Abstract
Aims
Tricuspid regurgitation (TR) is a frequent echocardiographic finding; however, its effect on outcome is unclear. The objectives of current study were to evaluate the impact of TR ...severity on heart failure hospitalization and mortality.
Methods and results
We retrospectively reviewed consecutive echocardiograms performed between 2011 and 2016 at the Tel-Aviv Medical Center. TR severity was determined using semi-quantitative approach including colour jet area, vena contracta width, density of continuous Doppler jet, hepatic vein flow pattern, trans-tricuspid inflow pattern, annular diameter, right ventricle, and right atrial size. Major comorbidities, re-admissions and all-cause mortality were extracted from the electronic health records. The final analysis included 33 305 patients with median follow-up period of 3.34 years (interquartile range 2.11–4.54). TR (≥mild) was present in 31% of our cohort. One-year mortality rates were 7.7% for patients with no/trivial TR, 16.8% for patients with mild TR, 29.5% for moderate TR, and 45.6% for patients with severe TR (P < 0.001). Univariate and multivariate analyses demonstrated a positive correlation between TR severity and overall mortality and rates of heart failure re-admission after adjustment for potential confounders. The proportional hazards method for overall mortality showed that patients with moderate hazard ratio (HR) 1.15, 95% confidence interval (CI) 1.02–1.3, P = 0.024 and severe TR (HR 1.43, 95% CI 1.08–1.88, P = 0.011) had a worse prognosis than those with no or minimal TR.
Conclusions
The presence of any degree of TR is associated with adverse clinical outcome. At least moderate TR is independently associated with increased mortality.
A large number of patients around the world are recovering from coronavirus disease 2019 (COVID-19); many of them report persistence of symptoms. The aim of this study was to test pulmonary, ...cardiovascular, and peripheral responses to exercise in patients recovering from COVID-19.
Patients who recovered from COVID-19 were prospectively evaluated using a combined anatomic and functional assessment. All patients underwent clinical examination, laboratory tests, and combined stress echocardiography and cardiopulmonary exercise testing. Left ventricular volumes, ejection fraction, stroke volume, heart rate, E/e' ratio, right ventricular function, oxygen consumption (Vo
), lung volumes, ventilatory efficiency, oxygen saturation, and muscle oxygen extraction were measured in all effort stages and compared with values in historical control subjects.
A total of 71 patients were assessed 90.6 ± 26 days after the onset of COVID-19 symptoms. Only 23 (33%) were asymptomatic. The most common symptoms were fatigue (34%), muscle weakness or pain (27%), and dyspnea (22%). Vo
was lower among post-COVID-19 patients compared with control subjects (P = .03, group-by-time interaction P = .007). Reduction in peak Vo
was due to a combination of chronotropic incompetence (75% of post-COVID-19 patients vs 8% of control subjects, P < .0001) and an insufficient increase in stroke volume during exercise (P = .0007, group-by-time interaction P = .03). Stroke volume limitation was mostly explained by diminished increase in left ventricular end-diastolic volume (P = .10, group-by-time interaction P = .03) and insufficient increase in ejection fraction (P = .01, group-by-time interaction P = .01). Post-COVID-19 patients had higher peripheral oxygen extraction (P = .004) and did not have significantly different respiratory and gas exchange parameters compared with control subjects.
Patients recovering from COVID-19 have symptoms associated with objective reduction in peak Vo
. The mechanism of this reduction is complex and mainly involves a combination of attenuated heart rate and stroke volume reserve.
Right ventricular (RV) dysfunction and tricuspid regurgitation (TR) may coexist with aortic stenosis. The aim of this study was to assess the association between RV dysfunction, TR, associated ...comorbidities, and outcomes following transcatheter aortic valve replacement (TAVR).
A retrospective analysis was conducted of baseline and 6-month clinical and echocardiographic parameters, including TR grade, RV size (grade, end-diastolic and end-systolic areas, annular diameter), and function (grade, tricuspid annular plane systolic excursion TAPSE, fractional area change, Tei index), in 519 consecutive TAVR patients.
The prevalence of moderate or greater TR was 11% (n = 59). Although TR was associated with increased mortality (P = .02) in unadjusted analysis, it did not demonstrate an independent association with outcome when adjusted for RV dysfunction (TAPSE; P = .30) or multiple clinical parameters (P ≥ .20). RV parameters associated with poor outcomes included TAPSE (P = .006) and Tei index (P = .005). TAPSE was associated with lower survival even when adjusted for TR (P = .009) and all clinical parameters (P = .01). Persistence of moderate or greater TR 6 months after TAVR seemed to be associated with lower survival (P = .02), even when adjusted for clinical and RV parameters (P = .07).
TR in association with aortic stenosis is frequently progressive despite TAVR but is not independently associated with outcomes. RV function is a stronger driver of adverse outcomes compared with TR itself, and RV quantitative rather than qualitative evaluation is the key to stratify these patients.
