Retrospective Analysis Research Articles

Changing patterns in clinical, echocardiographic and haemodynamic characteristics, and management strategies that may be translated to improved survival in pulmonary hypertension

Abstract Background and aims In this retrospective analysis of a single-center series on pulmonary hypertension (PH), we aimed to evaluate clinical, echocardiographic, and hemodynamic characteristics, management strategies, morbidity, and mortality in PH subgroups across three consecutive periods. Methods The study included 1071 patients enrolled in the Evaluation of Pulmonary Hypertension Risk factors Associated with Survival study (EUPHRATES). In reference to enrollment time, patients were assessed in three periods ; before 2016, the era of primarily monotherapy or sequential combinations; between 2016 and 2019, post-approval and reimbursement of macitentan in our country, marking a shift towards more proactive sequential combinations; and after 2019, signifying the initiation of earlier sequential combinations with selexipag in pulmonary arterial hypertension (PAH). The ESC/ERS 2022 risk scoring, COMPERA 2.0 and REVEAL lite 2 models were used for risk predictions. Composite endpoint (CEP) definitions were adopted from the SERAPHIN and GRIPHON trials. Annual incidence curves for mortality and CEP were evaluated, but 2020 analysis was adjusted to account for the possible adverse effects of the COVID-19. Results During the 1st, 2nd and 3rd periods, 481, 352, and 238 patients with PH were diagnosed, respectively. Incident cases comprised 91% of them. Idiopathic PAH (IPAH), PAH-associated with congenital heart diseases (CHD-PAH), PAH-associated with connective tissue diseases (CTD-PAH), group II, III, IV and V PH were documented in 24 %, 28 %, 4.6 %, 4.3 %, 11%, 27 % and 0.7 % of patients, respectively. Age and female dominance remained unchanged. Incidences of Group 1 PH and CHD-PAH decreased while IPAH, drug-associated PAH, and Group II and IV PH increased across three periods (p-values varying from <0.001 to 0.03). Although baseline functional class became worse (p=0.013), six-minute walk distance, N-terminal pro brain natriuretic peptide and risk scores showed no change (p=NS). Baseline echo and hemodynamic measures became better, and triple combinations increased after 2019 (p<0.001 for all). For overall PH, rates of all-cause mortality and CEPs at 1st, 2nd and 3rd periods were 52 % and 59 %, 30 % and 35 %, and 11 % and 13 %, respectively (p< 0.001, for all). Mortality rates for 1st, 2nd and 3rd periods were 36 %, 38 % and 26 % in IPAH, 60 %, 28 % and 13 % in CHD-PAH, 55 %, 22% and 22% in CTD-PAH, 38 %, 38% and 24 % in group IV PH, respectively (p< 0.001, for all). Mortality curves showed sudden increases in 2020, but excluding 2020, a steady improvement in the annual mortality was evident. Conclusions Our findings suggest a trend towards better clinical, echocardiographic, and hemodynamic presentations and improved survival in the PAH subgroups, and Group IV PH across the three periods that might be attributed to more proactive management strategies favouring earlier initiation of combinations.

Prevalence and incidence of chronic wounds in Austria - a population-based real-world data analysis

Abstract Background Chronic wounds are associated with pain, odor, loss of mobility, an increased risk for infection and sepsis and a reduced quality of life. Treatment costs are rising due to the longevity of the population and increasing number of diabetes cases. For service planning in healthcare, it is thus necessary to describe patient characteristics and estimate the prevalence and incidence of chronic wounds. Currently, no data exists on this subject broken down by age group, gender, and province in Austria. Methods A retrospective analysis of real-world data was conducted using two merged datasets from an outpatient wound centre and the Austrian Health Insurance Fund. The study population consisted of people who resided in Austria and were covered by statutory health insurance from 2018 to 2022. We performed a descriptive, socio-demographic analysis of the data of patients, followed by a set of cluster analyses using the unsupervised K-means algorithm. From these clusters, we derived subgroup characteristics and patient trajectories and calculated prevalence and incidence rates for chronic wounds according to diagnoses, different age groups, gender, and different regions. Results Gender was almost evenly distributed in the wound centre’s data set (n = 4963; 49.6% female). The age distribution revealed the age group from 71-80 years being the largest group. In general, more women than men are affected by chronic wounds from the age of 81 onwards. 31% of chronic wound patients had diabetes as an underlying condition. More men were affected by peripheral arterial occlusive disease and diabetic foot syndrome and, conversely, more women by chronic venous insufficiency. These are preliminary results of the analyses. Conclusions Chronic wound patients were characterised by older age and multi-morbidity. Interestingly, gender differences appeared in the occurrence of comorbidities. Key messages • This study makes a crucial contribution in making routine data usable for the epidemiological study of chronic wounds, a cluster of diseases of complex aetiology. • It thus contributes to filling a knowledge gap. The prevalence estimate serves as a basis of knowledge for health care planning and a basis for the health economic assessment of the problem.

