Need For Pacemaker Research Articles

Incidence of aortic valve reintervention in patients with aortic stenosis undergoing transcatheter aortic valve implantation versus surgical aortic valve replacement: a systematic review and updated meta-analysis of randomized studies.

Transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) are established interventions for alleviating symptoms and enhancing survival in individuals with severe aortic stenosis (AS). However, the long-term outcomes and incidence of reintervention associated with TAVI and SAVR remain uncertain. We conducted a systematic review and meta-analysis to compare the incidence of reintervention in TAVI versus SAVR. PubMed, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs). Risk ratios (RR) and 95% confidence intervals (CI) were pooled with a random-effects model. A p-value < 0.05 was considered statistically significant. Nine RCTs were included, with 5144 (50.9%) patients randomized to TAVI. Compared with SAVR, TAVI increased reinterventions (RR 1.89; 95% CI 1.29-2.76; p < 0.01) and the need for pacemakers (RR 1.91; 95% CI 1.49-2.45; p < 0.01). In addition, TAVI significantly reduced the incidence of new-onset atrial fibrillation (RR 0.43; 95% CI 0.32- 0.59; p < 0.01). There were no significant differences in all-cause mortality (RR 1.04; 95% CI 0.92-1.16; p = 0.55), cardiovascular mortality (RR 1.04; 95% CI 0.94-1.17; p = 0.44), stroke (RR 0.97; 95% CI 0.80-1.17; p = 0.76), endocarditis (RR 0.96; 95% CI 0.70-1.33; p = 0.82), and myocardial infarction (RR 1.06; 95% CI 0.79-1.41; p = 0.72) between groups. In patients with severe AS, TAVI significantly increased the incidence of reinterventions and the need for pacemakers as compared with SAVR.

Initial experience with transcatheter aortic valve replacement before and after lung transplant

ObjectivesPatients with end-stage lung disease and lung transplant (LTx) recipients are high-risk candidates for surgical aortic valve replacement (AVR). Transcatheter AVR (TAVR) is an established treatment for aortic stenosis. Experience with TAVR in the LTx population is limited. We sought to report our experience in patients who underwent TAVR before or after LTx. MethodsSingle-center, retrospective analysis, including all patients who underwent TAVR pre- or post-LTx from 2000 to 2020. Indications, mode of anesthesia, timing of TAVR, and procedural outcomes were reviewed. ResultsIn total, 10 LTx patients underwent TAVR. Aortic stenosis was the indication for TAVR in all patients: 5 had TAVR pre-LTx, and 5 post-LTx. All 10 TAVRs were performed with transfemoral access, and 9 out of 10 with intravenous sedation and monitored anesthesia care; only 1 required general anesthesia. In the TAVR pre-LTx group, mean age was 62 years and 4 patients were men. Four TAVR valves were balloon-expandable and 1 self-expanding. Median time from TAVR to transplant was 7.4 months (range, 1.7-36 months), and median length of stay after TAVR 4 days (range, 2-36 days). The only TAVR-related complication was a pacemaker for heart block (1 out of 5). All 5 subsequently underwent successful double LTx (1 with concurrent liver transplant). In the TAVR post-LTx group, mean age was 66 years and 2 patients were men. Four TAVR valves were balloon-expandable and 1 was self-expanding. Median time from LTx to TAVR was 5 years (range, 2.6-7.6 years), and median length of stay post-TAVR was 2 days (range, 1-17 days). The only TAVR-related complication in this group was heart block requiring pacemaker (1 out of 5). In both groups, there were no intraprocedural mortality or conversion to surgical AVR. No patients required post-TAVR surgical intervention during study follow-up. ConclusionsOur initial experience suggests that TAVR is safe and feasible for treatment of aortic stenosis in patients with end-stage lung disease awaiting LTx, and in patients who have undergone LTx. Overall TAVR-related complications included need for pacemaker. TAVR should be considered for treatment of aortic stenosis in patients with end-stage lung disease awaiting transplant, and for post-LTx patients as an alternative to surgical aortic valve replacement.

Impact of permanent pacemaker for iatrogenic atrioventricular block on outcomes after congenital heart surgery

ObjectiveThe need for permanent pacemaker (PPM) for iatrogenic atrioventricular block (AVB) after congenital heart surgery is approximately 1%. We aimed to evaluate the long-term outcomes of patients with PPM for iatrogenic AVB and compare them with patients with an optimal repair (trivial/no residual) Residual Lesion Score (RLS) Class 1 repair without PPM need. MethodsWe reviewed 183 patients discharged with PPM for iatrogenic AVB from 2011 to 2022. Patients who survived to discharge with >30 days of follow-up were matched 1:1 with a cohort of patients categorized as RLS Class 1 on the basis of fundamental diagnosis and primary procedure. ResultsMedian age at PPM placement was 1.4 years (interquartile range, 4.3 months to 3.9 years). The cumulative incidence of moderate or greater ventricular dysfunction at 1 year and 5 years was 11% and 18% in patients with PPM, respectively, compared with 3% and 7% in patients categorized as RLS Class 1 (subdistribution hazard ratio, 2.6; 95% confidence interval, 1.2-6.1; P = .022). Independently, patients with PPM with hypoplastic left heart syndrome (P = .027) and who had undergone Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 5 procedures (P = .033) were at greater risk of ventricular dysfunction. Transplant-free survival at 1 year and 5 years was 94% and 89% in patients with PPM, respectively, compared with 98% and 97% in patients categorized as RLS Class 1 (P = .044). In addition, patients with PPM with palliated circulation had significantly lower transplant-free survival (P < .001). ConclusionsCompared with patients with an optimal repair without PPM, patients with PPM for iatrogenic AVB are at greater risk of developing moderate or greater ventricular dysfunction and have lower transplant-free survival.