Abstract Background White blood cell count is an independent predictor of cardiovascular events and mortality. Neutrophil/lymphocyte ratio (NLR) is a biomarker that can single out individuals at risk ...for vascular events. Objective To evaluate whether NLR adds additional information beyond that provided by conventional risk factors and biomarkers for coronary artery disease (CAD) severity and adverse outcome, in a large cohort of consecutive patients referred for coronary angiography. Materials and methods NLR was computed from the absolute values of neutrophils and lymphocytes from the complete blood count of 3005 consecutive patients undergoing coronary angiography for various indications. CAD severity was determined by an interventional cardiologist unaware of the study aims. The association between NLR and CAD severity was assessed by logistic regression and the association between NLR and 3-years outcome were analyzed using Cox regression models, adjusting for potential clinical, metabolic, and inflammatory confounders. Results The cohort was divided into 3 groups according to the NLR value (<2, 2–3, and >3). NLR was independently associated with CAD severity and it contributed significantly to the regression models. Patients with NLR >3 had more advanced obstructive CAD (OR = 2.45, CI 95% 1.76–3.42, p < 0.001) and worse prognosis, with a higher rate of major CVD events during up to 3 years of follow-up (HR = 1.55, CI 95% 1.09–2.2, p = 0.01). Conclusion Neutrophil/lymphocyte ratio is independently associated with CAD severity and 3-years outcome. NLR value appears additive to conventional risk factors and commonly used biomarkers.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, SAZU, SBCE, UL, UM, UPCLJ, UPUK
Implantation of a device to narrow the coronary sinus and increase myocardial venous pressure was compared with a sham procedure in patients with refractory angina. The proportion of patients with ...improvement at 6 months was significantly greater with the device.
A growing number of patients with severe and diffuse obstructive coronary artery disease who are not candidates for revascularization have debilitating angina despite medical therapy.
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The worldwide prevalence of refractory angina is increasing, and new therapeutic options are needed.
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An endoluminal, balloon-expandable, stainless steel, hourglass-shaped device designed for percutaneous implantation in the coronary sinus (Reducer, Neovasc) creates a focal narrowing that leads to increased pressure in the coronary sinus, which may relieve angina (Figure 1). A nonrandomized first-in-human study involving 15 patients with refractory angina who were treated with the device showed significant improvement with respect to angina class. . . .
The diagnostic accuracy of the stethoscope is limited and highly dependent on clinical expertise. Our purpose was to develop an electronic stethoscope, based on artificial intelligence (AI) and ...infrasound, for the diagnosis of aortic stenosis (AS).
We used an electronic stethoscope (VoqX; Sanolla, Nesher, Israel) with subsonic capabilities and acoustic range of 3-2000 Hz. The study had 2 stages. In the first stage, using the VoqX, we recorded heart sounds from 100 patients referred for echocardiography (derivation group), 50 with moderate or severe AS and 50 without valvular disease. An AI-based supervised learning model was applied to the auscultation data from the first 100 patients used for training, to construct a diagnostic algorithm that was then tested on a validation group (50 other patients, 25 with AS and 25 without AS). In the second stage, conducted at a different medical center, we tested the device on 106 additional patients referred for echocardiography, which included patients with other valvular diseases.
Using data collected at the aortic and pulmonic auscultation points from the derivation group, the AI-based algorithm identified moderate or severe AS with 86% sensitivity and 100% specificity. When applied to the validation group, the sensitivity was 84% and specificity 92%; and in the additional testing group, 90% and 84%, respectively. The sensitivity was 55% for mild, 76% for moderate, and 93% for severe AS.
Our initial findings show that an AI-based stethoscope with infrasound capabilities can accurately diagnose AS. AI-based electronic auscultation is a promising new tool for automatic screening and diagnosis of valvular heart disease.