The impact of tricuspid regurgitation on the timing of pulmonary valve replacement in adult patients after Tetralogy of Fallot repair

Abstract Background Tricuspid regurgitation (TR) in patients with repaired tetralogy of Fallot (rTOF) is an important finding with a wide spectrum of etiologies. TR represents an important risk factor in adult patients with rTOF, influencing clinical outcomes and the requirement for additional surgical interventions. In this study, we reviewed the long-term outcomes of TR in ACHD patients with rTOF as well as its impact on the timing of surgical pulmonary valve replacement (PVR). Methods This was a retrospective analysis of a single institutional cohort which included 149 ACHD patients with a history of rTOF (transannular patch only) with CMR data, complete follow-up, and a recent (< 1 year) outpatient clinic visit. Results Overall follow-up time was 25.5 years (95% CI 24.5,26.4). Between 2002 and 2021, 93 patients required isolated PVR at a mean time from TOF repair of 16.6 years (95% CI 15.5,17.7) and at a mean age of 17.9 years (95% CI 16.8,19.0). In the whole cohort, significant TR was associated with a two-fold increase in the likelihood of requiring PVR (log-rank p = 0-.0023, HR 2.02; 1.09-4-47). Moderate to severe TR was more frequent in those who underwent VSD closure through a right atriotomy (17 versus 0, p = .0002) and affected time to PVR (13.9 versus 16.3 years, p = .0071), with equal preoperative RVEDVi at CMR. After PVR, RVEDVi normalized in all patients, regardless of the preoperative amount of TR (median 115.3 ml/m2 versus 112.3 ml/m2, p = .7). At a median time of 6.5 years from PVR, 13 patients (13/93, 14%) underwent redo PVR. Conclusions The preoperative severity of tricuspid regurgitation (TR) may have a substantial role on the likelihood of patients needing PVR at a younger age. This, in turn, could result in a reduced duration of freedom from valve failure. Replacing the pulmonary valve too early can effectively increase the lifetime number of procedures, preserving the function of the tricuspid valve at the time of TOF repair is of paramount importance.

Impact of mitral transcatheter edge-to-edge repair in patients with advanced heart failure evaluated for heart transplantation

Abstract Background Heart transplantation is sometimes the only therapeutic option in patients with advanced heart failure (HF), impaired ventricular function and significant functional or secondary mitral regurgitation (MR). The shortage of organs and the limitations of the recipient make it necessary to consider other therapeutic alternatives in these patients, such as mitral transcatheter edge-to-edge repair (M-TEER). The MitraBridge registry has recently been published in which they analyze the potential effect of M-TEER in patients with advanced HF and moderate-severe MI who are candidates for heart transplantation (mean age 59 years, left ventricular ejection fraction (LVEF) 27%); after a mean follow-up of 24 months, complete in 82.4%, they report an overall survival of 78.5%, a combined event-free survival of 47%, with a 6.5 % need for urgent transplantation and an HF hospitalization rate after M-TEER of 44/100 patient-years. The aim of our study is to assess the impact of M-TEER on mortality and the combined events of death, HF rehospitalization and the need for urgent transplantation or a ventricular assistance device in patients with moderate-severe functional MI and advanced HF who have also been evaluated for cardiac transplantation in our hospital. Methods This is a retrospective analysis of a prospective registry. Of the patients treated by M-TEER for severe MI, we selected those with advanced HF (defined as LVEF≤35%, and/or advanced functional class (NYHA III-IV)) who had also been evaluated as possible candidates for inclusion in the heart transplant list. Results From November 2011 to December 2023, 191 patients were treated by M-TEER, of whom 38 patients met the established criteria (median age 59 years [48-65], 31 (81%) males, mean LVEF was 26 ± 6%). All patients had at least one previous hospitalization for HF and optimal medical treatment according to guidelines; the rest of the baseline clinical characteristics are listed in Table 1. During the follow-up after M-TEER, with a median of 34 months [7-70], the probability of overall survival at 2 years was 75.6%. The combined endpoint of death, need for urgent transplantation or a ventricular assist device, and rehospitalization for heart failure occurred in 26 patients with a 2-year event-free survival probability of 48% (Figure 1). Five patients (13%) were transplanted, one (2.6%) urgently. Prior to M-TEER therapy, the rate of HF hospitalization was 108 hospitalizations/100 patient-years, which was significantly reduced after the procedure to 33 hospitalizations/100 patient-years (rate ratio 0.31 [95% CI 0.21-0.45, p<0.0005]). Conclusions In patients with advanced HF and severe functional MR who are candidates for cardiac transplantation, M-TEER is an effective therapeutic alternative, achieving a survival rate of more than three-quarters of the patients at 2 years of follow-up, a significant reduction in HF hospitalizations, and a low rate of need for cardiac transplantation.

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.

