Left ventricular outflow tract obstruction (LVOTO) causes exertional symptoms in two thirds of patients with hypertrophic cardiomyopathy (HCM). Consensus guidelines recommend surgical intervention in ...patients with drug refractory symptoms. The primary aim of this study was to perform a systematic review and meta-analysis to determine morbidity and mortality after surgery.
Study Selection: Studies reporting outcomes following surgical intervention for symptomatic LVOTO in HCM.
Data Extraction: Articles from searching two scientific databases (PubMed and Web of Science) were reviewed and data were extracted by two investigators. Meta-analysis of data was performed with heterogeneity assessed using I2 statistic.
85 studies were included in the systematic review and 35 studies in the meta-analysis. Contemporary early (<30 days) and late (>30 days) mortality following septal myectomy were 1.4% (CI 0.8, 2.4) I2 9.0%, p = 0.36 and 0.7% (CI 0.3, 1.2) I2 70.7%, p < 0.05 respectively. Sixty-eight studies (80%) reported perioperative complications. The contemporary rate of a perioperative ventricular septal defect was 1.4% (0.8, 2.3) I2 0%, p < 0.05. Late morbidities including atrial fibrillation, stroke, heart failure and transplant were reported in fewer than 22% of studies and few studies compared mortality and clinical outcomes using different surgical approaches to LVOTO. The incidence rate (IR) of reintervention with a further surgical procedure was 0.3% (CI 0.2, 0.4) I2 52.5%, p < 0.05.
Contemporary surgical management of LVOTO is associated with low operative mortality rates but further studies are needed to investigate the impact of surgical therapy on non-fatal early and late complications.
•Contemporary operative mortality following SM and SM with MV repair is low.•Contemporary outcome data on the use of MV replacement for LVOTO is less robust.•Reporting of long-term morbidity is less robust than that of early complications.•Further studies are required on long-term surgical outcomes in LVOTO.
We aimed to assess the use of enhanced stent visualisation (ESV) on outcomes, after PCI with overlapping stents, specifically using CLEARstent technology.
Stent underexpansion and overlap are both ...significant risk factors for restenosis and stent thrombosis. Enhanced stent visualisation (e.g. CLEARstent) systems could provide important data to reduce under-expansion and stent overlap.
This was a cohort study based on this institution's percutaneous coronary intervention (PCI) registry. A total of 2614 patients who had PCI for stable angina or acute coronary syndromes (ACS, excluding cardiogenic shock) with overlapping 2nd generation drug eluting stents (DES) in the same vessel between May 2015 and January 2018 were included in the analysis. Patients were divided into ESV (n = 1354) and no ESV guided intervention (n = 1260). The primary end-point was major adverse cardiovascular events (MACE: target vessel revascularisation, target vessel myocardial infarction and all-cause mortality) recorded at a median follow up of 2.4 years.
Groups were comparable for patient characteristics (age, diabetes mellitus, ACS presentation). A significant difference in MACE was observed between patients who underwent ESV-guided PCI (9.5%) compared with patients who underwent Standard PCI (14.4%, p = .018). This difference was mainly driven by reduced rates of target vessel revascularisation and recurrent myocardial infarction. Overall this difference persisted after multivariate Cox analysis (HR 0.86, 95% CI: 0.73–0.98) and propensity matching (HR = 0.88, 95% CI: 0.69–0.99).
We suggest that routine clinical use of ESV technology during PCI can be useful, and is associated with better medium-term angiographic and clinical outcomes. Further study is required to build on this promising signal.
•Stent underexpansion, underdeployment and geographical miss remain risk factors for stent complications in the DES era.•ESV systems are easy to install and use, adding a few extra contrast free seconds onto standard image acquisition.•In this large study of over 2500 patients, we found a significant association between ESV use and MACE rates compared to standard PCI alone (9.5% vs 14.4% (p = .0018)).•This suggests that the routine use of this simple, quick, cheap and widely available technology may improve patient outcomes after PCI Further randomized trials are needed to see whether the routine use of ESV technology replicates this promising signal.
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Hypertrophic cardiomyopathy (HCM) is a recognized cause of sudden cardiac death and dysrhythmias. Patients with HCM and ...marked left ventricular outflow tract obstruction (LVOTO) may benefit from invasive therapies such as septal myectomy or alcohol septal ablation (ASA) (1). This study aimed to compare patient outcomes post-ASA and post-septal myectomy within a specialized tertiary centre.
