Severe Heart Disease Research Articles

Comparison of FFR, iFR, and QFR assessment in patients with severe aortic stenosis and coronary heart disease.

IntroductionSome patients with coronary heart disease are diagnosed with severe aortic stenosis. For further treatment, coronary angiography is performed in these patients. For intermediate lesions, obtaining coronary artery physiological data can facilitate clinical decision-making regarding revascularization.AimThe study compared the physiological significance of coronary artery stenosis using the fractional flow reserve (FFR) method with instantaneous wave-free pressure ratio (iFR) and quantitative flow ratio (QFR) in patients qualified for aortic valve replacement.Material and methodsData were collected on patients hospitalized in the years 2019–2020 at the 2nd Department of Cardiology, University Hospital in Krakow.ResultsTwelve patients with severe aortic stenosis and borderline lesions in the coronary artery were qualified for physiological assessment. There were 6 women, whose mean age was 73.8 ±7.5 years. The mean left ventricular ejection fraction was 52 ±15%. The mean aortic valve area was 0.80 ±0.16 cm2. The left anterior descending artery was assessed in 12 from 13 cases (92%). In comparison to FFR, all iFR measurements were concordant with FFR. The total agreement between QFR and FFR/iFR assessment was 69%.ConclusionsDespite the controversy and uncertainty of some operators regarding the interpretation of the FFR test in patients with severe aortic stenosis, we obtained complete agreement of FFR with iFR assessment. This fact suggests that in patients with severe aortic stenosis the choice of an invasive method to assess the physiological significance of the stenosis in the coronary artery is not crucial – both iFR and FFR allow comparable results.

Homecare-Oriented ECG Diagnosis With Large-Scale Deep Neural Network for Continuous Monitoring on Embedded Devices

The accurate electrocardiogram (ECG) interpretation is important for several potentially life-threatening cardiac diseases. Recently developed deep learning methods show their ability to distinguish some severe heart diseases. However, since deep neural network requires a high cost on memory consumption and computation, implementation scenarios of these interpretation methods are constrained to nonportable devices. Few commercial portable devices only have heartbeat detection ability, and therefore, only a few simple cardiac diseases can be diagnosed. In this article, to achieve diagnosing a wide range of cardiac diseases and continuous monitoring, a homecare-oriented ECG diagnosis platform is designed based on a large-scale multilabel deep conventional neural network. The accuracy of the proposed neural network model is guaranteed by our constructed large-scale ECG dataset, which is comprised of 206 468 standard 12-lead ECG recordings from 89 488 patients, with respect to 26 types of most common heart rhythms and conduction abnormalities. Meanwhile, targeting lightweight homecare or wearable applications, algorithm-hardware co-optimization is conducted to accelerate the model computation on an embedded platform with field-programmable gate array (FPGA) for continuous monitoring. Channel-level pruning and parameters quantization strategy are employed to optimize the network, and a reconfigurable accelerator hardware architecture is designed to accelerate the convolution computation on FPGA. The final quantified model achieved a promising <inline-formula xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink"> <tex-math notation="LaTeX">$F_{1}$ </tex-math></inline-formula> score of 0.913% and 86.7% exact match ratio, in which parameters and floating-point operations per second (FLOPs) are significantly penalized compared to the original large-scale model. Real-time analysis is performed. Specifically, the average processing time for each ECG record is 2.895 s, and it can be applied to homecare or portable ECG diagnosis devices for continuous monitoring.

Safety Control Architecture for Ventricular Assist Devices

In patients with severe heart disease, the implantation of a ventricular assist device (VAD) may be necessary, especially in patients with an indication for heart transplantation. For this, the Institute Dante Pazzanese of Cardiology (IDPC) has developed an implantable centrifugal blood pump that will be able to help a diseased human heart to maintain physiological blood flow and pressure. This device will be used as a totally or partially implantable VAD. Therefore, performance assurance and correct specification of the VAD are important factors in achieving a safe interaction between the device and the patient’s behavior or condition. Even with reliable devices, some failures may occur if the pumping control does not keep up with changes in the patient’s behavior or condition. If the VAD control system has no fault tolerance and no system dynamic adaptation that occurs according to changes in the patient’s cardiovascular system, a number of limitations can be observed in the results and effectiveness of these devices, especially in patients with acute comorbidities. This work proposes the application of a mechatronic approach to this class of devices based on advanced control, instrumentation, and automation techniques to define a method to develop a hierarchical supervisory control system capable of dynamically, automatically, and safely VAD control. For this methodology, concepts based on Bayesian networks (BN) were used to diagnose the patient’s cardiovascular system conditions, Petri nets (PN) to generate the VAD control algorithm, and safety instrumented systems to ensure the safety of the VAD system.