A higher adherence to perindopril-based anti-hypertensive therapy is associated with a reduced risk of cardiovascular outcomes and all-cause mortality in real clinical practice in Italy

Abstract Background Therapeutic management of hypertension is a landmark of cardiovascular (CV) risk prevention. Combined therapies with at least 2 anti-hypertensive agents are required in many patients in whom monotherapy and lifestyle interventions failed in blood pressure control. It is well-known that poor medication adherence remains a major barrier to achieving the therapeutic targets for all CV drugs, including anti-hypertensives. Purpose We evaluated the relationship between adherence to perindopril (PER)-based therapeutic regimen prescribed as single-pill combination (SPC) or free-pill and CV outcomes and all-cause mortality in a large Italian population. Methods A retrospective analysis was performed using administrative databases corresponding to around 6.7 million health-assisted residents. Hypertensive adults were first identified through hospitalization discharge diagnosis or exemption codes for hypertension between 2010 and 2021. Patients prescribed PER-based therapies were screened for all combinations of PER with amlodipine (AML) and/or indapamide (IND) (all formulations, single-pill or free-pill). Time of the first prescription of a PER-based regimen during the inclusion period was considered the index-date. The analysis included all hypertensive subjects prescribed a PER-based therapy, having available data at least 12 months before and 24 months after the index-date, respectively. Since the analysis was focused on the possible associations between adherence level and CV outcomes and all-cause mortality, adherence was assessed during the first year of follow-up on alive patients and outcomes were assessed during the second year. Adherence was assessed using the proportion of days covered (PDC) approach on 1-year follow-up, and considering a PDC<80% as poor-to-moderate adherence, and PDC ≥80% as good adherence. The Cox’s proportional hazard model was applied to estimate Hazard Ratio (HR) adjusting for baseline covariates, including comorbidity profile and pill burden. Results The included cohort (N=24,476) was divided into sub-groups according to adherence in poor-to-moderate (N=6,781) and good adherent patients (N=17,695) with a mean age of 64.8±13.3 and 64.6±11.9 years old, respectively. The Cox’s proportional hazard model showed that good adherence was associated with a relative risk reduction of 23% in all-cause mortality (Table 1A), 21% in all CV events (Table 1B), 17% in ischemic heart disease (Table 1C), 33% in cerebrovascular events (Table 1E), and 22% in the composite outcome of CV events/all-cause mortality (Table 1G). Conclusions The present analysis provided evidence from the Italian real clinical practice that good adherence to PER-based anti-hypertensive therapy results in significantly lower cardiovascular risk and all-cause mortality. These data further emphasize the importance of promoting cost-effective measures to increase medication adherence in patients on anti-hypertensive treatment.

Prognostic influence of the neurological complications in patients supported with venoarterial extracorporeal membrane oxygenation

Abstract Background Neurologic injuries including ischemic or hemorrhagic stroke and hypoxic-ischemic encephalopathy are common in patients supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO). Purpose Our objective was to analyze the prognostic influence of neurological injuries on in-hospital survival. Methods Retrospective analysis of consecutive VA-ECMO cases in a referal center. We studied the neurological diagnoses and the results of complementary tests (brain computed tomography –CT- and electroencephalogram –EEG-) and their influence on in-hospital evolution. Results 238 VA-ECMO were implanted between oct 2013-jan 2024. Baseline, admission and evolution characteristics are collected in the table. 58.4% of patients had suffered cardiac arrest (prior to VA-ECMO implantation, and extracorporeal cardiopulmonary resuscitation was performed in 28.6% of cases. 6 (2.5%) suffered intracranial hemorrhage, 13 (5.5%) ischemic stroke and 40 (16.8%) some degree of hypoxic-ischemic encephalopathy. In-hospital survival was 32.4% (n=77). In 17.2% of the cases neurological damage influenced death (adequacy of therapeutic effort or non-escalation of therapies) and in 14.7% of cases death was directly due to neurological cause (table). Survival was lower in patients with ischemic (stroke survival 23.1% vs no stroke 33.2%, p=0.555) or hemorrhagic stroke (16.7% vs 33%, p=0.667), although without statistically significant differences. The presence of hypoxic brain damage was related to lower hospital survival (survival in patients with encephalopathy 15% vs. without 36.8%, p=0.009). Best EEG pattern registered was related to survival: I survival 33.3% and II 12.5% (good prognosis), III 25% (uncertain prognosis), IV 16.7% and V 0% (poor prognosis), p=0.048. The presence of status epilepticus showed a non-statistically significant trend towards lower survival (survival status 0% vs no estatus 25%, p=0.082). VA-ECMO preimplantation cardiac arrest was associated with the occurrence of encephalopathy (encephalopathy 84% vs. not 40%, p=0.049). The duration of cardiac arrest and lactate before VA-ECMO implantation were significantly higher as the EEG pattern was worse (figure). Conclusions Neurological damage is relevant in patients under VA-ECMO support, being a determining factor in death in up to 17.2% of patients. Hypoxic-ischemic encephalopathy was associated with lower survival, with the EEG pattern associated with previous cardiac arrest, its duration and lactate.Table.Baseline, admission and follow-upFigure.Cardiac arrest, lactate and EEG

Prognostic significance of coronary flow velocity reserve in patients with peripheral arterial disease