Analysis of Risk Factors of Difficult Weaning from Mechanical Ventilation after Pediatric Cardiac Surgery: A Single Center Prospective Study

Abstract Background Weaning from mechanical ventilation (MV( and timing of extubation are crucial components in the postoperative management of cardiac surgery as altered respiratory mechanics and positive pressure ventilation may have significant influence on hemodynamics. Aim: To evaluate risk factors for failure of weaning from mechanical ventilation after pediatric cardiac surgery and to assess the frequency of phrenic nerve injury. Methodology This Cohort study included medical records of 101 children admitted consecutively to Pediatric post-cardiac surgery ICU in Academy of Cardiovascular surgery in Ain Shams university Hospitals between April, 2020 and April, 2021, who had undergone heart surgery. The patients were divided into two groups : - successefully weaned group. - Difficult to wean group. Diaphragmatic ultrasound was done for every difficult weaning patient to assess diaphragmatic paralysis. Result: Age (P &amp;lt; 0.001), Weight (P &amp;lt; 0.001), volum intake (P &amp;lt; 0.001), systolic blood pressure (P = 0.017), Diastolic blood pressure (P = 0.004), were significantly lower in patients who showed difficult weaning compared to patients with successful weaning. Furthermore operation time (P &amp;lt; 0.001), use of noradrenaline (P = 0.019), use of adrenaline ( P = 0.017), use of Milirinon ( P = 0.003), respiratory rate ( P = 0.003), inotropic support (P = 0.001), positive fluid balance (P &amp;lt; 0.001), heart failure, renal failure, Pulmonary complications, need of pace maker, sepsis ( P &amp;lt; 0.001), diaphragmatic paralysis ( P &amp;lt; 0.001), transposition of great arteries operations ( P = 0.009), were significantly higher in patients who showed difficult weaning compared to patients with successful weaning. While use of dobutamine, discharge with open chest, reoperation, transfusion &amp;gt; 50 ml / kg, urine output, reoperation bleeding and any operation other than atrial septal defect, transposition of great arteries all did not affect weaning difficulty. Conclusion younger age, operation time, as well as sepsis were the best predictors for difficulty of weaning.

Elevated myocardial extracellular volume fraction is associated with the development of conduction pathway defects following transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) has become an established method of aortic stenosis treatment but suffers from the risk of heart block and pacemaker requirement. Risk stratification for patients who may develop heart block remains imperfect. Simultaneously, myocardial fibrosis as measured by cardiac magnetic resonance imaging (CMR) has been demonstrated as a prognostic indicator of ventricular recovery and mortality following TAVR. However, the association of CMR-based measures of myocardial fibrosis with post-TAVR conduction disturbances has not yet been explored. We evaluated whether myocardial fibrosis, as measured by late gadolinium enhancement and extracellular volume (ECV) from CMR would be associated with new conduction abnormalities following TAVR. One hundred seventy patients who underwent CMR within 2 months before TAVR were retrospectively reviewed. Septal late gadolinium enhancement (LGE) and ECV measurements were made as surrogates for replacement and interstitial fibrosis respectively. New conduction abnormalities were defined by the presence of transient or permanent atrioventricular block, new bundle branch blocks, and need for permanent pacemaker. Association of myocardial fibrosis and new conduction derangements were tested using receiver operator curve (ROC) and regression analysis in patients with and without pre-existing conduction issues. Forty-six (27.1%) patients developed post-TAVR conduction deficits. ECV was significantly higher among patients who experienced new conduction defects (26.2 ± 3.45% vs. 24.7% ± 4.15%, p value: 0.020). A greater fraction of patients that had new conduction defects had an elevated ECV of ≥26% (54.3% vs. 36.3%, p value: 0.026). ECV ≥ 26% was independently associated with the development of new conduction defects (odds ratio [OR]: 2.364, p value: 0.030). ROC analysis revealed a significant association of ECV with new conduction defects with an area under the receiver operating characteristic curve (AUC) of 0.632 (95% confidence interval: 0.555-0.705, p value: 0.005). The combination of prior right bundle branch block (RBBB) and ECV revealed a greater AUC of 0.779 (0.709-0.839, p value: <0.001) than RBBB alone (Delong p value: 0.049). No association of LGE/ECV with new conduction defects was observed among patients with pre-existing conduction disease. Among patients without baseline conduction disease, ECV was independently associated with the development of new conduction deficits (OR: 3.685, p value: 0.008). The present study explored the association of myocardial fibrosis, as measured by LGE and ECV with conduction deficits post-TAVR. Our results demonstrate an association of ECV, and thereby interstitial myocardial fibrosis, with new conduction derangement post-TAVR and introduce ECV as a potentially new risk stratification tool to identify patients at higher risk for needing post-TAVR surveillance and/or permanent pacemaker.

