Introduction
There is scarce knowledge about gender differences in clinical presentation, management, use of risk stratification tools and prognosis in cardiogenic shock (CS) patients.
Purpose
The ...primary endpoint was to investigate the differences in characteristics, management, and in-hospital mortality according to gender in a cohort of CS patients admitted to a tertiary hub center. The secondary endpoint was to evaluate the prognostic performance of the Society of Cardiovascular Angiography and Interventions (SCAI) classification in predicting in-hospital mortality according to sex.
Methods
This is a retrospective single-Center cohort study of CS patients treated by a multidisciplinary shock team between September 2014 and December 2020. Baseline characteristics and clinical outcomes according to gender were registered. Discrimination of SCAI classification was assessed using the area under the receiver operating characteristic curve (AUC).
Results
Overall, 163 patients were included, 39 of them female (24%). Mean age of the overall cohort was 55 years (44–62), similar between groups. Compared with men, women were less likely to be smokers and the prevalence of COPD and diabetes mellitus was significantly lower in this group (
p
< 0.05). Postcardiotomy (44 vs. 31%) and fulminant myocarditis (13 vs. 2%) were more frequent etiologies in females than in males (
p
= 0.01), whereas acute myocardial infarction was less common among females (13 vs. 33%). Regarding management, the use of temporary mechanical circulatory support, mechanical ventilation, or renal replacement therapy was frequent and no different between the groups (88, 87, and 49%, respectively, in females vs. 42, 91, and 41% in males,
p
> 0.05). In-hospital survival in the overall cohort was 53%, without differences between groups (52% in females vs. 55% in males,
p
= 0.76). Most of the patients (60.7%) were in SCAIE at presentation without differences between sexes. The SCAI classification showed a moderate ability for predicting in-hospital mortality (overall, AUC: 0.653, 95% CI 0.582–0.725). The AUC was 0.636 for women (95% CI 0.491–0.780) and 0.658 for men (95% CI 0.575–0.740).
Conclusions
Only one in four of patients treated at a dedicated CS team were female. This may reflect differences in prevalence of severe heart disease at young (<65) ages, although a patient-selection bias cannot be ruled out. In this very high-risk CS population of multiple etiologies, overall, in-hospital survival was slightly above 50% and showed no differences between sexes. Treatment approaches, procedures, and SCAI risk stratification performance did not show gender disparities among treated patients.
Cardiac allograft vasculopathy (CAV) remains a major cause of morbidity and mortality among long-term heart transplant recipients. There is an unmet need for a non-invasive biomarker of CAV that ...could obviate the need to perform surveillance coronary angiograms in these patients. Our aim was to evaluate the performance of Donor-derived Cell Free DNA (dd-cfDNA) as a biomarker of CAV.
We prospectively measured dd-cfDNA levels in all patients undergoing routine coronary angiography >1 year after heart transplant at a single center. Endpoints included the association between dd-cfDNA levels and the presence CAV, according to several prespecified criteria.
We included 94 heart transplant recipients, a median of 10.9 years after transplant. Coronary angiogram revealed CAV
, CAV
, CAV
, and CAV
in 61, 19, 14, and 6% of patients, respectively. Comparison of dd-cfDNA levels in patients with CAV
and CAV
(primary end-point) did not show significant differences (0.92%, IQR 0.46-2.0 vs. 0.46%, IQR 0.075-1.5,
= 0.059), nor did the comparison between patients with stable CAV (no new coronary lesions since previous angiogram,
= 77) and progressive CAV (
= 17); dd-cfDNA values 0.735% (IQR 0.195-2.0) vs. 0.9% (IQR 0.12-1.8),
= 0.76. However, we found an association between NTproBNP levels and CAV degree (
= 0.017). Dd-cfDNA levels did not correlate with NTproBNP (ρ = -0.095).
In this study, dd-cfDNA did not perform as a useful biomarker to avoid surveillance coronary angiograms for CAV diagnosis.
Potential Role of Donor-derived Cell Free DNA as a Biomarker in Cardiac Allograft Vasculopathy, NCT04791852.
Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy over the last decade. Pembrolizumab, a humanized monoclonal IgG4 antibody, binds to the programmed death 1 (PD-1) receptor, ...blocking its interaction with programmed death-ligand 1 (PD-L1) and thereby increasing the anti-tumor activity of the host immune system. These drugs are associated with immune-mediated side effects that can be life threatening, and myocarditis is among the most serious events. We present a 48-year-old woman with a history of progressive thymoma who developed complete atrioventricular block associated with fulminant myocarditis and myasthenia gravis 2 weeks after starting treatment with pembrolizumab. She had also presented a couple of days before to the emergency department due to dyspnea that was related to pleural effusion. Electrocardiogram (ECG) and echocardiogram were unremarkable, but she had very mildly increased troponin levels that were attributed to acute respiratory compromise, so she was discharged after successful thoracentesis. Despite aggressive treatment combination of high-dose corticosteroids, immunosuppressive agents and anti-thymocyte globulin, the disease rapidly progressed to the fatal outcome. This report remarks on the importance of rapid consideration of ICI-induced myocarditis even if cardiac biomarkers are slightly elevated, as a mild presentation can go unnoticed and progress to a severe case. Therefore, a high index of suspicion is warranted in these patients and cardiac imaging techniques such as magnetic resonance could have a role diagnosing incipient cardiac inflammation.
Introduction and objectives: Endomyocardial biopsy (EMB) is an established diagnostic tool in myocardial disease. However, this technique may carry major complications. We present the diagnostic and ...safety results of our experience in EMB in the non-transplant setting. We also present the results after the implementation of a technical and safety protocol developed at our center.
Methods: We retrospectively analyzed the data of all EMBs conducted in non-transplant patients from September 2004 through July 2018. We compared the diagnostic yield and rate of major complications of EMB in two different periods: before and after implementing the protocol.
Results: We included 204 EMBs performed in 190 patients. The most frequent indications were the evaluation of ventricular dysfunction or suspected myocarditis (51.5%) and the evaluation of restrictive cardiomyopathy or suspected infiltrative disease (44.6%). One hundred and seventy-two EMBs were performed in the right cardiac chambers (84.3%) and 30 EMBs in the left cardiac chambers (14.7%). The samples were taken from both ventricles on 2 cases only. Definite diagnosis was reached in 52% of the cases. After the implementation of the protocol, the diagnostic yield significantly improved (42.5% vs 58.1%; P = .030) and the rate of major complications decreased (from 7.5% to 3.2%; P = .167), with a statistically significant lower rate of cardiac perforation (6.3% vs 0.8%; P = .025).
Conclusions: The EMB is a diagnostic tool with a great potential in patients with suspected cardiomyopathy. Our experience shows that a technical and safety protocol can help decrease the rate of complications and improve the diagnostic yield of EMB.
Introducción y objetivos: La biopsia endomiocárdica (BEM) es una técnica diagnóstica fundamental en el diagnóstico de distintas miocardiopatías, pero no está exenta de posibles complicaciones. Se presentan los resultados en términos de rentabilidad diagnóstica y seguridad de la serie de BEM realizadas en corazón no trasplantado en nuestro hospital, así como las consecuencias de la implementación de un protocolo de actuación y seguridad en BEM desarrollado en nuestro centro.
Métodos: Se revisaron de forma retrospectiva todas las BEM en corazón no trasplantado realizadas desde septiembre de 2004 hasta julio de 2018. Se comparó la rentabilidad diagnóstica y seguridad en dos etapas: antes y después de la puesta en marcha del protocolo.
Resultados: Se incluyeron 204 BEM realizadas en 190 pacientes. La indicación más frecuente fue el estudio de disfunción ventricular o sospecha de miocarditis (51,5%), seguida de estudio de miocardiopatía restrictiva o infiltrativa (44,6%). Se realizaron 172 BEM en cavidades derechas (84,3%) y 30 en cavidades izquierdas (14,7%); solo en 2 de los procedimientos se tomaron muestras de ambos ventrículos. La BEM permitió el diagnóstico definitivo en el 52% de los casos. Tras la implementación del protocolo se observó una mejoría en la rentabilidad diagnóstica (42,5 frente a 58,1%; p = 0,030) y una disminución en la tasa de complicaciones mayores (del 7,5% al 3,2%; p = 0,167), con una reducción estadísticamente significativa en la tasa de perforaciones cardiacas (6,3 frente a 0,8%; p = 0,025).