Abstract Background Patients with lower extremity peripheral arterial disease (PAD) have a higher risk of cardiovascular events. Stress echocardiography (SE) based on regional wall motion abnormality (RWMA) is imperfect for risk stratification in PAD, but it can be complemented with an assessment of coronary flow velocity reserve (CFVR) in the mid-distal left anterior descending coronary artery. Purpose To assess the value of SE with RWMA and CFVR to predict survival in PAD. Methods In a retrospective analysis of prospectively acquired data in an observational, multicenter study, we recruited 359 patients (age 69±8 years, 240 [67%] males) with PAD referred for dipyridamole SE in 3 accredited laboratories. We assessed RWMA and CFVR (abnormal value <2.0). All patients were followed up for a median of 4.7 (interquartile range: 2.0 to 8.2 years). All-cause death was the outcome end-point. Results The positivity rate was 37/359 (10%) for RWMA and 159/359 (44%) for CFVR. During follow-up, 97 (27%) deaths were registered. At multivariable analysis, inducible RWMA and/or CFVR <2.0 (HR 2.58, 95% CI 1.65-4.04; p<0.0001), age ≥70 years, diabetes, dialysis treatment, and ejection fraction ≤50% were associated with decreased survival. The annual mortality was 7.4% in patients with RWMA and/or CFVR <2.0 and 2.7% in those with no RWMA and CFVR >2.0 (Figure, p<0.0001). Conclusion In patients with PAD, SE shows more than 4-fold higher prevalence of abnormal CFVR compared to RWMA. The prognostic value of CFVR outperforms RWMA, showing the importance of coronary microvascular dysfunction and diffuse, subcritical coronary atherosclerosis in determining the outcome.

Impact of comorbid coronary artery disease on short and medium-term outcomes after carotid artery stenting

Abstract Background Current recommendations acknowledge carotid artery disease as a clinical criteria for very high cardiovascular risk and carotid artery stenting (CAS) as one of the main therapeutic options for carotid artery stenosis. Carotid artery disease is often present in patients with coronary artery disease (CAD), presumably enhancing the cardiovascular risk of these patients. In this study, we aimed to appraise the prevalence and prognostic effects of comorbid CAD diagnosis in patients with significant carotid artery disease undergoing CAS. Methods We conducted a single-center retrospective analysis including consecutive patients that underwent CAS, between January 2007 and August 2023. Our main objective was to analyze the association of comorbid CAD in patients undergoing CAS, regarding 30-day major adverse cardiovascular events (MACE), 30-day global mortality, 1-year global mortality and major periprocedural complications. On a second perspective, we strived to identify if there was any modifiable factor that influenced worse outcomes in these populations, addressed by a Chi-Square Test. Data was collected by the medical team in our Centre, over the years of follow-up. Results A total of 380 patients were enrolled in this study, with a mean age of 72.1±8.3 years and no major differences concerning demographic characteristics. Based on the presence of previous CAD diagnosis, there was no statistical significance in 30-days MACE (p=0.442), 30-days global mortality (p=0.161), 1-year mortality (p=0.658) or periprocedural complications (p=0.062). Despite these results, there was a statistically significant difference in individuals with CAD and comorbid hypertension in 30-days CV death (p=0.002), 30-days global mortality (p=0.007) and 1-year global mortality (p=0.036). Conclusions Comorbid CAD in patients undergoing CAS due to carotid stenosis does not seem to be significantly associated with medium-term adverse events. Nevertheless, the results of this casuistry support the importance of rigorous blood pressure control in patients with significant carotid artery disease.Baseline CharacteristicsStudy outcomes

Cusp-overlap technique to reduce permanent pacemaker implantation rate after transcatheter aortic valve implantation

Abstract Background Persistent conduction disturbances requiring permanent pacemaker (PPM) implantation are one of the most common complications after Transcatheter Aortic Valve Implantation (TAVI). Cusp-Overlap Technique (COT) is a novel approach for self-expandable valve implantation to minimize the rate of procedural complications, mainly PPM implantation. Purpose To determine if the COT during TAVI with self-expandable valves leads to a reduction of PPM implantation rate in the real-world setting. Methods A retrospective analysis of consecutive patients undergoing TAVI between January 2020 and November 2023 in one high-volume tertiary care center in Portugal was conducted. Two groups were defined, the COT group and the control group based on the fluoroscopic approach. A baseline comparison between the 2 groups was made using independent-samples t-test and chi-square analysis to determine if there was a difference between the prevalence of known risk factors for PPM implantation after TAVI. Afterwards, chi-square analysis was used to determine if COT led to a reduction in the PPM implantation rate. Results Of the 539 completed procedures in this timeframe, 289 were excluded due to previous pacemaker implantation, use of a valve not amenable to COT or valve-in-valve implantation. COT was used in 57.6% of eligible cases. Baseline comparison did not show a significant difference in the prevalence of several known risk factors for PPM implantation, including complete right bundle branch block, atrio-ventricular block, calcium score, aortic ring dimensions and pre/post-dilation. PPM implantation after TAVI was required in 31.6% of cases. In the COT group the PPM implantation rate was 22.9% and in the control group 43.4%. Chi-square analysis showed a very statistically significant difference between the 2 analyzed groups (p-value = 0.001). Conclusion PPM implantation remains a frequent complication of TAVI. However, this study showed that the utilization of COT leads to a reduction of the PPM implantation rate.

