt; median value of 5.3 mmHg/mL (HR = 2.14, 95% CI 1.53-2.99, p=0.020) were independent predictors of mortality. Ten-year survival was 95% in the pooled first (&amp;lt;3.8 mmHg/mL) and second (3.8-5.2 mmHg/mL) quartiles vs 80% in the pooled third (5.3-7.8 mmHg/mL) and fourth quartiles (&amp;gt;7.8 mmHg/mL), see figure. Conclusion HCM patients with higher values of resting LV elastance show a worse survival, highlighting the dark prognostic side of an excess of force in these patients. Table Legends E/e’, early mitral inflow to early mitral annulus motion ratio, EF, left ventricular ejection fraction, LAVI, left atrial volume index; LVOTG, left ventricular outflow tract peak gradient, MR, mitral regurgitation; MWT, maximal wall thickness, NYHA, New York Heart Association classification, RWT, relative wall thickness; SCD risk, risk score for sudden cardiac death in hypertrophic cardiomyopathy, SPAP, systolic pulmonary arterial pressure.Table.Clinical and TTE findingsFigure.Survival in the force quartiles

Predictors of acute ischemic strokes and subsequent mortality in patients hospitalized for percutaneous coronary interventions

Abstract Background Acute ischemic strokes (AIS) occurring post percutaneous coronary intervention (PCI) are an infrequent but severe complication, resulting in increased mortality rates and morbidity in survivors. Purpose We aimed to investigate independent predictors of AIS and subsequent mortality in patients hospitalized for PCI in a nationwide cohort. Methods A retrospective analysis using on ICD-10-GM and OPS-codes obtained from 2006-2021 from the German Federal Statistical Office was performed. Patients with a peri-interventional AIS aged ≥18 years which were admitted for PCI were included in this analysis. A stepwise regression analysis was employed to identify factors independently associated with AIS and to determine variables linked to in-hospital mortality. Results From 4,910,430 PCI cases registered from 2006-2021, AIS occurred in 4,098 (0.08%) patients. Patients with an AIS were 70.9±11.3 years of age, predominantly male (65.3%) and displayed a high burden of comorbidities such as diabetes (36.1%), a prior medical history of atrial fibrillation (34.6%) and chronic kidney disease (19.4%). In patients with AIS, 27.4% presented with a ST-elevation myocardial infarction (STEMI), whilst 38.9% were admitted with a Non-STEMI. Concerning procedural characteristics, 84.2% underwent a coronary stent implantation, and in 5.5% cases a coronary thrombectomy was carried out. Important predictors of peri-interventional AIS after a PCI were: carotid artery disease, history of stroke, presentation with myocardial infraction, atrial fibrillation, and coronary thrombectomy. For variables like hyperlipoproteinemia, obesity and stent implantation an inverse association was noted (also see Figure 1A). With regard to mortality, during a mean in-hospital stay of 18 ± 15.1 days, a total of 18.1% (n=742) patients died. We identified several independent predictors of mortality including clinical presentation with cardiogenic shock, dialysis and STEMI as indication for PCI. A negative correlation with in-hospital mortality was seen for variables such as arterial hypertension and coronary stent implantation (see Figure 1B for full set of independently associated variables). Conclusion In a nationwide cohort of patients hospitalized for PCI over 16 years, we identified important predictors of AIS including carotid artery disease and coronary thrombectomy. Moreover, a substantial rate of in-hospital mortality as well as several predictors of death were recognized. Our findings might help clinicians identify patients undergoing PCI who are at highest risk for ischemic cerebral complications and subsequent mortality.

Comparative analysis of a novel preoperative stratification method versus traditional scores in patients with severe aortic stenosis undergoing aortic valve surgery