Added predictive value of right ventricular ejection fraction compared with conventional echocardiographic measurements in patients who underwent diverse cardiovascular procedures

Abstract Background and aim Right ventricular (RV) ejection fraction (EF) assessed by 3D echocardiography is a powerful measure to detect RV dysfunction. However, its prognostic value in routine clinical practice has been scarcely explored. Accordingly, we aimed at investigating whether RVEF is associated with 2-year all-cause mortality in patients who underwent diverse cardiovascular procedures and to test whether RVEF can overcome conventional echocardiographic parameters in terms of outcome prediction. Patients and methods One hundred and seventy-four patients were retrospectively identified who underwent clinically indicated transthoracic echocardiography comprising 3D acquisitions. The patient population consisted of heart failure with reduced ejection fraction patients (44%), heart transplanted patients (16%), and severe valvular heart disease patients (39%). Beyond conventional echocardiographic measurements, RVEF was quantified by 3D echocardiography. The primary endpoint of our study was all-cause mortality at two years. Results Twenty-four patients (14%) met the primary endpoint. Patients with adverse outcomes had significantly lower RVEF (alive vs. dead; 48 ± 9 vs. 42 ± 9%, P &lt; 0.01). However, tricuspid annular plane systolic excursion (21 ± 7 vs. 18 ± 4 mm), and RV systolic pressure (36 ± 15 vs. 39 ± 15 mmHg) were similar. By Cox analysis, RVEF was found to be associated with adverse outcomes (HR [95% CI]: 0.945 [0.908–0.984], P &lt; 0.01). By receiver-operator characteristic analysis, RVEF exhibited the highest AUC value compared with the other RV functional measures (0.679; 95% CI: 0.566–0.791). Conclusions Conventional echocardiographic measurements may be inadequate to support a granular risk stratification in patients who underwent different cardiac procedures. RVEF may be a robust clinical parameter, which is significantly associated with adverse outcomes.

Energy-sparing by 2-methyl-2-thiazoline protects heart from ischaemia/reperfusion injury.

AimsCardiac ischaemia/reperfusion (I/R) injury remains a critical issue in the therapeutic management of ischaemic heart failure. Although mild hypothermia has a protective effect on cardiac I/R injury, more rapid and safe methods that can obtain similar results to hypothermia therapy are required. 2‐Methyl‐2‐thiazoline (2MT), an innate fear inducer, causes mild hypothermia resulting in resistance to critical hypoxia in cutaneous or cerebral I/R injury. The aim of this study is to demonstrate the protective effect of systemically administered 2MT on cardiac I/R injury and to elucidate the mechanism underlying this effect.Methods and resultsA single subcutaneous injection of 2MT (50 mg/kg) was given prior to reperfusion of the I/R injured 10 week‐old male mouse heart and its efficacy was evaluated 24 h after the ligation of the left anterior descending coronary artery. 2MT preserved left ventricular systolic function following I/R injury (ejection fraction, %: control 37.9 ± 6.7, 2MT 54.1 ± 6.4, P < 0.01). 2MT also decreased infarct size (infarct size/ischaemic area at risk, %: control 48.3 ± 12.1, 2MT 25.6 ± 4.2, P < 0.05) and serum cardiac troponin levels (ng/mL: control 8.9 ± 1.1, 2MT 1.9 ± 0.1, P < 0.01) after I/R. Moreover, 2MT reduced the oxidative stress‐exposed area within the heart (%: control 25.3 ± 4.7, 2MT 10.8 ± 1.4, P < 0.01). These results were supported by microarray analysis of the mouse hearts. 2MT induced a transient, mild decrease in core body temperature (°C: −2.4 ± 1.4), which gradually recovered over several hours. Metabolome analysis of the mouse hearts suggested that 2MT minimized energy metabolism towards suppressing oxidative stress. Furthermore, 18F‐fluorodeoxyglucose‐positron emission tomography/computed tomography imaging revealed that 2MT reduced the activity of brown adipose tissue (standardized uptake value: control 24.3 ± 6.4, 2MT 18.4 ± 5.8, P < 0.05). 2MT also inhibited mitochondrial respiration and glycolysis in rat cardiomyoblasts.ConclusionsWe identified the cardioprotective effect of systemically administered 2MT on cardiac I/R injury by sparing energy metabolism with reversible hypothermia. Our results highlight the potential of drug‐induced hypothermia therapy as an adjunct to coronary intervention in severe ischaemic heart disease.