Outcomes of pediatric heart transplantation in children with selected genetic syndromes

ObjectiveGenetic syndromes (GSs) are often linked to congenital heart disease (CHD) and cardiomyopathy (CM). The effect of GSs on survival following pediatric heart transplant (HT) has not been well described. We aimed to compare outcomes following HT between children with a GS and those without a GS. MethodsThe United Network for Organ Sharing (UNOS) transplantation database was merged with the Pediatric Health Information System (PHIS) administrative database to identify children with GS who underwent HT between 2009 and 2019. Characteristics and outcomes were compared between children with a GS (GS group) and those without a GS (no GS group). ResultsGSs were present in 225 of 2429 HT recipients (9%). The most common GSs were DiGeorge syndrome (n = 28), muscular dystrophy (n = 27), Down syndrome (n = 26), and Turner syndrome (n = 14). The incidence of CHD was higher in the GS group compared to the no GS group (54% vs 38%; P < .1); however, patient demographics, hemodynamics, renal and hepatic dysfunction, and requirements for dialysis, mechanical ventilation, extracorporeal membrane oxygenation, and mechanical circulatory support were not different between the 2 groups. Time on the waitlist was not significantly different between the GS and no GS groups (55 days vs 53 days; P = .4). There also was no between-group difference in the incidence of post-transplantation complications, including dialysis (8% vs 5%; P = .38), stroke (3% vs 4%; P = .34), primary graft dysfunction (2% vs 2%; P = .75), need for pacemaker (1% vs 1%; P = .84) and rejection (3.4% vs 3.4%; P = .96). Survival at 10 years post-HT was 75% for the no GS group and 72% for the GS group (P = .59). The survival curves also did not differ between patients with CM and those with CHD. ConclusionsChildren with certain GSs and end-stage heart failure can be expected to have similar post-transplantation outcomes to those without a GS. Although early and late post-transplantation care is individualized to each patient, the presence of a GS should not influence the decision to list for HT.

HV interval cutoff should be different in women and men with syncope and bundle branch block

Abstract Background Determining the optimal HV interval cutoff for predicting the need for pacemaker (PM) implantation has been a recent focus of research. Current ESC guidelines recommend HV &amp;gt; 70 msec based on initial studies; however, new data suggest that a cutoff of &amp;gt;60 msec could appropriately identify patients at high risk for requiring PM implantation. While previous studies have indicated that women with bundle branch block (BBB) have a lower risk of AV block (AVB), gender differences in the optimal cutoff for considering a positive EPS have not been thoroughly investigated. Methods This cohort study included consecutive patients with unexplained syncope and BBB, enrolled from January 2010 to October 2021, with a median follow-up time of 3 years. Patients underwent a stepwise workup protocol involving an electrophysiological study (EPS) and long-term follow-up with an implantable cardiac monitor (ICM). Results Of the 503 patients in the study, 185 (38%) were women. The median age was 78 years (IQR 71-83), the median LVEF was 58% (IQR 50-62), and 110 (22%) had ischemic heart disease. The ECG showed LBBB in 194 (39%) patients and RBBB in 287 (57%). Among these, 177 (35%) also had left anterior hemiblock. The median HV interval was 60 msec (IQR 52-73), and EPS was diagnostic in 252 (50%) patients, with the majority (221, 44%) for AVB. In 91 patients with initially negative EPS, a diagnosis was made during follow-up with an ICM, and in 35, AVB was documented. In patients with negative EPS, an HV interval &amp;gt;60 msec was associated with an increased risk of AVB during follow-up (HR 2.5, 95% CI 1.6-4). However, significant gender differences were found. The risk of AVB was 2.5 times higher in men (95% CI 1-6) (Figure 1). Furthermore, sensitivity, specificity, PPV, and NPV for the cutoff of 60 msec were 47%/84%/51%/82% in men and 21%/78%/21%/78% in women. The AUC to predict AVB was 0.72 (95% CI 0.6-0.8) in men and 0.51 (95% CI 0.4-0.6) in women (Figure 2). Conclusions In patients with initially negative EPS, an HV interval &amp;gt;60 msec was associated with a higher risk of AVB during follow-up; however, significant gender differences were observed in diagnostic accuracy. In women, a cutoff of HV interval &amp;gt;60 msec presented poor diagnostic accuracy compared to men. Moreover, the HV interval did not adequately predict the development of AVB in women with a basal HV interval &amp;lt;70 msec, suggesting it may not be suitable for considering PM implantation in female patients.FIGURE 1FIGURE 2