Abstract Introduction It is crucial to consider factors that complicate the indication of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis (AS), such as narrow valve ring, extensive calcification or inadequate vascular access. (1-4) Thus, aortic valve replacement surgery (SAVR) remains a recommended indication, with its pre-surgical stratification being a challenge. (1-3) Despite the widespread use of scores like the STS and EuroSCORE II, they exhibit limitations, being validated primarily for populations outside Latin America and focusing predominantly on individual factors while often neglecting structural parameters like left ventricular hypertrophy, diastolic dysfunction, or left atrium volume. (3-5) Purpose This study aimed to assess whether a novel modified Généreux stratification method offers superior predictive value for postoperative mortality in AS patients compared to traditional scoring systems. Methods We conducted a retrospective, single-center study involving patients with confirmed severe AS who underwent aortic valve replacement surgery between January 2017 and December 2021. The new stratification method categorized patients into three stages based on echocardiographic parameters (see Figure 1). Univariate and multivariate Cox regression analyses were conducted to identify predictors of mortality, with survival analysis performed using Kaplan-Meier curves. A p-value &amp;lt;0.05 was considered statistically significant. Results A total of 508 patients were included in the study. Stage 1 patients had a lower median age (62 years vs. 67 years in stages 2 and 3). The median EuroSCORE and STS were 2.75 and 2.62%, respectively, with stage 3 showing significantly higher scores (p ≤0.001). Over a median follow-up of 81 months, 56 deaths occurred (11%). Kaplan-Meier curve analysis revealed significant differences in all-cause mortality among the three groups (HR 4.073, log-rank p≤0.001), as illustrated in Figure 1. Multivariate analysis identified the three preoperative stages (HR 3.22, [95% CI 1.44-7.20], p=0.004) and mean transaortic gradient (HR 0.96, [95% CI 0.92-0.99], p=0.021) as independent predictors of mortality. The new stages demonstrated a superior area under the ROC curve of 0.758 compared to traditional scores (see Figure 1). Conclusions The novel three-stage preoperative classification and low transaortic gradient serve as significant predictors of mortality in patients undergoing SAVR. These stages exhibit robust predictive capability for mortality compared to EuroSCORE II and STS.Baseline and multivariate analysisKaplan-meier and ROC curve

Mortality based right ventricle functional echocardiographic cutoffs in patients with compared to without tricuspid regurgitation

Abstract Introduction Tricuspid-annular-plane-systolic-excursion (TAPSE) and peak-lateral-tricuspid-annular-systolic-velocity (S’) are frequently used echocardiographic indices of right-ventricle (RV) function. Tricuspid regurgitation (TR) is present in 70-90% of the general population, and while trivial or mild TR may not have prognostic implications, several studies have demonstrated that ≥moderate TR is an independent predictor of adverse outcomes, and that increasing TR severity incurs an increased risk of mortality. The abnormality thresholds for TAPSE and S' are based on published mean and standard deviation data obtained from healthy adults, but not on outcome data. The effect of significant TR on the abnormality threshold of TAPSE and S’ prime is currently unknown. Purpose We aimed to re-examine the abnormality thresholds for TAPSE and S' based on their association with mortality in consecutive patients, stratified to with, or without, significant tricuspid regurgitation (TR). Methods We performed a retrospective analysis of consecutive patients undergoing echocardiography between 2011-2021 in a large tertiary center. TR was assessed using a semi-quantitative method. Cut-off values associated with excess mortality were assessed using spline curves in univariate, and multivariate Cox logistic regression analyses. Results A total of 24717 subjects were included in the current analysis with a median (interquartile range) follow up of 1321 (581-1902) days. 1143 (4.6%) subjects had clinically significant (≥moderate) TR. In the entire cohort, TAPSE&amp;lt;20.9 mm and S’ &amp;lt;10.9 cm/s were associated with excess mortality. In sub-group analysis, among subjects with significant TR, TAPSE&amp;lt;18.0 mm and S'&amp;lt;10.0 cm/s was the cutoff associated with excess mortality, while subjects without TR had a higher cutoff of TAPSE&amp;lt;21.5 mm and S'&amp;lt;10.9 cm/s. In a multivariate model adjusted for the presence of TR and baseline characteristics, TAPSE&amp;lt;20.9 mm (HR 1.20, 95% CI 1.14-1.27; p&amp;lt;0.001) and S’&amp;lt;10.9 cm/s (HR 1.07, 95% CI 1.01-1.13; p=0.015) were independent predictors for mortality. A sensitivity analysis, which included 14,664 patients with additional echocardiographic indices, demonstrated that low TAPSE remained an independent predictor of mortality (aOR=1.15; 95% CI: 1.07-1.24; p&amp;lt;0.001) Conclusion TAPSE and S’ thresholds associated with excess mortality are higher than those previously reported in healthy adults. The TAPSE and S' cutoffs associated with excess mortality were lower in patients with significant TR compared to patients without, suggesting that a personalized approach for their interpretation is needed.Central illustration

Multiparametric risk predictions for morbidity and mortality in patients with pulmonary arterial hypertension: insights from a nation-wide registry