Impact of changes in left heart geometry on predicting new-onset atrial fibrillation in patients with hypertension

Abstract Background Hypertension-induced left ventricular hypertrophy (LVH) increases end-diastolic LV pressure and contributes to left atrial enlargement (LAE), which are associated with development of atrial fibrillation (AF). However, the impact of LVH and LAE and their regression following antihypertensive therapy on AF incidence remains unclear. Purpose This study aimed to investigate the impact of changes in the LVH and LAE status on the occurrence of new-onset AF (NOAF). Methods This retrospective analysis included patients with sinus rhythm who underwent echocardiography at hypertension diagnosis and after 6–18 months. LVH was defined as LV mass index >115 g/m2 (men) and >95 g/m2 (women), and LAE was defined as LA volume index >42 ml/m2. LVH and LAE regression was defined as the absence of LVH and LAE on follow-up echocardiography, respectively. The occurrence of NOAF was assessed in relation to changes in LVH and LAE status. Results Among the 1,464 patients included in the study, 163 (11.1%) patients developed NOAF during a median follow-up of 63.8 months (interquartile range, 35.9–128.5 months). On average, 12 electrocardiograms per patient were reviewed for AF detection. New-onset LVH (adjusted HR 1.88, 95% CI 1.20–2.94, P=0.006) and LAE (adjusted HR 1.89, 95% CI 1.05–3.40, P=0.034) were significant predictors of NOAF. Conversely, regression of LVH (adjusted HR 0.51, 95% CI 0.280.91, P=0.022) or LAE (adjusted HR: 0.30, 95% CI 0.15–0.63, P=0.001) after antihypertensive therapy was associated with a reduced risk of NOAF. The risk of NOAF was higher in patients with LVH and LAE together (adjusted HR 4.30, 95% CI 2.81–6.56, P<0.001) than in those with either LVH or LAE, or those with neither, as determined by follow-up echocardiography. Conclusion In patients with hypertension and sinus rhythm, regression of LVH and LAE following antihypertensive therapy is associated with a decreased incidence of NOAF, whereas newly developed LVH or LAE is associated with a higher risk of NOAF. The changes in left heart geometry can serve as a predictive marker for NOAF in patients with hypertension.

Increased frailty is associated with risk of hospital-acquired infections and death during heart failure hospital admissions

Abstract Background Frailty is common in patients admitted with acute decompensation of heart failure (ADHF) and it is unclear how the frailty syndrome affects heart failure (HF) patients during their acute hospital admission. Understanding the interplay between frailty, impaired renal function, hospital-acquired infections (HAI), and death may be useful in optimising patient care and prognosis. Purpose The aim of this analysis was to explore the relationship between admission frailty levels and the incidence of HAI, acute kidney injury (AKI), and mortality in acute HF hospital admissions. Methods This is a retrospective analysis of data submitted from a single centre to the National HF audit between January and June 2023. Additional frailty and baseline renal function data was retrospectively collected from electronic patient health records. Patients were categorised into three groups according to their Rockwood Clinical Frailty Scale (CSF) (1): no/mild frailty (CFS 1-3), moderate frailty (CFS 4-6) and severe frailty (CFS 7-9). AKI was defined based on baseline and admission creatinine, as per KDIGO guidelines (2). Chi-squared and t-tests were used to compare baseline characteristics between frailty groups. Chi-squared tests were used to compare frailty groups in terms of: HAI, AKI, mortality. Results Between 1st January and 22nd June 2023, there were 344 acute HF hospital admissions in our centre. Most patients had moderate frailty on admission (n=256, 74.4%). Frail patients were significantly older, had a lower admission mean haemoglobin and more were female, compared to non-frail patients (Figure 1A). Patients who were more frail were more likely to experience HAI during their admission; p=0.035 (figure 1B). Furthermore, patients with HAI had a greater risk of mortality, at a median follow-up of 171 (IQR 100.25) days after admission, compared to those without HAI (p>0.001). 41.9% of acute HF admissions were associated with an AKI, and although numerically more frail patients had an AKI, this did not achieve statistical significance (p=0.084). Patients who were more frail were more likely to die, both during hospital admission and at 3 months following discharge; p<0.001 (Figure 1B). Furthermore, this trend persisted after follow-up; p<0.001 (Figure 2). Conclusions Patients with moderate or severe frailty are at greater risk of adverse events (HAI, death) during an acute HF hospital admission, than patients with no or mild frailty. It is imperative to consider the frailty status of all patients with ADHF, to be aware of the frailty-associated risks, and act proactively with targeted interventions (screen for infections, daily bloods, early conversations with patients and their families about treatment escalation plans and patient priorities) to improve outcomes and enhance the quality of care for this vulnerable patient population. Further research is warranted to explore potential interventions to address frailty-related risks in HF management.