Long-term results of cardioneuroablation evaluated by implantable loop recorder

Abstract Background Cardioneuroablation (CNA) is a catheter ablation technique based on radiofrequency application in the atrial endocardium to decrease vagal response. Since the first series publication, its use has greatly increased, with CNA being now used in vasovagal syncope (VVS), functional atrioventricular block (AVB), symptomatic sinus bradycardia (SB) and Atrial Fibrillation (AFib). There is still limited data regarding long-term follow-up (FUP) of patients who have undergone this procedure. Purpose The aim of this study was to evaluate long-term results of CNA in a single center with the use of an implantable loop recorder (ILR). Methods We performed a prospective single-center cohort study. Patients with significant documented functional bradyarrhythmias between September 2019 and October 2023 were enrolled. All patients underwent ILR implantation before ablation. CNA was performed using catheter ablation aiming at right epicardial GPs with 3-dimensional electroanatomical mapping support. A 2 mg atropine test (bolus) was carried out before and after CNA and the subsequent heart rate (HR) increase registered. Successful CNA was defined as absence of HR increase with atropine after the ablation. HR pre and post ablation was compared. Immediate and late procedure complications were assessed. Recurrence of symptoms, the presence significant vagal-induced bradyarrhythmias on ILR and the need for pacemaker (PM) implantation were also assed. Results Fifteen patients (pts) were included, with a mean age of 64 (± 12 years) and a 53.3% male prevalence. None of the pts had structural heart disease. The main indication for CNA was AFib with brady-tachy syndrome (8 pts, 53.3%), followed by VVS (4 pts, 26.7%), SB (2 pts, 13.3%) and AVB (2:1 AVB; 1 pt). The most common symptom was syncope (46.7%), followed by pre-syncope (40%) and fatigue (20%). There was a significant improvement in HR after CNA (55 ± 13 vs. 67 ± 14 bpm pos-CNA, p=0.002). The achievement of success was verified in all patients (mean HR variation with atropine before CNA 35 ± 10% vs. 2 ± 2% after CNA; p=0.001). Procedure mean time was 28 ± 12 min. During a maximum FUP of 48 months (minimum 1 month, median 5), 1 patient had recurrence of VVS with a 10s pause documentation on ILR requiring PM implantation and 1 patient had a 4s pause without translation into symptoms and a duration decreasing tendency during FUP. Freedom from recurrence of symptoms was 93.3%, freedom from pacemaker implantation was 93.3% and freedom from significant bradyarrhythmias was 86.7% – Figure 1. No immediate or long-term complications were seen. Conclusions CNA aiming at the right GPs is a safe and quick procedure for patients with functional bradyarrhythmias. This ablation technique in most patients not only reduces symptoms, but also avoids early PM implantation, therefore improving quality of life. Further randomized clinical trials are needed to support these data and refine patient selection criteria.

Influence of age on the incidence of acute complete atrioventricular block in right coronary artery infarction

Abstract Funding Acknowledgements None. Introduction Bezold-Jarisch is a cardioinhibitory reflex originating in cardiac vagal receptors, more concentrated in the inferoposterior wall of left ventricle, whose stimulation produces bradycardia and hypotension. The limited evidence suggests that vagal tone would predominate in younger individuals, whereas sympathetic tone would predominate in the elderly, resulting in a more striking Bezold-Jarisch reflex response among younger patients. Its maximum expression would be the occurrence of acute complete atrioventricular block (cAVB). Methods Observational, retrospective, single-centre analysis of consecutive patients hospitalised in the CCCU for STEACS with RCA or ADA as culprit artery (CA) between July 2011 and September 2022. We analysed the influence of age on the incidence of acute cAVB. Linear trend analysis and multivariate analysis were performed. Results A total of 723 patients with RCA as CA were included, with the baseline characteristics listed in Table1. Patients were divided into 4 groups: under 60 years (n=316 43.7%), 60-69 (n=223 30.8%), 70-79 (n=122 16.9%) and 80 or older (n=62 8.6%). The incidence of acute cAVB was 10.4%, 14.3%, 16.4% and 25.8% respectively (Fig1). A Cochran-Armitage analysis was performed, showing a significant linear trend between age and the incidence of acute cAVB (p=0.001). A multivariate analysis was performed using stepwise regression including age, sex, diabetes, hypertension, obesity, peripheral arterial disease, systolic blood pressure (SBP) at admission, renal failure, COPD, Killip-Kimbal (KK) score at admission and treatment with ticagrelor (for its described adenosine-like effect). Age (p=0.011), KK score (p&amp;lt;0.001) and lower SBP (p&amp;lt;0.001) were associated with a higher incidence of acute cAVB. Regarding the need for transient pacemaker, 6.2% of patients under 60, 7.7% aged 60-69, 10.1% aged 70-79, and 22.0% aged 80 and over required its implantation. As with cAVB, there was a significant linear trend between age and device implantation (p&amp;lt;0.001). Permanent pacemaker was implanted in only 6 patients. In-hospital mortality was significantly higher in patients with acute cAVB than all other patients with RCA infarction (7.9% vs 2.1%; p=0.001). Finally, as controls, acute cAVB data were analysed in patients with STEACS with ADA as CA (N=837). 366 patients (43.7%) were under 60 years, 204 (24.4%) 60-69, 155 (18.5%) 70-79 and 112 (13.4%) 80 or older. Only 10 patients presented with cAVB (1.2%), with no differences between those younger and older than 75 years (1.0% vs 2.3% respectively; p=0.13). Given the low incidence of cAVB in this group no further analysis was performed. Conclusion In RCA STEACS patients, there is a significant trend towards a higher incidence of acute cAVB with increasing age. These data suggest that older patients do not have a mitigated response to Bezold-Jarisch reflex. The inverse relationship between SBP and occurrence of cAVB supports the reflex nature of the mechanism.Table 1.Baseline characteristics.Fig 1.cAVB incidence among age groups.