Abstract Background and aims In this retrospective analysis of a nation-wide registry on pulmonary arterial hypertension (PAH), group IV and V, we aimed to evaluate risk predictions for morbidity and mortality. Methods This study included 903 patients enrolled from 24 cardiology centers participating in the RegiStry on clInical outcoMe and sUrvival in pulmonaRy hypertension Groups (SIMURG II). ESC/ERS 2022 risk scoring, COMPERA 2.0 and REVEAL lite 2 models were used for baseline risk predictions, and COMPERA 2.0 model was used for risk evaluation at follow-up. Composite endpoint (CEP) definitions were adopted from the SERAPHIN and GRIPHON trials. Results Age (mean +SD) was 51.27 + 21.37 years, and 72 % of patients were female. Incident cases were noted in 65.9 % of overall study group. Idiopathic PAH (IPAH), PAH-associated with congenital heart diseases (CHD-PAH), PAH-associated with connective tissue diseases (CTD-PAH), porto-PAH, Group IV and V pulmonary hypertension (PH) were documented in 33 %, 33.5 %, 12 %, 1.6 %, 20 % and 1.7 % of overall patients, respectively. Background mono and dual targeted combinations, and sequential dual or triple combinations were noted in 17 %, 57 % and 26 % of patients, respectively. According to the ESC/ERS 2022 baseline risk scoring, low-, intermediate-, and high-risk were noted in 1.2 %, 14.1 %, and 84.7 %, respectively. Median follow-up time was 867 (412-1667) days. Overall rates of mortality and CEP were 26 % and 39%, respectively. Prevalent versus incident cases were associated signifinatly lower mortality and CEP ( p=0.028 and p=0.024, respectively). Mortality and CEP rates were 31 % and 44 % in IPAH, 20 % and 39 % in CHD-PAH, 31 % and 43 % in CTD-PAH, and 25 % and 30 % in group IV patients, respectively. Baseline high versus intermediate /low risk status were associated with a lower survival estimates for mortality and CEP in patients with PAH ( p=0.03 and p=0.003, respectively). Baseline COMPERA 2.0 risk status revealed significant differences in overall survival and CEP-free survival among risk groups ( p&amp;lt;0.0001 for both), but 1st year COMPERA 2.0 score did not (p=0.39 and p=0.06, respectively) . As compared to baseline, 1st year COMPERA 2.0 score decreased in 31 %, and remained unchanged in 34 % of patients. Baseline REVEAL lite 2.0 score was associated with mortality (hazard ratio (HR): 1.14;1.08-1.2, p&amp;lt;0.0001) and CEP (HR:1.17;1.1-1.25, p&amp;lt;0.0001) risks. Male sex (HR: 1.73; 1.2-2.51, p = 0.004), six-minute walk distance (p&amp;lt;0.001), functional class III/IV (HR: 2.52;1.47-4.32, p&amp;lt;0.001) and baseline low-risk status (HR:0.37;0.21-0.65, p&amp;lt;0.001) were independent predictors of mortality. Conclusions Our nation-wide data revealed current insights concerning the multiparametric risk predictions for morbidity and mortality in PAH.

A novel 12-lead standard ECG derived scoring system for risk stratification in the emergency department

Abstract Background/Aims The ECG represents a routinely used diagnostic tool in the assessment of patients in the emergency department. Beside specific alterations within the ECG indicative of underlying pathologies, such as ST-elevation in myocardial infarction, several other parameters have been developed over the past decades that proofed themselves as strong and independent predictors of worsened outcome independent of a specific underlying pathology. These include basic metrics such as heart rate and QRS duration, but also more advanced biomarkers such as QRS microfragmentation (QRSµf) [1] and total cosine R to T (TCRT) [2] . In this work, we aimed to summarize all these markers derived from 12-lead standard ECGs into one novel risk score and evaluate its performance as mortality predictor in the emergency department. Methods We retrospectively collected 10- second 12- lead ECG recordings unselected patients presenting to the emergency department of a large university hospital between September 2019 and June 2022. For each patient a risk score was calculated from the first retrieved ECG using the criteria displayed in Figure 1. Calculation of all parameters was done as previously published. Patients with a total score of 0-1 points, 2-3 points, 4-6 points and 7 points were considered as low, intermediate, high and very high risk, respectively. The performance of the risk score was evaluated using Cox regression analysis and Kaplan-Meier curves with all-cause mortality within one year as primary endpoint. Results In total, 10 781 patients were included in our analyses. Median age was 69 (IQR 54-80) years, 5 588 (52%) were male and 5 193 (48%) were female. 6 966 (65%) patients were considered as low risk, 2 656 (25%) patients as intermediate risk, 1 098 (10%) patients as high risk and 61 (1%) patients as very high risk according to the ECG risk score with one year mortality rates of 8%, 17%, 26% and 43%, respectively (p &amp;lt; 0.001 for difference). In cox regression analysis the novel ECG risk score was a strong and independent predictor of one-year all-cause mortality with a hazard ratio of 1.35 (95% CI 1.31-1.39, p &amp;lt; 0.001). Kaplan-Meier survival curves for different risk categories are displayed in Figure 2. Conclusion In an unselected population of patients presenting to the emergency department of a large university hospital a novel risk score calculated from standard 12-lead ECGs recorded during clinical routine was a strong and independent mortality predictor. Further studies are needed to evaluate how incorporation of the novel score into existing triage systems can improve patient care.Figure 1:Calculation of ECG risk scoreFigure 2:Kaplan-Meier survival curves