Predictors of maternal and neonatal complications in women with severe valvular heart disease during pregnancy in Tunisia: a retrospective cohort study

BackgroundSevere valvular heart disease, especially stenosis, is a contraindication for conception according to the World Health Organization. This is still encountered in countries with a high rheumatic fever prevalence. The objective of this study was to determine predictors of maternal cardiac, obstetric and neonatal complications in pregnant women with severe valve disease.MethodsThis is an observational retrospective cohort study of all pregnant women with severe heart valvulopathy who gave birth between 2010 and 2017.ResultsWe included 60 pregnancies in 54 women. Cardiac complications occurred during 37 pregnancies (61%). In multivariate analysis, parity (aOR =2.41, 95% CI[1.12–5.16]), revelation of valvulopathy during pregnancy (aOR = 6.34; 95% CI[1.26–31.77]), severe mitral stenosis (aOR = 6.98, 95% CI[1.14–41.05],) and systolic pulmonary arterial pressure (aOR =1.08, 95% CI[1.01–1.14]) were associated with cardiac complications. Obstetrical complications were noted during 19 pregnancies (31.8%). These complications were associated with nulliparity (aOR = 5.22; 95% CI[1.15–23.6]), multiple valve disease (aOR = 5.26, 95% CI[1.19–23.2]), systolic pulmonary arterial pressure (aOR =1.04, 95% CI[1.002–1.09]), and treatment with vitamin K antagonists (aOR = 8.71, 95% CI[1.98–38.2]). Neonatal complications were noted in 39.3% of newborns (n = 61) and these were associated with occurrence of obstetric complications (aOR = 16.47, 95% CI[3.2–84.3]) and revelation of valvulopathy during pregnancy (aOR = 7.33, 95% CI[1.4–36.1]).ConclusionsRevelation of valvular heart disease during pregnancy is a predictor of not only cardiac but also neonatal complications. Valvular heart disease screening during pre-conceptional counseling is thus crucial.

The Individual and Combined Effects of Shear, Tension, and Flexure on Aortic Heart Valve Endothelial Cells in Culture

The necessity of living engineered heart valves to treat patients with severe heart disease poses a challenge to tissue engineers. To reach such goal it is crucial to fully understand the role and the activities of valvular endothelial cells (VECs) when they face different types of mechanical stimuli. This study focuses on decomposing the roles of different mechanical stimuli on heart valve endothelial surfaces and the response of VECs in terms of morphology and phenotype change. This study utilizes soft hydrogel-based scaffolds to use as a substrate for cell culture to mimic heart valve tissue leaflet. VECs were cultured as a monolayer on the gel surface and different types of mechanical stimuli were applied. Finally, the response of cells was investigated in terms of morphology and protein expression changes. Single stimuli introduces actin fibers reorganization in VECs, change in cell morphology, and higher mesenchymal protein expression. On the other hand, combined stimuli application has lower impact on actin fibers reorganization and cell morphology change, with lower mesenchymal protein expression. When VECs face a single mechanical stimuli, they undergo transdifferentiation and transform into mesenchymal cells. However, when these cells face a combination of mechanical stimuli, the rate of transformation decreases compared to single stimuli applications. This indicates that a single stimulus induces endothelial to mesenchymal transition in VECs while the process is slower under the combination of multiple mechanical stimuli.

Abstract 10971: Prevalence and Risk Factors of Silent Brain Microbleeds in Patients with Severe Valvular Heart Disease

Introduction: The presence of cerebral microbleeds (CMBs) has been described using MRI in patients with cardiovascular risk factors or prior stroke and could predict future cognitive dysfunction or cardiovascular mortality. CMBs are highly frequent (&gt; 50%) in patients with infective endocarditis (IE). However, the association of CMBs and clinical factors in patients' valvular disease without IE remains unclear. Hypothesis: Valvular heart disease without IE confers a risk factor for microbleeds. Methods: We retrospectively examined data from the consecutive 96 patients ( 72 ± 9 years, 49 men) with severe valvular disease who underwent T2*-weighted brain MRI before cardiac surgery. The patients with neurological abnormalities or IE were excluded. Conventional echocardiography was performed to evaluate the left ventricular volume and valvular abnormalities. CMBs were coded by researchers blind to clinical details, who independently assessed the presence and location of CMBs using a standardized form. The study population consisted of 59 patients with severe aortic stenosis (AS) (group A) and 40 patients with severe aortic or mitral regurgitation (group B). Results: CMBs were found in 26 patients (27%), 14 (15%) had multiple CMBs. CMBs were most frequently seen in the lobar locations (69%), followed by deep or infratentorial locations (62%). No significant relationship was found between CMBs in dyslipidemia, diabetes mellitus, smoking status, anticoagulant, and antiplatelet therapy in both groups. In group A, the HAS-BLED score was higher in patients with CMBs, and the presence of CMBs was associated with hypertension (P&lt;0.05); however, no significant differences were observed in the left ventricular mass index (LVMI), LV end-diastolic volume (LVEDV), any aortic valve severity parameters. In group B, there were significant differences in LVMI and LVEDV between patients with CMBs and those without (154 ± 40 g/m 2 vs 125 ± 32 g/m 2 , P &lt; 0.01 ; 150 ± 39 ml vs 111 ± 38 ml, P&lt;0.01). Conclusion: CMBs were frequently observed in severe valvular heart disease without IE. The presence of CMBs was independent of antiplatelet or anticoagulant therapy. In aortic or mitral regurgitation patients, LV remodeling may contribute to the development of CMBs.