Comparison between beta-blockers and calcium channel blockers in patients with atrial fibrillation according to renal function.

Rate control is the most commonly employed first-line management strategy for atrial fibrillation (AF) in patients with chronic kidney disease (CKD). Principal agents used to control heart rate (HR) include beta-blockers (BB) and nondihydropyridine calcium channel blockers (ND-CCB). However, there is a paucity of published studies of the differences between those drugs in CKD patients. The present study aimed to investigate the differences, in terms of hospitalizations due to a poor HR control, in patients with AF under a rate-control strategy according to glomerular filtration rate (GFR). The study cohort included 2804 AF patients under rate-control regime (BB or ND-CCB) between January 2014 and April 2020. The end point, determined by competing risk regression, was hospitalizations for AF with rapid ventricular response (RVR), slow ventricular response (SVR), and need for pacemaker. On multivariate analysis, there were no statistical differences between ND-CCB and BB for subjects with GFR > 60 mL/min/1.73 m2 (subdistribution heart rate [sHR] 0.850, 95% confidence interval [CI]: 0.61-1.19; p = .442) and GFR 30-59 mL/min/1.73 m2 (sHR 1.242, 95% CI: 0.80-1.63; p = .333), while in patients with GFR < 30 mL/min/1.73 m2, ND-CCB therapy was associated with increased hospitalizations due to poor HR control (sHR 4.53, 95% CI: 1.19-17.18; p = .026). In patients with GFR ≥ 30 mL/min/1.73 m2, the choice of ND-CCB or BB had no impact on hospitalizations due to poor HR control, while in GFR < 30 mL/min/1.73 m2, a possible association was detected. The effects of these drugs on GFR < 30 mL/min/1.73 m2 would require further investigation.

Determinants of Surgical Outcomes in Tricuspid Valve Endocarditis

BackgroundCurrent treatment guidelines for infective endocarditis focus on left-sided infective endocarditis. Because right-sided infective endocarditis has different presentations and outcomes, it is crucial to further delineate surgical outcomes for isolated tricuspid valve endocarditis (TVE). MethodsThis retrospective study reviewed 374 surgically treated patients with isolated TVE from January 2012 through April 2022 who underwent isolated tricuspid valve surgical procedures. Primary outcomes were in-hospital mortality, permanent pacemaker need, and postsurgical inotropic support. ResultsThe in-hospital mortality was 4% (n = 15). Patients with liver disease had 3.81-times higher odds of death vs no liver disease (odds ratio [OR], 3.81; 95% CI, 1.22-12.17). A pacemaker was required in 17% of patients without a prior pacemaker, which was 4.07 times the odds with tricuspid valve replacement (OR, 4.07; 95% CI, 1.72-11.60) vs tricuspid valve repair. Each yearly increase in patient age demonstrated lower odds of permanent pacemaker requirement by 7% (OR, 0.93; 95% CI, 0.89-0.97). The odds for postoperative inotropic support increased 2.55-times higher in patients receiving preoperative inotropic agents (OR, 2.55; 95% CI, 1.29-5.05), 2.27-times higher with renal failure (OR, 2.27; 95% CI, 1.38-3.74), and 86% higher in patients administered preoperative heparin (OR, 1.86; 95% CI, 1.14-3.02). ConclusionsMortality of surgical treatment for TVE was 4%, with higher risks with liver disease. Tricuspid valve replacement was associated with higher odds for permanent pacemaker vs repair. Renal failure, preoperative inotropic support, and preoperative heparin were associated with higher odds for postoperative inotropic support. These findings further illustrate surgical outcomes with TVE.

Short- and Mid-Term Outcomes of Early Alcohol Septal Ablation Therapy for Patients with Mildly Symptomatic Hypertrophic Obstructive Cardiomyopathy: A Tertiary Center Experience.

Background: Left ventricular outflow tract obstruction (LVOTO) impairs survival and diminishes quality of life in patients with hypertrophic obstructive cardiomyopathy (HOCM). In this study, we aimed to investigate the safety and the efficacy of earlier alcohol septal ablation (ASA) in patients with HOCM. Methods: A total of 47 patients with mildly symptomatic HOCM (NYHA II) and having poor functional capacity despite maximal tolerated medical therapy were included. Results: The mean age of the patients was 55 ± 14, and 57% of the patients were male. All clinical endpoint targets including 30 d mortality (1% vs. 0% p < 0.01), 30 d adverse complications (10% vs. 0% p < 0.01), 30 d complete heart block resulting in need for permanent pacemaker (10% vs. 4.2% p < 0.01), more than moderate residual mitral regurgitation (5% vs. 2.1% p < 0.01), repeat procedure rate (10% vs. 4.2% p < 0.01), improvement of (NYHA) class (90% vs. 95.7% p < 0.01), rest and provoked (LVOT) gradient < 50 mmHg (90% vs. 97.8% p < 0.01) were significantly reached. Conclusions: In patients with mildly symptomatic HOCM (NYHA II), earlier ASA may be performed as an effective and safe procedure in experienced centers.