Beyond 2D echocardiography: A novel multiparametric assessment of right ventricular dysfunction in transcatheter tricuspid valve repair

Abstract Background Patients with severe tricuspid regurgitation (TR) are heterogenous and complex in terms of etiology, comorbidities and state of disease. Right ventricular (RV) function measured by RV to pulmonary artery coupling (RVPAc) is prognostic in transcatheter tricuspid valve repair (T-TEER). However, traditional 2D echocardiographic measures have critical limitations and RVPAc fails to respect the degree of volume overload/dilation of the RV, which is a key clinical tracer for right ventricular dysfunction (RVD). Purpose We aimed to refine RVPAc by incorporating RV dilation, assessed by 3D echocardiography, to improve the assessment of RV dysfunction for an enhanced outcomeprediction in T-TEER patients. Methods We analyzed 262 patients undergoing T-TEER with complete 3D echocardiography. Results Despite similar RV function across groups, RV dilation (HR 1.85; 1.10, 3.12; p=0.020) and impaired RV free wall longitudinal strain (RVFWLS, HR 1.73, 1.02, 2.92, p=0.042) predicted increased 1-year mortality. A novel RVPAc parameter [RVFWLS/(3D-RVEDV*sPAPinvasive)] was developed, associating RVPA-Uncoupling with a tripled risk of death (HR 3.19, 1.7-6.0, p&amp;lt;0.001). NYHA Class IV and the new RVPAc were independent mortality predictors after T-TEER, with the modified RVPAc showing superior predictive value over traditional RVPAc (c-index 0.68 vs. 0.57, p=0.027). Conclusion The novel RVPAc parameter, integrating RV dilation and function, is a powerful predictor of survival post-T-TEER, underscoring the importance of timely intervention in severe TR and RVD. 3D echocardiography plays a critical role in assessing RV dimension and function, with implications for the management and prognosis of TR patients.Central Figure

The prognostic value of metabolic dysfunction associated steatotic liver disease in acute myocardial infarction

Abstract Background Patients with metabolic dysfunction-associated steatotic liver disease (MASLD) are at increased risk of incident cardiovascular disease. However, the clinical characteristics and prognostic importance of MASLD in patients presenting with acute myocardial infarction (AMI) have yet to be examined. Methods This study compared the characteristics, and outcomes of patients with and without MASLD presenting with AMI at a tertiary centre in Singapore. MASLD was defined as hepatic steatosis, with at least one of five metabolic criteria. Hepatic steatosis was determined using the Hepatic Steatosis Index. Propensity score matching was performed to adjust for age and sex. Kaplan-Meier curve was constructed for long-term all-cause mortality. Cox regression analysis was used to investigate independent predictors of long-term all-cause mortality. Results In this study of 4446 patients with AMI, 2223 patients with MASLD were matched with patients without MASLD using propensity scores. The mean follow-up duration was 3.4 ± 24 years. The MASLD group had higher rates of obesity, diabetes, and chronic kidney disease than their counterparts. Patients with MASLD had early excess all-cause mortality (6.8% vs 3.6%, p&amp;lt;0.001) at 30 days, with unfavorable mortality rates sustained in the long-term (18.3% vs 14.5%, p=0.001) compared to those without MASLD. After adjustment, MASLD remained independently associated with higher long-term all-cause mortality (HR 1.338, 95% CI 1.115-1.604). Conclusion MASLD embodies a higher burden of metabolic dysfunction and is an independent predictor of long-term mortality in the AMI population. Its early identification may be beneficial for risk stratification and provide therapeutic targets for secondary preventive strategies in AMI.Kaplan Meier curve of long-term all-caus

Epicardial adipose tissue volumes for long-term risk stratification in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