Purpose
To establish the efficacy and safety outcomes of septal reduction therapies. Postoperative conduction abnormalities are the most common long-term postoperative complications in this population (2); however, specific patient outcomes at our tertiary heart centre were previously unknown.
Methods
This retrospective analysis included patients who underwent ASA (n= 66) or septal myectomy (n=151) between 2015 and 2021. Ethical approval was obtained before commencing the study. Two independent investigators extracted the preoperative and postoperative data from echocardiograms, electrocardiograms, clinic letters, and discharge forms. Normally distributed variables were reported as mean and standard deviation and analysed using an unpaired T-test with Welch's correction. Non-normally distributed variables were reported as median and interquartile range and analysed using the Mann-Whitney U test.
Results
The mean follow-up time was 2.69 ±1.37 years in the ASA cohort and 1.38 ±1.18 years in the myectomy cohort. There were no differences in gender or ethnic composition; however, on average, patients in the ASA cohort were 10.40 ± 1.82 years older than those in the myectomy cohort (95% CI: 13.99 to 6.81, p< 0.0001). Significant improvements in New York Heart Association (NYHA) class occurred across both cohorts (p< 0.0001). Post-ASA resting LVOT gradients decreased from 54.00 to 13.00 mmHg (95% CI: -45.00 to -21.00, p< 0.0001). Post-myectomy resting LVOT gradients decreased from 60.00 to 4.90 mmHg (95% CI: -57.00 to -41.00, p< 0.0001) and were significantly lower than post-ASA (p= 0.0007). In addition, re-intervention rates were higher post-ASA compared to post-myectomy 40% vs 1.32% respectively, (p< 0.0001). ASA also carried a greater risk of permanent pacemaker implantation 18% vs. 8% (p=0.0270), complete heart block 22% vs. 6% (p= 0.0016), and right bundle branch block 28% vs 0% (p< 0.0001) compared to septal myectomy. In contrast, septal myectomy had a greater risk of postoperative atrial fibrillation 20% vs 1.5% (p= 0.0004), and left bundle branch block 60% vs 7% (p< 0.0001) compared to ASA. Perioperative mortality was 0 (0%) in both cohorts.
Conclusion
In conclusion, both interventions were safe and provided significant symptomatic relief and effective gradient reduction. However, conduction abnormalities remain a considerable risk of septal reduction therapies and may contribute to patient morbidity. More research is needed to minimize intervention risks and further improve patient outcomes.
Abstract
Introduction
A monogenic cause of a dilated cardiomyopathy (DCM) phenotype is found in upto 37% of patients 1.
Purpose
Evaluate the influence of genotype on end-stage heart failure (ESHF) ...outcomes in DCM.
Methods
Consecutive patients carrying variants from the 3 most prevalent DCM genotypes in a database from a cardiomyopathy unit (TTN, DSP and LMNA) and with features of DCM at baseline were retrospectively recruited. Consecutive DCM patients returning a negative result from a next generation DCM panel were recruited for comparison. ESHF was defined as left ventricular assist device implantation, heart transplantation or heart-failure related death. The incidence of ESHF was compared between genotypes during follow-up.
Results
493 patients from 445 families (311 (63.1%) males, presenting at a median IQR age of 50.8 years 37.3 – 59.8) with a median follow-up of 46.5 28.1 – 88.2 months were recruited (Table 1). 26/493 (5.3%) of patients had ESHF by last evaluation. The highest incidence of ESHF was seen in LMNA variant-carriers and the lowest in genotype-negative patients (Figure 1). In a multivariable Cox model including age at presentation, sex and proband status, LMNA variant-carriage was associated with an increased risk of ESHF (HR 9.7 4.6 – 20.6, p < 0.001) and genotype-negative status was associated with a reduced risk of ESHF (HR 0.08 0.02 – 0.41, p = 0.002)
Conclusions
Genotype impacts the incidence of ESHF in patients with DCM. Close monitoring with early initiation of heart failure therapies is essential to mitigate this risk, particularly in LMNA variant-carriers.Table 1Figure 1
Abstract
Background
Genetic testing of patients with dilated cardiomyopathy (DCM) results in identification of a causative gene variant in around 19-37% of individuals 1. Serial clinical assessment ...of relatives found to carry genetic variants is recommended, but there are no data to guide screening intervals or to better understand the influence of age, sex and genotype on disease expression.