Validation of the MIDA mortality risk score in a surgical cohort of patients with primary mitral regurgitation

Abstract Background and aim The MIDA scale is a prognostic tool for stratification of short- and long-term mortality risk in patients with primary mitral regurgitation (PMR). The aim of this study is to validate the MIDA (1) score in our population of PMR treated with surgery. Methods Retrospective analysis of a prospective cohort of patients with PMR who underwent mitral valve surgery in a tertiary care center from 2014 to 2022. The necessary parameters for calculating the MIDA Score (age, symptoms, atrial fibrillation, left atrial diameter, right ventricular systolic pressure (RVSP), left ventricular end-systolic diameter (LVESD), and LV ejection fraction (LVEF)) were collected, and the MIDA score for each patient was calculated. Thereafter, patients were classified into seven different risk groups. One year and long-term mortality during follow-up were recorded. A logistic regression analysis was performed to evaluate the association of each parameter with outcomes. Finally, curves for the cumulative incidence of all-cause mortality according to the MIDA score were generated with the Kaplan–Meier method. Results A total of 349 patients were included. Mean age was 68.5 [12.4] years, 55.8% were male, and the median LVEF was 60% (55-65). Mean follow up was 3.28 (2) years. One year mortality occurred in 29 (8.3%) patients, and long-term mortality in 59 (16.9%). According to the MIDA score, the distribution of patients in each subgroup was as follows: score 0 (n=28), score 1-2 (n=35), score 3-4 (n=60), score 5-6 (n=99), score 7-8 (n=81), score 9-10 (n=35), score > 11 (n=11). Most of our cohort was classified as intermediate-risk patients, with a median score of 6 (3-8). In the univariable logistic regression analysis, age, symptoms before surgery and RVSP were the only MIDA parameters significantly associated with mortality (Table-Figure 1). In our population, the discriminatory capacity of the MIDA score, was moderate, with an area under the ROC curve of 0.676 CI (0.624-0.725) for one year mortality, and 0.702 (0.651-0.749) for long term mortality. The best cut-off point for predicting one-year and long-term mortality was a MIDA score of 7. Kaplan-Meier curves for mortality during follow-up are shown in Figure 2. Conclusions The MIDA score showed a fair discriminatory capacity in our surgical cohort of patients with PMR. Variables included in the score that had a significant association with mortality were age, presence of symptoms and elevated RVSP. LV parameters included in the MIDA, which are the current class I indication for surgery, did not show a significant association with outcomes. Different echocardiographic variables to evaluate cardiac damage in PMR are needed to achieve better stratification.Table-Figure 1Figure 2

Fitness to fly: assessing cardiac disease among Air Force pilots

Abstract Introduction Aviation is a risk activity, particularly in pilots with cardiovascular (CV) disease. The occurrence of acute clinical events during flight may have catastrophic implications, justifying the relevance of cardiologic evaluation in Aviation Medicine. However, the evidence about the impact of CV diseases in this population is scarce. Aim To study the cardiac causes of incapacitation among pilot candidates and pilots of the Portuguese Air Force (PoAF) over a period of 20 years. Methods and results A retrospective analysis of cardiac causes of incapacitation between January 1999 and December 2018 was performed, both in PoAF candidates and pilots. In this period, the overall number of candidates was 2529 and the number of PoAF pilots was 760. Among the candidates, 41% (N=1086) were considered unfit, of which 4% (N=39) due to cardiac causes (all men aged 17-25), namely valvular diseases (N=27) and conduction/heart rhythm disturbances (N=12). Among the pilots, 2% (N=18) were considered unfit, mainly due to cardiac disease (50%; N=9). These pilots considered unfit pilots due to cardiac disease were men with mean age of 47±9 (30-60) years old, all unfit due to acute myocardial infarction, none occurring during flight. Conclusion Cardiac diseases were an uncommon cause of incapacitation among the pilot aviator candidates, but it was the main cause among the pilots of the PoAF during two decades, all due to acute myocardial infarction. Cardiac evaluation in Aviation Medicine is essential, focusing on CV risk stratification and preclinical detection of coronary artery disease.Figure 1

Assessment of safety, efficacy and learning curve of intravascular lithotripsy in real world practice within a high volume calcium modification centre