Abstract 10970: Added Predictive Value of Right Ventricular Ejection Fraction Compared with Conventional Echocardiographic Measurements in Patients Who Underwent Diverse Cardiovascular Procedures

Introduction: Right ventricular (RV) ejection fraction (EF) assessed by 3D echocardiography is a powerful measure to detect RV dysfunction. However, its prognostic value in routine clinical practice has been scarcely explored. Accordingly, we aimed at investigating whether RVEF is associated with 2-year all-cause mortality in patients who underwent diverse cardiovascular procedures and to test whether RVEF can overcome conventional echocardiographic parameters in terms of outcome prediction. Methods: One hundred and seventy-four patients were retrospectively identified who underwent clinically indicated transthoracic echocardiography comprising 3D acquisitions. The patient population consisted of heart failure with reduced ejection fraction patients (44%), heart transplanted patients (16%), and severe valvular heart disease patients (39%). Beyond conventional echocardiographic measurements, RVEF was quantified by 3D echocardiography. The primary endpoint of our study was all-cause mortality at two years. Results: Twenty-four patients (14%) met the primary endpoint. Patients with adverse outcomes had significantly lower RVEF (alive vs. dead; 48±9 vs. 42±9%, p&lt;0.01). However, tricuspid annular plane systolic excursion (21±7 vs. 18±4mm), and RV systolic pressure (36±15 vs. 39±15mmHg) were similar. By Cox analysis, RVEF was found to be associated with adverse outcomes (HR [95% CI]: 0.945 [0.908 - 0.984], p&lt;0.01). By receiver-operator characteristic analysis, RVEF exhibited the highest AUC value compared with the other RV functional measures (0.679; 95% CI: 0.566 - 0.791). Conclusions: Conventional echocardiographic measurements may be inadequate to support a granular risk stratification in patients who underwent different cardiac procedures. RVEF may be a robust clinical parameter, which is significantly associated with adverse outcomes.

Abstract 13789: Identification of a Proteomic Signature Showing Ongoing Inflammation in Severe Rheumatic Heart Disease

Introduction: Rheumatic heart disease (RHD) remains a major source of morbidity and mortality in developing countries. A deeper insight into the pathogenetic mechanisms underlying RHD could provide opportunities for drug repurposing, guide recommendations for secondary penicillin prophylaxis, and/or inform development of near-patient diagnostics. Methods: We conducted a proteomic study in 215 African patients with severe RHD and 230 controls, using the SWATH-MS technique. We applied a machine learning (ML) approach to feature selection among the 366 proteins quantifiable in at least 40% of samples, using the Boruta wrapper algorithm. The case-control differences and contribution to AUC of the ROC for each of the 56 proteins identified by the Boruta algorithm were calculated by Logistic Regression adjusted for age, sex and BMI. Biological pathways and functions enriched for proteins were identified using ClueGo pathway analyses. Results: Adiponectin, complement component C7 and fibulin-1, a component of heart valve matrix, were each higher in cases when compared with controls. Ficolin-3, a protein with calcium-independent lectin activity that activates the complement pathway, was lower in cases than controls. The top 6 biomarkers from the Boruta analyses conferred an AUC of 0.90 indicating excellent discriminatory capacity between RHD cases and controls. Conclusions: These results support the presence of an ongoing inflammatory response in RHD, at a time when severe valve disease has developed, and distant from previous episodes of acute rheumatic fever. This biomarker signature could have potential utility in recognizing different degrees of ongoing inflammation in RHD patients, which may in turn be related to prognostic severity.

Maternal and perinatal outcomes of pregnancies complicated by cardiac disease at a tertiary level hospital

Heart disease in pregnancy is one of the leading non-obstetric causes of maternal mortality and is the leading cause of maternal intensive care unit admissions in the world. To study the prevalence of heart disease in antenatal mothers and fetal outcome with obstetric management. The presence of comorbidities and the occurrence of obstetric, fetal, and cardiovascular complications during delivery among women with heart disease hospitalized for delivery were studied in 35 women at GSL Medical College, Rajahmundry for a period of 1 year from 01/01/2019 to 1/1/2020: Over a period of 12 months, 35 subjects were recruited. During this period, there were 5005 deliveries. The majority of women were aged between 20-25yrs and were unbooked cases belonging to NYHA class I or II. Cesarean section and operative vaginal delivery were more common. Despite the multidisciplinary approach, 3 women succumbed to the disease of which one was a case of severe rheumatic heart disease with valve failure, the second was a case of postpartum cardiomyopathy and the third was a case of severe pulmonary arterial hypertension. Fetal outcome in cardiac patients is usually good and only a little different from those patients who do not suffer from heart disease. Pregnant women with heart disease were more likely to experience adverse events during delivery. These women require a multidisciplinary team for optimal maternal and foetal outcomes.