Abstract Background Accurate risk stratification is important to improve patient selection and outcome of patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). As epicardial adipose tissue (EAT) is discussed to be involved in cardiovascular disease, it could be useful as a marker of poor prognosis in patients with severe AS undergoing TAVR. Purpose We hypothesized that EAT impacts long-term outcome of patients with severe AS undergoing TAVR independently from subtype and other risk factors. Methods A total of 416 patients diagnosed with severe AS by transthoracic echocardiography were assigned for TAVR and enrolled for systematic assessment. Patients underwent clinical surveys and 5-year long-term follow-up, with all-cause mortality as the primary endpoint. EAT volume was quantified on pre-TAVR planning CTs. Patients were retrospectively dichotomized at the median of 74cm3 of EAT into groups with low-EAT and high-EAT volumes. Mortality rates were compared using Kaplan-Meyer plots and uni- and multivariable cox regression analyses. Results A total number of 341 of 416 patients (median age 80.9years, 45% female) was included in the final analysis. Patients with high-EAT volumes had similar short-term outcome (p=0.794) but significantly worse long-term prognosis (p=0.023) compared to patients with low-EAT volumes. Increased EAT volumes were associated with worse long-term outcome (HR1.59;p=0.031) independently from concomitant cardiovascular risk factors, general type of AS and functional echocardiography parameters of AS severity (HR1.69;p=0.013). Conclusion Increased EAT volume is an independent predictor of all-cause mortality in patients with severe AS undergoing TAVR. It can be easily obtained from pre-TAVR planning CTs and may thus qualify as a novel marker to improve prognostication and management of patient with severe AS.Graphical Abstract

Association of P2Y12 inhibitor pretreatment strategy with short and long term ischemic and bleeding outcomes in NSTE-ACS patients

Abstract Background and Aims Oral P2Y12 inhibitors form the basis of both short and long term antiplatelet therapy in NSTE-ACS patients. While reducing thrombogenic activity and ischemic risk is the basis of routine P2Y12 inhibitor pretreatment in NSTE-ACS patients, timing of treatment became controversial as a result of studies showing routine P2Y12 inhibitor pretreatment is associated with an increased risk of bleeding. Even though routine pretreatment is no longer recommended in the ESC guidelines, the inadequacies in RCTs combining all treatment modalities have been noted. Our study aims to determine the relationship between P2Y12 inhibitor pretreatment strategy and short and long-term ischemic and bleeding events. Methods The study was designed as a single-center, prospective and observational study. 2602 patients, aged between 18 and 85, diagnosed with NSTE-ACS in accordance with ESC guidelines were included in the study. 2189 patients were administered with P2Y12 inhibitor pretreatment while 413 patients weren't. Demographic data, CVD risk factors, ECG, echocardiography and laboratory findings at the time of admission, interventional procedural details, type of antiplatelet and anticoagulant treatment and application time were recorded. Patients were divided into two groups as pretreatment and no-pretreatment according to the time of administration of P2Y12 inhibitor loading dose. In the no-pretreatment group choice of P2Y12 inhibitor was left to operator in the cath lab before proceeding to PCI. Post-procedural in-hospital and long term follow up (1 year) were obtained through hospital and national registry systems and patient survey. Results In the no-pretreatment group 91.3% of patients underwent coronary angiography and PCI was performed in 51.8%. In patients proceeding to PCI, 58.5% were given clopidogrel and 41.5% were given a potent P2Y12 inhibitor. In the pretreatment group, clopidogrel was the drug of choice in 93.8% of patients. In the pretreatment group, the primary composite endpoint (MACE and bleeding events) were more common during in-hospital follow-up and this difference was due to a significant increase in both BARC class I &amp; II and class III, IV &amp; V bleedings (Table 1). In the long-term follow up, statistically significant difference was only seen in BARC class I &amp; II bleedings in the pretreatment group. There were no difference in MACE rates in neither in-hospital or long-term follow up (Table 2). Also in multivariate regression analysis, pretreatment with a P2Y12 inhibitor was found to be an independent predictor of short term primary composite endpoints and long-term all-cause mortality. Conclusion The results of our study investigating the effects of the P2Y12 inhibitor pretreatment strategy on ischemic and bleeding endpoints in NSTE-ACS patients showed that the pretreatment strategy did not lead to an improvement in MACE rates in in-hospital and long-term follow-up but caused on overall increase in bleeding events.Kaplan-Meier Survival Analysis

Impact of rhythm control strategy on outcomes in patients with first diagnosed atrial fibrillation in an 11-year real-world registry