Our Experience in Transcatheter Aortic Valve Implantation (TAVI) from the Anesthesiologist's Perspective: A Single-Center Retrospective Study

Objectives This study is aimed to review the perioperative complications, morbidity, and mortality rates of patients undergoing TAVI at our tertiary care hospital. Material and Methods The data for this retrospective study including 34 patients was collected from medical records of the patients. Statistical analyses were performed using SPSS 26 programme. The results were considered statistically significant at p&lt;0.05. Results The study cohort, predominantly the elderly population (mean age 77.3 years), underwent TAVI under local anesthesia and sedation. Anesthetic induction involved fentanyl, ketamine and midazolam, with adjustments using propofol as needed. Hypotension emerged as the most common anesthesia-related complication. Importantly, the procedure was completed with conscious sedation in all cases that are not complicated by surgery, with no instances of respiratory complications. The most frequent procedure-related complication was atrioventricular bundle branch block. Postoperative outcomes demonstrated a significant reduction in aortic valve parameters, validating the efficacy of the procedure. Notably, the 30- and 90-day mortality rates were 0%, indicating favorable short-term survival. The study highlighted the importance of maintaining hemodynamic stability through vasopressors, with noradrenaline being the preferred choice. While the overall length of hospital stay averaged six days, the study emphasized the evolving landscape of TAVI, with shorter hospitalizations attributed to increasing procedural experience and refined anesthetic approaches. The need for permanent pacemaker was observed in 20% of cases. Conclusion This comprehensive analysis contributes valuable insights into the evolving field of TAVI, emphasizing the role of experienced anesthesiologists in optimizing patient outcomes. The study underscores the importance of refining anesthesia protocols, staying abreast of emerging guidelines and developing solution algorithms for emergency scenarios, ultimately enhancing the safety and efficacy of TAVI procedures in a rapidly expanding patient population.

Diferencias clínicas entre la amiloidosis cardiaca por transtirretina y la cardiopatía hipertensiva

IntroductionA significant percentage of patients eventually diagnosed with cardiac transthyretin amyloidosis (TTRA) was previously diagnosed with hypertensive heart disease (HHD), since both conditions usually present with heart failure (HF) with preserved ejection fraction (HFpEF) and ventricular hypertrophy. Our objectives were to evaluate the clinical, electrocardiographic and echocardiographic differences, and to analyse whether there exists a differential prognosis between these two nosological entities. Materials and methodsWe retrospectively included all patients with HHD for whom a cardiac scintigraphy with 99mTc-diphosphonate (GDPD) and a free light chains test in blood and urine were ordered for ATTR screening in our centre, in the period between 2016 and 2021. Those diagnosed with other types of amyloidosis were excluded from the analysis. ResultsA total of 72 patients were analyzed: 33 were finally diagnosed with TTRA and 39 with CHTA. Patients with TTRA had higher levels of ultrasensitive troponin I (TnI-US) and N-terminal brain natriuretic propeptide (NT-ProBNP); in electrocardiography (ECG) they presented a pseudo-infarction pattern more frequently as well as conduction disturbances; in echocardiography (TTE) they presented a higher degree of ventricular hypertrophy, left ventricular dysfunction and worse diastolic function parameters, with elevated filling pressures. In the 4-year follow-up, the ATTR group showed greater need for pacemaker (PCM), with no evidence regarding mortality, development of atrial fibrillation (AF), or more admissions for heart failure (HF). ConclusionsIn our series, patients with TTRA showed clinical, electrocardiographic and echocardiographic differences compared to patients with HHD, with increased risk of need for PCM.

Cusp overlap method for self-expanding transcatheter aortic valve replacement.

Conduction disturbances and the need for permanent pacemaker (PPM) implantation remains a common complication for transcatheter aortic valve replacement (TAVR), particularly when self-expanding (SE) valves are used. We compared in-hospital and 30-day rates of new PPM implantation between patients undergoing TAVR with SE valves using the conventional three-cusp coplanar implantation technique and the cusp-overlap technique. We retrospectively compared patients without a pre-existing PPM who underwent a TAVR procedure with SE Evolut R or PRO valves using the cusp-overlap technique from July 2018 to September 2020 (n = 519) to patients who underwent TAVR using standard three-cusp technique from April 2016 to March 2017 (n = 128) in two high volume Canadian centers. There was no significant difference in baseline RBBB between the groups (10.4% vs. 13.2; p = 0.35). The rate of in-hospital new complete heart block (9.4% vs. 23.4%; p ≤ 0.001) and PPM implantation (8% vs. 21%; p ≤ 0.001) were significantly reduced when using the cusp-overlap technique. The incidence of new LBBB (30.4% vs. 29%; p = 0.73) was similar. At 30 days, the rates of new complete heart block (11% vs. 23%; p ≤ 0.001) and PPM implantation (10% vs. 21%, p ≤ 0.001) remained significantly lower in the cusp-overlap group, while the rate of new LBBB (35% vs. 30%; p = 0.73) was similar. Cusp-overlap approach offers several potential technical advantages compared to standard three-cusp view, and may result in lower PPM rates in TAVR with SE Evolut valve.