Impact of specialized electrophysiological care on the outcome of catheter ablation for supraventricular tachycardias in adults with congenital heart disease: Independent risk factors and gender aspects.

Limited data exist on the impact of gender and specialized care on the requirement of repeat treatment of supraventricular tachycardia (SVT) in adult patients with congenital heart disease (ACHDs). The study aimed to assess independent predictors of a combined end point of re-catheter ablation (CA) or cardioversion at 3 years of follow-up, including the impact of gender and specialized ACHD care. All ACHDs registered in a database of one of the largest German health insurers (≈9.2 million members) who underwent CA for SVT were analyzed. Of 38,892 ACHDs 16 years or older, 485 (49.5% women; median age 58.4 years; interquartile range 42.1-70.8 years) underwent CA for SVT. Over 3-year follow-up, the number of yearly CA procedures increased significantly, particularly for atrial fibrillation (+195%) and atrial flutter (+108%). Moderate to severe complexity heart disease (odds ratio [OR] 1.66; P = .01), advanced age (OR 1.85 per year; P = .02), chronic kidney disease (OR 1.70; P= .01), and atrial fibrillation (OR 2.02; P = .002) emerged as independent predictors of retreatment. Retreatment was significantly less often performed if primary CA was carried out at a specialized CHD center (P = .009) in patients with moderate to severe complexity heart disease. Women treated in specialist centers had a 1.6-fold reduced risk of undergoing retreatment (P = .01). CA for SVT is increasingly performed in ACHDs, especially for atrial flutter and atrial fibrillation. Patients with moderate and severe complexity congenital heart defects and female ACHDs benefit from upfront referral to specialized CHD centers for CA. Centralization of care for ACHD arrhythmias should thus be advocated.

Specialized pro-resolving mediators prevents cardiac dysfunction by modulating Ca2+ handling and NRF2 axis

Abstract Background and purpose Myocarditis is a severe inflammatory heart disease and a leading cause of sudden death in young adults; but currently no specific treatment is available. Lipoxins and their derivatives promote the resolution of inflammation contributing to recover tissue homeostasis; but their role in cardiac inflammation is poorly understood. Methods and results BML-111, a stable lipoxin A4 receptor agonist, protects against cardiac dysfunction in a murine model of experimental autoimmune myocarditis (EAM) by preventing Ca2+ mishandling. Cardiac proteomic analysis revealed an enhanced cardiac oxidative profile in EAM-induced mice with reduced activation of NRF2, a master antioxidant transcription factor. In vitro analysis showed that 15-epi-lipoxin A4 increased systolic Ca2+ release and sarcoplasmic reticulum (SR)-Ca2+ load in cardiomyocytes isolated from wild-type mice and augmented the rate of SR-Ca2+ uptake by SERCA2a, but failed to induce any functional change in cells from Nrf2−/− mice. BML-111 increased SERCA2a cardiac expression in wild-type mice, and the transcriptional activity of Nrf2 determined SERCA2a expression in human ventricular cells. Human myocarditis-positive myocardium showed a reduced expression of both ATP2A2 (SERCA2a) and NF2L2 (NRF2). Conclusions Our results demonstrated new cardioprotective mechanisms of pro-resolving lipid mediators that may emerge as innovative treatments for myocarditis. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ISCIII [PI17/01344]), Sociedad Española de Cardiología: Proyecto Traslacional 2019Fondo Europeo de Desarrollo Regional (FEDER), FSE, and CIBER-CV, a network funded by ISCIII