Abstract Background There has been a rapid uptake in the use of intravascular lithotripsy (IVL) for calcium modification during percutaneous coronary intervention (PCI) due to its ease of use and excellent safety profile, particularly when compared to atherectomy devices. Purpose To review the adoption and safety of IVL in a high volume centre with established use of alternative calcium modification techniques Methods This was a retrospective analysis of all patients undergoing PCI from the introduction of IVL in January 2019 until December 2023. Patient demographics, comorbidity, procedure details and procedural complications were compared between IVL and non-IVL cases. Line charts were created to demonstrate the uptake and use of IVL per quarter compared with other established calcium modification strategies. A further line chart was created to compare the frequency of IVL use per quarter in more complex cases (left main intervention, ST elevation, treatment of in stent restenosis and in combination with rotational/orbital atherectomy). Results In the analysis timeframe there were 7,843 PCI cases performed, of which there were 301 IVL cases, 263 rotational/orbital atherectomy cases and 77 excimer laser atherectomy. IVL cases were older, more likely to have previous revascularisation (PCI (40.8% vs 57.1 % (p<0.001)) or bypass grafts 4.8% vs 8.0% (p=0.012)), diabetes mellitus (22.7% vs 33.6% (p<0.001)) and hypertension (45.4% vs 56.5% (p<0.001)). From a procedural perspective, treatment of left main and restenosis were more common with IVL compared with the rest of the cohort (7.0% vs 27.6% (p<0.001) and 8.3% vs 28.9% (p<0.001) respectively). IVL cases were more frequently guided by intracoronary imaging (intravascular ultrasound 35.9% vs 70.4% (p<0.001), optical coherence tomography 3.7% vs 18.9% (p<0.001)). Atherectomy was more frequent in IVL cases (excimer laser atherectomy 0.7% vs 7.3% (p<0.001) and rotational/orbital atherectomy 2.6% vs 22.9% (p<0.001)). Figure 1 shows the frequency of IVL use compared with other established calcium modification strategies per quarter and demonstrates the rapid and sustained uptake in IVL usage. Interestingly the use of other atherectomy techniques does not appear to have reduced. Figure 2 shows that IVL was quickly utilised in more complex calcification cases and again this has remained consistent since the introduction. Both figures demonstrate the short learning curve associated with IVL. Finally, there was no significant increase in perforation or slow/no reflow with IVL use (0.5% vs 0.7% (p=0.647) and 1.1% vs 1.3% (p=0.675) respectively) consistent with the published literature. There was an increase in documented coronary dissection with uncertain impact (3.4% vs 6.5% p=0.017). Conclusions IVL has become an essential tool within the calcium modification algorithm as a result of its ease of use, efficacy and excellent safety profile.Calcium modification per quarterFrequency of complex IVL cases

LVEF trajectory in HFimpEF and its association with prognosis

Abstract Background The 2021 revised Universal Definition of Heart Failure (HF) introduced the subgroup known as HF with improved ejection fraction (HFimpEF), aiming to establish a standardized definition for left ventricular ejection fraction (LVEF) improvement and emphasize the importance of longitudinally assessment of LVEF. However, there remains an insufficient characterization of the association between serial LVEF trajectory before and after impEF, and outcomes in HFimpEF. Purpose We aim to delineate the LVEF trajectory in patients with impEF and to discern specific LVEF trajectory pattern that portends an unfavorable prognosis. Methods We conducted a retrospective analysis by including hospitalized HF patients with baseline LVEF ≤ 40% and satisfactory serial echocardiographic follow-ups. ImpEF was defined as a follow-up LVEF measurement of > 40% with a ≥10-point increase from baseline. Longitudinal LVEF trajectories for patients with impEF (before and after LVEF improvement) were plotted according to the clinical outcome of all-cause death using Loess curves. LVEF changes over time were analyzed by unconditional non-linear mixed-effects modeling, and compared between the groups of patients who died and those who survived using conditional non-linear mixed-effects modeling. Results Among the initial 923 patients with reduced LVEF, 517 had impEF. According to Loess curves and non-linear mixed-effects analysis, LVEF trajectory of impEF differed according to the clinical outcome of death. For patients who suffered all-cause death, there was a comparatively limited improvement in LVEF followed by a more rapid plateauing and decline, exhibiting an inverted U-shaped pattern with lower LVEF values towards both ends of the distribution. Conclusions In HFimpEF, an inverted U-shaped trajectory of LVEF, characterized by limited initial improvement followed by subsequent decline, is associated with poorer prognosis. Serial LVEF monitoring in patients with HFimpEF could help with early identification of at-risk patients.Graphical Abstract

Predictors of heart failure hospitalization after surgery in patients with primary mitral regurgitation: the relevance of left atrial coupling index

Abstract Background and Aims The main indications for surgery in patients with primary mitral regurgitation (PMR) include the presence of symptoms, left ventricular dysfunction (LVEF ≤60%) and dilation (LVESD ≥ 40 mm), but novel markers are needed to detect early myocardial damage. Our aim was to explore the impact of echocardiographic parameters on the incidence of heart failure (HF) hospitalizations after surgery in our cohort of patients with PMR. Methods Retrospective analysis of a prospective cohort of patients with PMR who underwent mitral valve surgery in a tertiary care center from 2014 to 2022. Echocardiographic parameters measured prior to surgery were analyzed. The primary outcome was HF admissions during follow-up. Results 349 patients were included. The mean age was 69 (12) years and 55.9% were male. During a mean follow up of 3.28 (2) years, 13 patients (3.7%) were admitted due to HF. Variables significantly associated with HF admissions were: female gender, atrial fibrillation prior to surgery, LVEF, LV end-diastolic volume index, LV global longitudinal strain, left atrial coupling index [LACI] (end-diastolic left atrial volume/end-diastolic LV volume), TAPSE and right ventricular-arterial coupling. In a multivariable logistic regression analysis, the only independent predictors of HF admissions were female gender (OR 5.68), LVEF (OR 0.93) and LACI (1.87) (p<0.05). Conclusions In our cohort of patients with PMR, apart from LVEF, LACI was the only echocardiographic parameter independently associated with HF hospitalizations after surgery. This easy to obtain echocardiographic parameter, which takes into account the interrelation between LA and LV compliance, could help guide patients’ management in this setting.Table 1