Temporal trends, patient characteristics and hospital volume outcomes after alcohol septal ablation and septal myectomy for treatment of obstructive hypertrophic cardiomyopathy

Abstract Background Hypertrophic obstructive cardiomyopathy (HOCM) represents a clinically and morphologically diverse hereditary cardiac disease that is frequently associated with poor prognosis. Nationwide data on septal reduction therapy (SRT), alcohol septal ablation (ASA) and septal myectomy (SM), remains scarce. The aim of this study was to investigate (i) temporal trends, (ii) patient characteristics, (iii) in-hospital outcomes, and associations between institutional procedural volumes and outcomes after ASA and SM in a large-scale nationwide cohort. Methods Using data from the German Federal Bureau of Statistics, this study analyzed all patients with HOCM who were hospitalized for ASA or SM in a nationwide inpatient database in Germany between January 1, 2006, through December 31, 2019. Rates of adverse in-hospital events (in-hospital mortality, need for permanent pacemaker) were examined. Multivariate logistic regression analysis was performed to compare overall outcomes after each procedure based on tertiles of hospital volumes of ASA and SM. Results A total of 8,514 patients underwent SRT, of whom 5,293 (62.2%) underwent ASA and 3,221 (37.8%) SM. Annual numbers for SM and ASA steadily increased over time: ASA procedures increased from 329 in 2006 to 451 in 2019 and SM procedures increased from 191 in 2006 to 222 in 2019, respectively. Patients with SM were older (mean 67.4 vs. 60.2 years), less likely female (56.4% vs. 49.9%), and had a higher burden of comorbidities (e.g., diabetes, atrial fibrillation, heart failure, chronic kidney disease) compared to patients with ASA. Over an observational period of 14 years, the majority of both ASA and SM procedures were performed at hospitals in the lowest volume category (≤20 procedures). The overall in-hospital mortality was higher in patients with SM (6.8%) compared to patients with ASA (0.8%), whereas the need for pacemaker implantation was more often observed in patients with ASA (19.3% vs. 13.1%; p&amp;lt;0.001). The lowest tertile of SM volume among hospitals was independently associated with an increased risk of in-hospital mortality (adjusted odds ratio (lowest vs. highest tertile), 2.64; 95% confidence interval, 1.49-4.66), whereas being in the lowest vs. the highest tertile of ASA by volume was not independently associated with risk of in-hospital mortality and adverse events. Conclusion In this contemporary cohort with more than 8,500 cases of SRT between 2006 and 2019, the majority of SRT was performed at centers with a low volume of SM and ASA procedures. Low SM volume was independently associated with increased in-hospital mortality, whereas low ASA volume was not associated with adverse outcomes. Our findings may help to further understand how institutional SRT procedural volumes affects outcomes and might encourage referral of patients with HOCM to centers of excellence for SRT.

Calcification of aortic valve cusps as independent predictor for permanent pacemaker requirement after transcatheter aortic valve implantation

Abstract Background High-degree atrioventricular (AV) block represents a frequent complication after transcatheter aortic valve implantation (TAVI). Extension of indication for TAVI towards subjects with lower surgical risk requires to reduce the likelihood for the need of permanent pacemaker (PPM) implantation. Purpose We examined the role of calcification of the aortic valve cusps and left ventricular outflow tract (LVOT) as potential predictors for PPM implantation after TAVI. Methods In a cohort of 1200 consecutive patients without PPM who underwent transfemoral TAVI, clinical and procedural characteristics as well as requirement for PPM implantation after TAVI were assessed systematically. In all patients, cardiac computed tomography (CT) was performed before TAVI including quantitative assessment of calcium volume of the aortic valve cusps and the LVOT in mm3 (see figure). Results Median patient age was 81 (IQR 7) years, 50% were male. 9.8% of patients had a pre-existing complete right bundle branch block (RBBB) in ECG. 68% of subjects received a balloon-expandable valve, 32% a self-expandable valve. Postinterventional PPM implantation was necessary in n=155 subjects (13%) due to high-degree AV block. In this group of subjects, calcification of the aortic valve cusps was more pronounced than in the group of subjects without high-degree AV block (see table). Univariate regression analysis revealed pre-existing complete RBBB (p&amp;lt;0.001, OR 8.564), implantation of a self-expandable prosthesis (p=0.013, OR 1.549) as well as calcification of the non-coronary (p=0.016, OR 1.001) and left-coronary cusp (p=0.025, OR 1.001) as significant predictors for PPM implantation. In multivariate regression analysis, these predictors – including calcification of the non-coronary cusp (p=0.037, OR 1.001) remained significant. With every mm3 of calcification, risk for high-degree AV block and PPM implantation increases by 0.1%. With a median calcification of 225 mm3 of the non-coronary cusp, this would make a 22.5% relative risk increase. Conclusion In a large cohort of 1200 patients, the volume of aortic cusp calcification, in particular calcification of the non-coronary cusp, was identified as independent predictor for PPM implantation following transcatheter aortic valve implantation. This might be explained by the anatomical proximity of both the AV node and left Tawara branch to the non-coronary cusp, resulting in a higher risk of compression during valve implantation. Our results may contribute to improved risk stratification regarding the need for PPM implantation after TAVI.Assessment of calcium volumeComparison of calcification

Conduction disorders after transcatheter aortic valve implantation: association with long-term outcome