Prognostic value of cardiopulmonary exercise testing in valvular heart disease

Abstract Introduction Cardiopulmonary exercise testing (CEPT) is not routinely used for the assessment of valvular heart disease (VHD) patients. The cutoff values of percentage of predicted peak VO2 and ventilatory efficiency parameters that carry out a bad prognosis have been predominantly validated in heart failure. The aim of this study was to analyze the prognostic value of CPET parameters in a broad population of VHD patients. Methods 163 patients (51% female) with moderate or severe VHD who underwent a CEPT (n=197) at their physician's discretion from 2017 until 2019 were included. We calculated the net reclassification index of CPET, compared to the classical clinical or echocardiographic parameters, regarding the need for surgical indication. Also, the predictive value of CPET for death and symptom development during follow-up was estimated using regression analysis. Results At inclusion, all patients were asymptomatic or with minimal equivocal symptoms. Aortic valvular lesions were the most common (47%), followed by mitral valvular disease (44%). There was a predominance of severe valvular heart disease (71%) and most of the CEPTs were performed on a treadmill (74%). The percentage of predicted peak VO2 was 76±18% and at anaerobic threshold was 61±18%. The mean follow-up time was 15±10 months. There were 5 deaths (3%) and 24 patients became symptomatic. The net reclassification index of CPET over either clinical or echocardiographic parameters was 46%. The CEPT parameters that predicted increased risk of death were VE/VCO2 slope (p=0.009), % of predicted peak VO2 (p=0.049) and Eq CO2 at anaerobic threshold (p=0.047). None of the CEPT parameters was predictive of symptom development during follow-up, however, in the subgroup of patients who became clearly symptomatic, the ventilatory efficiency parameters were similar to the cut off values that confer bad prognosis (see Table in Figure). Conclusion In our series, CPET added prognostic mortality value to patients with VHD. The cut off values used for patients with HF can also be applied in a VHD population. In addition, CEPT clearly improved the clinical decision for surgical referral. Nevertheless, these results need to be validated in a broader population. Funding Acknowledgement Type of funding sources: None.

Utility of left atrial strain imaging for the determination of diastolic dysfunction in patients with STEMI

Abstract Introduction Since echocardiographic parameters indicating increased left ventricular filling pressure were validated in patients with stable coronary artery disease and patients with acute coronary syndrome were excluded, the utility of these parameters in ACS patients is not clarified. Recent studies suggest that left atrial strain imaging is a reliable method for the assessment of left ventricular diastolic dysfunction. Purpose In this study, we aimed to investigate the clinical utility of left atrial strain imaging for the detection of increased LVFP. Methods We prospectively included patients diagnosed with ST-segment elevation myocardial infarction who were treated with primary percutaneous intervention (pPCI). Left ventricular end-diastolic pressure was measured following the procedure. Comprehensive echocardiographic evaluation was performed within 24 hours of pPCI. Patients with atrial fibrillation and severe valvular heart disease were excluded. Normal LV end-diastolic pressure was accepted as &amp;lt;18 mmHg. Results 76 patients were enrolled. Patients were divided into two groups according to LVEDP value. Group 1 patients included patients with normal LVEDP (42 patients) and the rest of the patients included into group 2 (27 patients). Comorbidities including hypertension (p: 0.408), diabetes (p: 0.696) and dyslipidaemia (p: 0.336) were similar between groups. Anterior myocardial infarction was more prevalent in group 2 patients (p: 0.012). Troponin and pro-BNP values were significantly higher in group 2 patients (p: 0.001 and p: 0.03 respectively). Left ventricular ejection fraction and left ventricular global strain values were significantly lower in group 2 patients (p: 0.048 and p: 0.025 respectively). Table 1 represents the comparison of strain values between groups. Left atrial reservoir strain rates were lower in group 2 patients (p: 0.09). Correlation analyses revealed that there is a statistically significant relationship between left atrial strain values and LVEDP (p: 0.003 and r: 0.238). Conclusion In conclusion, our study has demonstrated that left atrial strain imaging is a useful non-invasive method for the assessment of increased LVEDP in patients with STEMI. Funding Acknowledgement Type of funding sources: None. Echocardiographic variables

Natriuretic peptides predict future heart failure and cardiovascular death in an unselected population of patients presenting to hospital: interactions with atrial fibrillation