Purpose
To evaluate the trajectory of disease development in clinically unaffected relatives with a positive genetic test.
Methods
Families with a likely pathogenic or pathogenic variant in DCM related genes were identified from the database at a cardiomyopathy unit. Families were included only where phenotypes were consistent with DCM or hypokinetic non-dilated cardiomyopathy 2. Consecutive relatives from these families were retrospectively recruited where they had tested positive for the familial genetic variant and were clinically unaffected at baseline evaluation. Incidence rates of disease penetrance during follow-up were stratified by sex and genotype.
Results
131 relatives (59 male (45%) with median age 28.6 21.5 – 42.0 years at first evaluation) representing 75 families were included. The most prevalent genotypes were DSP (46/131, 35.1%), TTN (32/131, 24.4%) , LMNA (22/131, 16.8%), RBM20 (14/131, 10.7%) and BAG3 (8/131, 6.1%). The overall incident rate of phenotype development during follow-up was 11.6 8.9 – 14.2 per 100 person years and rates were significantly different between males and females (16.1 versus 8.8 per 100 person-years, log-rank p value = 0.006; Figure 1). LMNA variant-carriers had the highest incidence rate of disease penetrance at 17.7 9.8 – 25.7 per 100 person-years and disease penetrance occurred at a younger age than DSP and TTN variant-carriers (Figure 2).
Conclusions
Disease development during follow-up is common in genotype-positive relatives, particularly in males and in LMNA variant-carriers. Genotype-positive relatives should be rescreened at least once each year.Figure 1Figure 2
Abstract
Background
It has been previously reported during the first COVID outbreak that patients presenting with ST-Segment Elevation Myocardial Infarction (STEMI) and concurrent COVID-19 infection ...have increased thrombus burden and poorer outcomes 1. Subsequently, there have been multiple further waves of the pandemic with the emergence of at least two new COVID-19 variants and the emergence of vaccinations. To-date, there have been no reports comparing the outcomes of COVID-19-positive STEMI patients across all waves of the pandemic.
Purpose
The purpose of this study was to compare the baseline demographic, procedural and angiographic characteristics alongside the clinical outcomes of patients presenting with STEMI and concurrent COVID-19 infection across the COVID-19 pandemic in the UK.
Methods
This was a single-centre, observational study of 1250 consecutive patients admitted with confirmed STEMI treated with primary percutaneous coronary intervention (PCI) at Barts Heart Centre between 01/03/2020 and 10/03/2022. COVID +ve patients were split into 3 groups based upon the time course of the pandemic (Wave 1: March 2020-June 2020, Wave 2: Sept 2020-March 2021, Wave 3: October 2021-March 2022). Comparison was made between waves and with a control group of COVID-ve patients treated during the same timeframe.
Results
A total of 135 COVID +ive patients with STEMI (1st Wave: 39 patients, 2nd Wave: 60 patients, 3rd wave 35 pts) were included in the present analysis; and compared with 1115 COVID negative patients. Significant changes in the baseline characteristics, angiographic features and clinical outcomes of COVID +ive patients occurred over time. Early during the pandemic (Wave 1 2020), STEMI patients presenting with concurrent COVID-19 infection had high rates of cardiac arrest, evidence of increased thrombus burden (higher rates of multi-vessel thrombosis, stent thrombosis, higher modified thrombus grade higher use of GP IIb/IIIa inhibitors and thrombus aspiration, coagulability (more heparin for therapeutic ACT), bigger infarcts (lower myocardial blush grade and left ventricular function) and worse outcomes (mortality). However, by wave 3 (late 2021/2022), no differences existed in clinical characteristics, thrombus burden, infarct size or outcomes between COVID +ive patients and those without concurrent COVID-19 infection with significant differences compared to earlier COVID +ve patients. Poor outcomes later in the study period were predominantly in unvaccinated individuals.
Conclusions
Significant changes have occurred in the clinical characteristics, angiographic features and outcomes of STEMI patients with COVID-19 infection treated by primary PCI during the course of the pandemic. Importantly it appears that angiographic features and outcomes of recent waves are no different to a non-COVID-19 population.
Funding Acknowledgement
Type of funding sources: None.
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