Improving morbidity and mortality in patients with pulmonary 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 evaluated management strategies, morbidity and mortality across three consecutive time periods. 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). Patients were divided into three enrollment periods: before 2016, the era of monotherapy or sequential combination therapies; between 2016 and 2019, post-approval and re-imbursement of macitentan in our country, marking a shift towards more proactive sequential combinations; and after 2019, signifying the initiation of earlier sequential combinations with selexipag in PAH. ESC/ERS 2022, COMPERA 2.0 and REVEAL lite 2 models were used for risk predictions. Composite endpoint (CEP) definitions were adopted from the SERAPHIN and GRIPHON trials. Results Age (mean +SD) was 51.27 + 21.37 years, and 72 % were female. Incident cases were noted in 65.9 % of patients. 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 patients, respectively. Background mono and dual targeted combinations, and sequential 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 (day) was 867 (412-1667). Overall rates of mortality and CEP were 26 % and 39%, respectively. There were increases in the % of PAH and group IV PH, and decreases in the % of CHD-PAH across the three periods. Prevalent versus incident cases were associated signifinatly lower mortality and CEP ( p=0.028 and p=0.024, respectively). Outcomes for mortality and CEP were predicted by three risk models (p<0.0001 for all). 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. In overall PH population, rates of mortality and CEP documented at 1st, 2nd and 3rd periods were 64 % and 67 %, 29 % and 31 %, and 3.5 % and 5.1 %, respectively (p< 0.001, for all). Mortality rates for 1st, 2nd and 3rd periods were 49 %, 39 % and 11 % in IPAH, 62 %, 33 % and 5.3 % in CHD-PAH, 47 %, 45 % and 7.7 in CTD-PAH, and 37 %, 52 % and 11 % in group IV, respectively (p< 0.001, for all). However, mortality curves showed sudden increases in 2020 that might be attributed to COVID-19. Conclusions Our nation-wide data revealed improving survival in the overall PH population, PAH and Group IV PH that might be associated with risk-based earlier targeted combination strategies. However, this trend seems to be counterbalanced with COVID-19 pandemic.

A 16-year evaluation of opportunistic lung cancer screening with low-dose CT in China: comparative findings between non-smokers and smokers

BackgroundAlthough low-dose computed tomography (LDCT) screening effectively reduces LC mortality in high-risk individuals with a history of smoking in China, the feasibility and efficacy of lung cancer screening (LCS) in individuals who never smoked versus individuals who smoked remains unclear.MethodsWe conducted a retrospective analysis of prospective cohort studies at the National Cancer Center (NCC) in China from January 2006 to December 2022. A comprehensive LCS initiative was undertaken, involving 30,468 participants (54.5% male). Participants underwent LCS using LDCT. Potential malignancies were managed through joint consensus between patients and their physicians. Epidemiology, screening eligibility criteria, and LC detection rates and survival outcomes were compared between individuals who smoked and individuals who never smoked.ResultsAmong 30,468 participants, 339 LCs were pathologically confirmed in 289 patients. The LC detection rate was 0.9% (289/30,468) overall, 0.8% in individuals who smoked (71/9,042), and 1.0% in individuals who never smoked (218/21,426). In individuals who smoked, LC detection rates were 0.5% (21/4516) and 1.1% (50/4526) in the < 20 and ≥ 20 pack-year subgroups, respectively (P = 0.001). Early-stage LC (stage 0 or I) was detected in 73.8% of the individuals who smoked and in 78.8% of individuals who never smoked, while advanced LC (stage III–IV) was found 8.8% of individuals who smoked and 4.2% of individuals who never smoked, respectively. Significant differences in histologic types were found between individuals who smoked and individuals who never smoked (P = 0.01), although adenocarcinoma was the most prevalent in both groups, at 83.0% and 78.8%, respectively. The median nodule size was 9.9 mm (IQR, 8.0–13.8) in individuals who smoked and 9.2 mm (IQR, 6.8–13.6) in individuals who never smoked (P = 0.228). Individuals who never smoked tended to favour surgical treatment alone (88.0%) more than individuals who smoked (81.3%). The 10-year survival rate was higher in individuals who never smoked (92.6%) than in individuals who smoked (88.8%). Only 15.6% (45/289) of patients with LC met the United States Preventive Services Task Force (USPSTF) criteria for LDCT eligibility, while 29.0% (84/289) met the China guideline for the screening and early detection of lung cancer (CGSL) criteria. Median follow-up for those followed was 25.4 (IQR, 13.7–43.3) months.ConclusionsLDCT screening improves early LC detection and treatment outcomes for both individuals who smoked and individuals who never smoked. Significant differences exist in epidemiology, histologic type, and survival between these groups. The USPSTF and CGSL criteria miss a significant number of LC cases, particularly among individuals who never smoked. Integrating individuals who never smoked into LCS programs is essential, yet it comes with its own challenges, such as managing radiation risks, allocating resources effectively, and considering financial aspects. Consequently, there is an urgent need for LCS programs in China to better identify the “high-risk” non-smoker population susceptible to LC and to ensure that potential risks associated with screening are reduced.

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