Abstract Background Atrial fibrillation (AF) is a highly prevalent arrhythmia with a high burden of disease. This sub-study of the Heidelberg Registry of Atrial Fibrillation (HERA-FIB) sought to evaluate clinical characteristics, treatment strategies and outcomes in patients with first diagnosed AF (FDAF). Methods Patients with AF presenting to the emergency department (ED) of an University Hospital between June 2009 and March 2020 were consecutively enrolled. Follow-up was performed for all-cause mortality, stroke, major bleeding and myocardial infarction (MI). Outcomes were were related to patients with FDAF or pre-existing AF, as well as assigned treatement strategy (rhythm vs. rate control). The trial was registered at ClinicalTrials.gov Identifier: NCT05995561. Results Overall 2,758 (27%) of all patients presented with FDAF. Compared to FDAF, patients with pre-existing AF showed higher all-cause mortality HR 1.41 (95%CI 1.28-1.55, p&amp;lt;0.0001) and major bleeding events 1.29 (95% CI 1.06-1.56, p=0.0098). Non-implementation of rhythm control in FDAF was seen in 2,079 cases (75.4%) and was associated with an excess of all-cause mortality HR 1.66 (95%CI 1.30-1.99, p&amp;lt;0.0001) and incident MI HR 1.79 (95% CI 1.03-3.09, p=0.0385). A non-implementation of rhythm control remained an independent predictor for all-cause mortality and MI even after adjustment for significant univariate variables aHR: 1.34 (95%CI: 1.04-1.72, p=0.0234) and aHR: 1.79 (95%CI: 1.03-3.09, p=0.0385). Conclusion Real-world data from FDAF patients presenting in the setting of an ED showed a potential benefit regarding mortality and MI for rhythm control strategy. Further research is needed to validate this hypothesis.

Impact of QRS complex fragmentation on all-cause mortality before and after cardiac resynchronization therapy

Abstract Introduction Cardiac resynchronization therapy (CRT) have demonstrated to reduce all-cause mortality in selected patients with HFrEF. However, there is still a high rate of non-responders, so risk stratification is crucial. Fragmentation of the QRS complex (QRSf) has been suggested as a valuable prognostic factor in different cardiac diseases, but the evidence in patients undergoing CRT is controversial and limited. Purpose To evaluate if changes in QRSf status before and after CRT implantation has a prognostic role in patients undergoing CRT in terms all-cause mortality. Methods Consecutive patients undergoing CRT were prospectively included from October 2009 to December 2022. Demographic clinical, electrocardiographic and echocardiographic variables were recorded. Prospective follow-up variables were collected from electronic clinical records and telephone interview. QRSf complex was defined by the presence of different RSR′ patterns including additional R-waves (R′) and notches of the R-wave and S-wave in two contiguous leads corresponding to a main coronary artery territory in a 12-lead electrocardiogram performed before and after CRT. Results A total of 244 patients (mean age 71.8 ± 9.8 years, 79.5% male) were included. The etiology of LV systolic disfunction was ischemic in 50.0%. Mean LVEF before implantation was 25 ± 9%. A CRT-D was implanted in 176 patients (72.2%). The mean width of the paced QRS was 141 ± 23 ms. At baseline, 150 patients had a QRSf. After CRT implantation, 69 (28.4%) patients experimented a change in QRSf status: 29 patients (11.9%) without prior QRSf developed QRSf, whereas 40 patients (16.5%) resolved QRSf after CRT. Median follow-up time was 36.0 months (interquartile range 18.2-75.7). During the follow-up period, 90 patients died. In the multivariate Cox regression survival analysis, the presence of QRSf before the implantation with or without paced QRSf after CRT were independently associated with all-cause mortality (HR 4.43; 95% CI 1.53-12.80 and HR 3.69; 95% CI 1.16-11.80 respectively). Those without QRSf prior implantation who developed QRSf after CRT did not present significantly higher risk of all-cause mortality. Univariate and multivariate Cox regression analyses for all-cause mortality are presented in Table 1. Figure 1 presents Kaplan-Meier curves for all-cause mortality according to QRSf status before and after CRT implantation. Conclusions According to our results, preimplantation QRSf is an independent predictor of all-cause mortality regardless the resolution or maintenance of QRSf after CRT in patients with HFrEF undergoing CRT. Therefore, patients with QRSf before CRT implantation regardless the paced QRSf status, should be followed more strictly because they are at higher mortality risk.Table 1.Cox Regression Analyses