Conclusiones: La BEM es una técnica con un gran potencial diagnóstico en pacientes con sospecha de miocardiopatía. Aunque puede presentar complicaciones potencialmente graves, la puesta en marcha de un protocolo de actuación y seguridad se asocia a una reducción en la tasa de complicaciones y a una mejoría en la rentabilidad diagnóstica.
RESUMEN Introducción y objetivos: Los pacientes receptores de un trasplante cardiaco necesitan someterse a biopsias endomiocárdicas (BEM) para descartar el rechazo, procedimiento que habitualmente se ...realiza por acceso venoso yugular o femoral. En los últimos años hemos desarrollado una técnica de biopsia por vía braquial, que hemos implementado como acceso preferente. En este artículo describimos la técnica y la experiencia clínica inicial de 2 centros empleando el acceso braquial. Métodos: Entre 2004 y 2016 desarrollamos e implementamos la técnica de biopsia por vía venosa braquial. Se registraron las principales variables clínicas y del procedimiento de todas las BEM realizadas por vía braquial en ambos centros, y se compararon las características con los procedimientos realizados por vía femoral y yugular. Resultados: Se realizó la BEM por vía braquial en 544 casos, sin complicaciones mayores. El número de procedimientos braquiales por paciente varió entre 1 y 14. En el mismo periodo se realizaron 1.054 BEM femorales y 686 yugulares. La duración total del procedimiento fue similar por los distintos accesos (mediana braquial/femoral/yugular: 28/26/29 min; p = 0,31), con un menor tiempo de escopia por vía yugular (mediana 5/5/3 min, respectivamente; p < 0,001). Los procedimientos realizados por vía braquial se valoraron como menos dolorosos que los realizados por vía yugular o femoral (2/8/9 en la escala de dolor EVA de 1-10, respectivamente; p = 0,001), y fue la vía de elección por parte de los pacientes. Conclusiones: La BEM por vía venosa braquial es una buena alternativa a la punción venosa central y la vía de elección en nuestros centros, con altas factibilidad y seguridad, y mayor comodidad para el paciente.
ABSTRACT
Aims
To assess the prevalence, clinical characteristics, and outcomes of patients with heart failure (HF) with or without moderate to severe aortic valve disease (AVD) (aortic stenosis AS, ...aortic regurgitation AR, mixed AVD MAVD).
Methods and results
Data from the prospective ESC HFA EORP HF Long‐Term Registry including both chronic and acute HF were analysed. Of 15 216 patients with HF (62.5% with reduced ejection fraction, HFrEF; 14.0% with mildly reduced ejection fraction, HFmrEF; 23.5% with preserved ejection fraction, HFpEF), 706 patients (4.6%) had AR, 648 (4.3%) AS and 234 (1.5%) MAVD. The prevalence of AS, AR and MAVD was 6%, 8%, and 3% in HFpEF, 6%, 3%, and 2% in HFmrEF and 4%, 3%, and 1% in HFrEF. The strongest associations were observed for age and HFpEF with AS, and for left ventricular end‐diastolic diameter with AR. AS (adjusted hazard ratio HR 1.43, 95% confidence interval CI 1.23–1.67), and MAVD (adjusted HR 1.37, 95% CI 1.07–1.74) but not AR (adjusted HR 1.13, 95% CI 0.96–1.33) were independently associated with the 12‐month composite outcome of cardiovascular death and HF hospitalization. The associations between AS and the composite outcome were observed regardless of ejection fraction category.
Conclusions
In the ESC HFA EORP HF Long‐Term Registry, one in 10 patients with HF had AVD, with AS and MAVD being especially common in HFpEF and AR being similarly distributed across all ejection fraction categories. AS and MAVD, but not AR, were independently associated with increased risk of in‐hospital mortality and 12‐month composite outcome, regardless of ejection fraction category.
Aortic valve disease in patients with heart failure and reduced, mildly reduced and preserved ejection fraction: The ESC Heart Failure Long‐Term Registry. AR, aortic regurgitation; AS, aortic stenosis; AVD, aortic valve disease; BMI, body mass index; CI, confidence interval; EF, ejection fraction; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HR, hazard ratio; IHD, ischaemic heart disease; MAVD, mixed aortic valve disease; NT‐proBNP, N‐terminal pro‐B‐type natriuretic peptide; NYHA, New York Heart Association. Correction added on 26 July 2023, after first online publication: Graphical caption has been added in this version.
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