Abstract Background Mitral regurgitation (MR) is the most common valvular heart disease, and mitral valve surgery is the gold standard therapy for severe MR. Many patients with severe MR are not ...referred for surgery because of old age, comorbidities, or severe left ventricular dysfunction. Transcatheter mitral valve implantation may be a better therapeutic option for these high-risk patients with severe symptomatic MR. Objectives This study sought to describe the first-in-man series of transapical mitral valve implantation for mitral regurgitation with the TIARA device. Methods Extensive preclinical ex vivo and animal studies were conducted with the transapical mitral valve implantation of the Tiara system. The first 2 cases of human implantation were successfully performed in a 73-year-old man and a 61-year-old woman with severe functional MR. Both patients were in New York Heart Association class IV heart failure with depressed left ventricular ejection fraction, pulmonary hypertension, and additional comorbidities. Results The valve was implanted uneventfully in both patients. General anesthesia and transapical access were used. Patients were hemodynamically stable with no need for cardiopulmonary bypass. Immediately after implantation, systemic arterial pressure and stroke volume increased and pulmonary pressure decreased dramatically. There were no intraoperative complications, and both patients were extubated in the operating room. Post-procedural echocardiograms at 48 h, 1 month, and 2 months demonstrated excellent prosthetic valve function with a low transvalvular gradient and no left ventricular outflow tract obstruction. There was a trivial paravalvular leak in the first patient at 48 h, which was completely resolved at subsequent studies; no paravalvular leak occurred in the second patient. Conclusions Transapical transcatheter mitral valve implantation is technically feasible and can be performed safely. Early hemodynamic performance of the prosthesis was excellent. Transcatheter mitral valve implantation may become an important treatment option for patients with severe MR who are at high operative risk.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objectives The purpose of this research was to evaluate the relationship between coronary and carotid atherosclerotic disease using current guidelines for the definition of carotid artery stenosis ...(CAS). Background The reported prevalence of concomitant coronary and carotid atherosclerotic disease has varied among studies due to differences in study populations and methodologies used. Methods We performed a retrospective analysis of prospectively collected data obtained between January 2007 and May 2009 from consecutive patients undergoing same-day coronary angiography and carotid Doppler studies. Spearman correlations and multinomial logistic regression models were used to identify independent correlates of CAS. Results The study included 1,405 patients (age 65 ± 11 years, 77.2% male), of whom 12.8% had significant CAS (peak systolic velocity PSV >125 cm/s) and 4.6% had severe CAS (PSV >230 cm/s). Mild CAS (PSV <125 cm/s and the presence of a sonographic atherosclerotic lesion) was present in 58%. The severity of CAS and the extent of coronary artery disease (CAD) were significantly correlated (r = 0.255, p < 0.001). Independent predictors of severe CAS defined by PSV were the presence of left-main or 3-vessel CAD, increasing age, a history of stroke, smoking status, and diabetes mellitus. Conclusions The degree of internal carotid artery (ICA) stenosis is related to the extent of CAD, though the prevalence of clinically significant ICA stenosis is lower in specific CAD subsets than previously reported.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract New generation of the most widely used devices for transcatheter aortic valve implantation (TAVI) have been recently introduced into practice. We compare the short term outcomes of TAVI with ...the Edwards SAPIEN S3 and the Medtronic Evolut-R. We performed a retrospective analysis from a single high volume tertiary center. Valve Academic Research Consortium (VARC)-2 criteria were used to define composite endpoints of device success and safety at 30 days. Study population included 232 patients implanted with the SAPIEN S3 (n=124) and Evolut-R (n=108). Device success reached 91.9% and 95.4% in the SAPIEN S3 and Evolut-R groups, respectively (p=0.289). Post-procedural echocardiography showed higher AV gradients (22.8±7 mmHg vs. 16±9 mmHg, p<0.001) among SAPIEN S3 group. Paravalvular leak of ≥ moderate severity was observed in 2.4% and 0% in the SAPIEN S3 and Evolut-R groups, respectively (p=0.251). Similar rates of in hospital complications, including major bleedings, vascular complications and pacemaker implantations were recorded in both groups. At 30 day follow-up, the combined-safety endpoint was reached in 5.6% and in 6.5% of patients in the SAPIEN S3 and Evolut-R groups, respectively (p=0.790). During follow up of 237±138 days, all-cause mortality was higher among patients implanted with Evolut-R compared to SAPIEN S3 (7 vs. 1 cases, respectively, p=0.006), however, cardiovascular mortality was not significantly different between groups. In conclusions, in a single-center comparative analysis, comparable rate of device success as well as safety profile and long term cardiovascular mortality were observed with the SAPIEN S3 and Evolut-R valves.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
We sought to divide COVID-19 patients into distinct phenotypical subgroups using echocardiography and clinical markers to elucidate the pathogenesis of the disease and its heterogeneous cardiac ...involvement. A total of 506 consecutive patients hospitalized with COVID-19 infection underwent complete evaluation, including echocardiography, at admission. A k-prototypes algorithm applied to patients' clinical and imaging data at admission partitioned the patients into four phenotypical clusters: Clusters 0 and 1 were younger and healthier, 2 and 3 were older with worse cardiac indexes, and clusters 1 and 3 had a stronger inflammatory response. The clusters manifested very distinct survival patterns (C-index for the Cox proportional hazard model 0.77), with survival best for cluster 0, intermediate for 1-2 and worst for 3. Interestingly, cluster 1 showed a harsher disease course than cluster 2 but with similar survival. Clusters obtained with echocardiography were more predictive of mortality than clusters obtained without echocardiography. Additionally, several echocardiography variables (E' lat, E' sept, E/e average) showed high discriminative power among the clusters. The results suggested that older infected males have a higher chance to deteriorate than older infected females. In conclusion, COVID-19 manifests differently for distinctive clusters of patients. These clusters reflect different disease manifestations and prognoses. Although including echocardiography improved the predictive power, its marginal contribution over clustering using clinical parameters only does not justify the burden of echocardiography data collection.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
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