Abstract Aims Natriuretic peptides are routinely quantified to diagnose heart failure (HF). Their concentrations are also elevated in atrial fibrillation (AF). To clarify their interpretation, we measured natriuretic peptides in unselected patients with cardiovascular conditions and related their concentrations to AF and HF status and to outcomes. Methods and results Consecutive patients with cardiovascular conditions presenting to a large teaching hospital (median age 70 [IQR 60–78] years, 40% women) underwent clinical assessment, 7-day ECG-monitoring, and echocardiography to diagnose AF and HF. N-terminal pro B-type natriuretic peptide (NT-proBNP) was centrally quantified. Clinical characteristics and NT-proBNP concentrations were related to HF hospitalization or cardiovascular death. Follow-up data was available in 1611/1616 patients (99.7%) and analysis performed at 2.5 years. Based on a literature review, four NT-proBNP groups were defined (&amp;lt;300pg/ml, 300–999pg/ml, 1000–1999pg/ml and ≥2000pg/ml). Multivariate Cox proportional hazards analysis of the composite outcome against AF and HF phenotype groups. This was adjusted for confounding factors including age, sex, race, body mass index, hypertension, diabetes, coronary artery disease, severe valvular heart disease, left bundle branch block, hyponatraemia, urea, haemoglobin, estimated glomerular filtration rate, NT-proBNP, medical treatment with ACE inhibitors or angiotensin receptor blockers, beta-blockers, diuretic (thiazide or loop diuretics), and anticoagulants (novel oral anticoagulant or vitamin K antagonist). Cox proportional hazards analysis adjusted for confounding variables for the composite outcome against baseline NT-proBNP concentration ranges was also performed in each patient group based on AF and HF status. HF hospitalization or cardiovascular death increased from patients with neither AF nor HF (36/488, 3.2/100 person-years), to 55/353 (7.1/100 person-years) in patients with AF only, 91/366 (12.1/100 person-years) in patients with HF only, and, 128/404 (17.7/100 person-years) in patients with AF plus HF (p&amp;lt;0.001). Higher NT-proBNP concentrations predicted the outcome in patients with AF only (C-statistic 0.82 [95% CI 0.77 to 0.86], p-value&amp;lt;0.001) and in other phenotype groups (C statistic in AF plus HF 0.66 [95% CI 0.61 to 0.70], p-value&amp;lt;0.001)). Sensitivity analyses confirmed these findings. Conclusion Elevated NT-proBNP concentrations predict future HF events in patients with AF irrespective of the presence of HF. In line with previous studies in HF, an NT-proBNP threshold of 1000 pg/ml is useful to identify high-risk patients with AF whether or not they are diagnosed with HF at the time of assessment. Pending external validation, these findings encourage the routine quantification of NT-proBNP in the initial assessment of patients with AF. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): 1) This study was partially supported by European Union BigData@Heart and 2) CATCH ME (Characterising Afib by Translating its Causes into Health Modifiers in the Elderly)

Cardiac and Pregnancy Outcomes of Pregnant Patients With Congenital Heart Disease According to Risk Classification System

Pregnancy risk assessment for patients with adult congenital heart disease (ACHD) must include physiologic and anatomic impacts. We aimed to determine whether maternal cardiac and pregnancy outcomes vary by disease severity defined according to the following 3 different classifications: ACHD anatomic severity, ACHD physiologic class, and modified World Health Organization (mWHO) class. Cardiac outcomes included a composite of arrhythmia, heart failure, stroke, and thromboembolism. Pregnancy outcomes included a composite of intrauterine growth restriction, preterm birth, preeclampsia, or postpartum hemorrhage. We employed generalized estimating equations to account for multiple pregnancies. Of the 245 pregnancies, 17.1% were preterm and 45.7% were cesarean deliveries. Cardiac hospitalizations occurred in 22.0% and arrhythmias in 12.7%. Cardiac outcomes tended to be more prevalent in people with more severe heart disease. Pregnancy outcomes were U-shaped or less prevalent in people with more severe disease. There was a 2.9-fold increased risk for the composite cardiac outcome for complex anatomy (adjusted incidence rate ratio 2.90, 95% confidence interval 1.08 to 7.81, p=0.04), a 9.4-fold increased risk for physiologic class C or D (9.37, 1.28 to 68.79, p=0.03), and a fourfold increased risk for mWHO class III or IV (3.99, 1.53 to 10.40, p=0.005). There was a lower risk for the composite pregnancy outcome for mWHO class II or II to III (0.54, 0.36 to 0.79, p=0.002) but no association with anatomy or physiology. In conclusion, physiologic class may be most accurately associated with adverse outcomes and therefore efforts to optimize hemodynamics before pregnancy may help to mitigate the risk.

Re-discovering an Old Standard: Ilio-Femoral Bypass, with Adjunctive Procedures, for Primary orSecondary Iliac Artery Occlusion