Abstract Background As the indications for Transcatheter Aortic Valve Implantation (TAVI) are expanding, the long term consequences of its potential complications, such as the development of new left bundle branch block (LBBB) or the need for permanent pacemaker (PPM) implantation, are of increasing clinical importance. Studies on the prognostic impact of conduction disorders after TAVI showed conflicting results, and data after the first year are limited. Purpose To examine the progression of significant conduction abnormalities (CA) within the first year after TAVI, and investigate the long-term outcome of PPM implantation and permanent LBBB beyond the first year. Methods Patients who underwent TAVI between 2007-2019 and who had at least 1 year follow-up were included, and divided into 3 groups: 1)PPM implantation within the first year, 2)development of LBBB persisting until 1 year (permanent LBBB), and 3)no CA. Twelve-lead electrocardiograms (ECG) were collected at baseline, post-TAVI, and at 1 year. The primary end-point was all-cause mortality. Results Among 794 patients, 502 who underwent TAVI without baseline CA were divided into those with PPM(n=89), permanent LBBB(n=56), and no CA(n=357). Baseline clinical characteristics did not significantly differ, except for the self-expanding valve, which was more common among the PPM group (40% vs 25% in LBBB and 15% in no CA, p&amp;lt;0.001). Baseline echocardiographic parameters were also comparable. The PPM group showed more frequent first degree AV block and right bundle branch block, as well as longer PR and QRS intervals, on pre-TAVI ECG. Immediately post TAVI, 32% of patients developed new LBBB, but only 19% persisted until discharge, and 11% at 1 year (Figure 1). Meanwhile, 18% needed a PPM within the first year, with a median time of 4 days. At 1-year follow up, overall improvement in NYHA class was observed but significantly more patients remained in NYHA class III-IV among the LBBB group (11% vs 6% in PPM and 3% in no CA, p=0.039). At 1 year, echocardiographic parameters showed significant differences, with lower left ventricular ejection fraction and global longitudinal strain (GLS) in the PPM and LBBB group compared to the no CA group (55±9% and 15±4% vs. 54±11% and 15±4% vs. 58±9% and 17±4% respectively, p&amp;lt;0.001). Beyond 1 year, survival analysis showed a significant difference in all-cause mortality (2= 10.168, p=0.006) between PPM and no CA group (p=0.001, Figure 2) during a median follow-up of 49 months [IQR 34-74 months]. Multivariable Cox regression showed that PPM implantation (HR 1.654, p=0.011), baseline EuroSCORE II (HR 1.072, p=0.002), NYHA III-IV at 1 year (HR 4.432, p=&amp;lt;0.001) and GLS at 1 year (HR 0.950, p=0.027) were independently associated with outcomes. Conclusion Post-TAVI conduction disorders are dynamic until 1 year follow-up and patients who needed a PPM implantation showed worse long term outcomes. Therefore, adequate follow-up after TAVI is of paramount importance.Progression of LBBB and PPM after TAVRKaplan Meier Survival Analysis

The importance of GRACE risk score in the development of high-grade atrioventricular conduction blocks after non-st-segment elevation myocardial infarction.

The development of high-grade atrioventricular block (HG-AVB) after acute coronary syndrome (ACS) increases morbidity and mortality rates. A significant portion of HG-AVBs resolve spontaneously after revascularization. We aimed to evaluate the power of the GRACE scoring system in predicting the development of HG-AVB and its importance in determining the need for cardiac pacemakers. Patients who applied to our center between July 2020 and February 2023 were included in the study. 600 patients [340 (56.6%) male, mean age 65.4±13.6] without ST-segment elevation (NSTEMI) and who underwent revascularization were evaluated within the scope of the study. The heart rhythms of the patients were evaluated from the electrocardiograms (ECG) at admission. Patients with HG-AVB and other patients were divided into two groups. The heart rhythms of these patients were evaluated during their hospitalization. Then, HG-AVB patients were also divided into two groups (with and without PPM need). Demographic, laboratory, angiographic, and echocardiographic characteristics of these patients were evaluated. Morbidity and mortality were higher in the HG-AVB group. These patients had longer intensive care and hospital stays. The mean age, creatinine value, GRACE score (GS), total cholesterol (TC), and RCA lesion rates were higher in the HG-AVB group; hemoglobin level was found to be lower. As a result of regression analysis, RCA lesion, hemoglobin value, GRACE score, creatinine, and TC levels were predictors of HG-AVB development. In determining the need for PPM, these variables were found to be effective. ROC analysis was performed for GS, which predicted the development of HG-AVB, and the cut-off value was found to be 185.5. The development of HG-AVB after NSTEMI is an important health problem. By detecting these patients and those who may need PPM beforehand, various complications can be prevented, and the length of stay in the hospital can be shortened. Calculation of GS is an important parameter that can be used to predict the development and course of HG-AVB.

Native aortic valve regurgitation: TAVR's place in the PANTHEON.

The PANTHEON (Performance of Currently Available traNscaTHEter Aortic Valve Platforms in Inoperable Patients With Pure Aortic regurgitatiON of a native valve) study examined transcatheter aortic valve replacement in patients with severe pure native aortic valve regurgitation. With a real-world dataset from 16 centres in Europe and the USA, the study encompassed 201 patients. The major complications included valve embolization or migration in 12.4%, moderate to severe aortic regurgitation in 9.5% cases and need for permanent pacemaker in 22.3% cases. Self-expanding and balloon-expandable devices demonstrated similar outcomes. Those experiencing valve embolization or migration had higher 1-year adverse event rates.