<h3>Introduction and Objective</h3> Endovascular techniques constitute first-line treatment for iliac artery occlusions and enjoy outstanding primary and long-term durability. Some iliac occlusions are not amenable to endovascular repair because of calcification, chronic occlusion, and failed stents. Twenty-eight patients with unilateral iliac occlusion who were not candidates for or failed endovascular repair underwent ilio-femoral bypass. Extra-anatomical bypass was avoided because of previous contralateral procedures or risk to the contralateral extremity. This abstract reviews one surgeon's experience with ilio-femoral bypasses from December, 2014 to November, 2020. <h3>Case Report</h3> Twenty-eight (28) patients, 74% males, with an average patient age of 63.8 years and unilateral iliac occlusion, underwent ilio-femoral bypass. 88% were smokers, 38% were diabetics, and 30% had severe heart disease. Two patients had severe kidney disease requiring dialysis. Twenty-four patients underwent previous attempts at revascularization: 14 received iliac stents and 4 patients had failed aorto bifemoral or axillo/ilio femoral bypasses. There were 6 previous open interventions involving the femoral arteries. Two patients sustained rupture while undergoing endovascular procedures and required emergent bypasses. Indications for intervention were rest pain in 11, tissue loss in 8, and disabling claudication in 5. There were 3 urgent interventions: two required immediate intervention following rupture of an iliac artery angioplasty, and a third occurred during insertion of a thoracic stent. One procedure was performed fora 2-year-old infected iliac bypass with impending rupture. All operations were performed under general anesthesia. Proximal retro-peritoneal exposure of the iliac arteries was obtained via a curvilinear incision in the ipsilateral lower quadrant. Twenty-four (24) patients received a Dacron conduit, 2 PTFE, 1 bovine, and 1 femoral vein. Thirty-five (35) adjuvant procedures were done in conjunction with the bypass. In 14 cases (54%,) retrograde endarterectomy/thrombectomy/stent extraction was performed. Eleven patients (35%) required a femoral endarterectomy/thrombectomy. Angiography was used selectively if inflow was deemed inadequate. Six (6) intraoperative angiograms were needed with 2 patients requiring proximal stent insertions. Two patients received simultaneous femoral to distal bypasses done for tissue loss. <h3>Results</h3> Procedures were technically successful in 100% of patients. All bypasses were patent at the time of their loss to follow-up or death. Patients were followed for an average of 22.3 months. No secondary interventions were required. There was 1 groin infection that required excision of the graft; one above knee amputation was required for an infected knee prothesis. There was one groin hematoma. Two patients died within thirty days (8%), one from SIRS (multi-organ system failure following recent myocardial infarction) and one patient died of a coagulopathy following rupture of a calcified common iliac artery during angioplasty. There were no amputations due to vascular disease. 100% patency in this series was enhanced by adjunctive procedures. Ilio-femoral bypasses done to symptomatic elderly patient with occluded superficial femoral arteries frequently enjoyed relief of rest- pain without the morbidity of distal incisions. This group required endarterectomy of the common and deep femoral arteries. No hernias, local nerve injuries, lymphorrhea, damage to ureters, or major infections occurred. One groin infection was a catabolic, nursing home patient with an infected, ischemic, above knee residual limb. He required excision of the exposed graft. Patients tolerate the retroperitoneal approach usually without paralytic ileus and prompt restoration of bowel function. Respiratory insufficiency is also minimal since a major body cavity is not entered. The majority of patients were extubated before transfer to the post-operative acute care unit. <h3>Discussion</h3> Historically, ilio-femoral bypass is considered a durable operation with a cumulative patency of 92% 3- year patency and exhibit superior patency when compared to extra-anatomical bypasses that demonstrate a 73% 3-year patency. The operation has been largely supplanted by endovascular procedures which are equally durable and less invasive. There is a subset of patients in whom angioplasty/stents are not possible or who have failed endovascular intervention and require in flow procedures. In this series, ilio femoral bypass was only performed in 5 patients (19%) with claudication.The remaining patients had critical limb ischemia and required intervention for limb preservation. Ilio-femoral bypass with adjunctive procedures provided acceptable short term and mid-term results in complicated patients, 85% of whom had previously undergone ipsilateral vascular intervention.

Heart injury in juvenile systemic sclerodermy (clinical case)

Juvenile systemic sclerosis (JSS) has many clinical manifestations that differ from adults. Early diagnosis is problematic. The course of the disease and the severity of the prognosis depend on the involvement of internal organs in the process, first of all, the heart, lungs, kidneys. Cardiac pathology is a frequent and prognostically unfavorable target of the scleroderma process in adults, but it is rarely diagnosed in children. The aim of the work was to study the features of the clinical manifestations of systemic sclerosis in a child with severe heart disease. A polymorphism of the clinical symptoms of severe heart damage with the development of dilated cardiomyopathy in a one-year-old child with systemic sclerosis is presented. The features of the case are the early debut of systemic sclerosis in a child with a burdened hereditary history of autoimmune pathology (psoriasis in the father and grandmother), rapid progression of the autoimmune process, severe heart damage by the type of non-compact (dilated) cardiomyopathy, positive clinical dynamics when using pathogenetic therapy. Early detection of cardiovascular lesions using modern diagnostic methods, timely implementation of adequate therapy in a multidisciplinary team and regular cardiovascular screening can improve the prognosis, quality of life and reduce mortality.

Cardiac Scintigraphy and Screening for Transthyretin Cardiac Amyloidosis: Caveat Emptor.

Cardiac Scintigraphy and Screening for Transthyretin Cardiac Amyloidosis: Caveat Emptor.