Clinical Research in Cardiology最新文献

Background: Closure of a patent foramen ovale (PFO) is an effective strategy in the prevention of recurrent stroke after cryptogenic stroke. Residual shunt (RS) is a common issue following PFO closure and may affect safety and efficacy. Transesophageal echocardiography (TEE) is the key diagnostic tool, but standardized assessment of morphological parameters to prevent RS remains challenging.

Aims: In this study, we investigate the diagnostic value of different anatomical parameters assessed by TEE to predict RS after PFO closure.

Methods: We consecutively enrolled five-hundred and twenty-seven (n = 527) patients undergoing PFO closure. We performed pre-interventional TEE, and after PFO closure, we then screened for RS by TEE at 6-month follow-up.

Results: Pre-interventional TEE measures of PFO morphology revealed significant differences in patients with RS in comparison to those with closed PFO. Incidence of RS was significantly more frequent in patients with atrial septum aneurysm (p = 0.022) and increasing PFO size (p = 0.025). In patients with RS, we found significantly increased length (p = 0.005) of septum primum and PFO tunnel (p = 0.036) as well as excursion (p = 0.005) of septum primum. By training machine learning models on TEE parameters, stratification of PFO morphology resulted in high diagnostic accuracy to predict RS after PFO closure.

Conclusions: Our study elucidates that a baseline characterization of PFO morphology using TEE improves diagnostic precision to identify patients with RS after PFO closure. A standardized approach might thus enhance the efficacy and safety of transcatheter PFO closure. Prediction of complete closure might reduce complications and allow for a more refined patient selection and treatment.

Background: Catheter-directed thrombolysis using the EkoSonic™ Endovascular System (EKOS) is an established therapy for intermediate-high risk (IHR) pulmonary embolism (PE). However, whether the timing of intervention, during regular working hours (RW) versus (vs.) on duty hours (OD), impacts safety and efficacy outcomes remains unclear.

Methods: We retrospectively analyzed consecutive patients with IHR-PE treated with EKOS-lysis at three German centers between 08/2020 and 12/2023. Patients were grouped by timing into RW and OD group, based on institutional definitions of working hours. The primary endpoint was procedural safety, including in-hospital mortality of any cause and bleeding/non-bleedings complications. Secondary outcome compromised echocardiographic efficacy parameters, including reduction in right ventricular to left ventricular (RV/LV) ratio, systolic pulmonary artery pressure (sPAP), and improvement in tricuspid annular plane systolic excursion (TAPSE).

Results: Of 154 patients, 99 procedures were performed during RW hours, while 55 were done during OD hours. Baseline characteristics were comparable in both groups. Door-to-EKOS time (20.6 (4.8; 44) h vs. 7.2 (4,1; 19) h; p = 0.012) and CT-EKOS time (6.4 (1.3; 20) h vs. 2.3 (1.4; 3.5) h; p = 0.002) were significantly shorter during OD. Overall complication rates were lower OD (20 (20.2%) vs. 4 (7.3%); p = 0.038), with fewer bleeding events (18 (18.2%) vs. 3 (5.5%); p = 0.029). In-hospital mortality was similar (RW 8 (8.1%) vs. OD 2 (3.6%); p = 0.496). Both groups showed significant improvement in echocardiographic parameters with no significant intergroup differences in treatment efficacy.

Conclusion: EKOS-lysis performed during OD hours is safe and effective, with even fewer complications than during RW hours. These findings support the feasibility and safety of continuous PE-care by an experienced Pulmonary Embolism Response Team irrespective of procedural timing.

Background: Obesity or underweight can complicate and aggravate symptoms and progression of right heart failure in patients with pulmonary arterial hypertension (PAH). This study investigates the influence of different body mass index (BMI) categories on right heart function and outcome in PAH patients.

Methods: In this cross-sectional study with survival follow-up (mean follow-up 3.1 ± 2.6 years, median 2.7 years), clinical measures such as WHO-functional class and invasively measured hemodynamic parameters at initial diagnosis of PAH were compared between different BMI groups.

Results: Out of 2055 data sets, 755 patients with PAH (62.5% female) were eligible for the study (65 ± 15 years, 44.9% idiopathic PAH, 64.8% WHO functional class III or IV). Out of them 15 patients (1.99%) were underweight (BMI < 18 kg/m²), 248 (32.85%) patients had a normal weight (BMI 18.5-25 kg/m²), 256 (33.91%) were overweight (BMI > 25 to 30 kg/m²) and 236 patients (31.26%) were classified as obese (BMI > 30 kg/m²). Worst survival was denoted for patients with BMI < 18.5 kg/m², best survival for BMI > 25 to 30 kg/m². Cardiac output (CO) significantly differed between BMI groups (p < 0.0001, R = 0.268) and sex. In multivariable age-adjusted survival analysis, BMI-status, sex and right ventricular function were identified as independent predictors of survival.

Conclusions: This is the first study to assess RV function with regard to BMI status and survival in PAH. The study underlines the importance of the parameter body weight in the clinical management of PAH patients. It provides important insights in the relations of BMI and CO and documented significant gender differences.

Introduction: Supervised physical exercise has been shown to benefit patients with heart failure with preserved/mildly reduced ejection fraction (HFpEF/HfmrEF) by improving symptoms and diastolic function. This study aimed to investigate the correlation between unsupervised daily physical activity and changes in daily pulmonary artery pressure (PAP) in patients with stable NYHA class III heart failure (HF) and left ventricular ejection fraction (LVEF) of 45% or higher.

Methods: Daily physical activity was monitored over a 3-month period using a Holter-ECG with an accelerometer that calculated an activity-associated, heart rate-derived metabolic equivalent of task (MET) score. PAP was measured using an implanted sensor in 17 patients.

Results: During 3 months of PAP monitoring in parallel with Holter ECG in our HF patients (median age 77 [IQR 72-79.5] years, LVEF 55 [49-56] %, mean cardiac index 1.9 ± 0.3), mean, diastolic, and systolic PAP remained unchanged. Patients engaged in unsupervised daily activity with a mean MET score of 5.0 ± 1.2 and a median daily duration of 41 [13-123] minutes. Intensity of daily activity was associated with a higher diastolic PAP on the following day (R² = 0.017, p = 0.003), particularly in female patients and those with pulmonary hypertension (PH) (female: R² = 0.044, p = 0.002; PH: R² = 0.024, p = 0.004). Patients with longer daily activity durations had lower systolic and mean PAP (p = 0.038 and p = 0.048) and a similar diastolic PAP (p = 0.053) after 3 months.

Conclusions: Tracking changes in daily PAP based on intensity and duration of unsupervised daily activity using implanted sensors and a PocketECG^® is feasible. While daily activity duration was not directly linked to diastolic PAP on the first day after daily activity, intensity, especially in female and PH patients, was associated with increased diastolic PAP. In addition, longer daily activity, rather than higher intensity, might be more important for lowering PAP in the long term. Further research in larger trials is warranted to confirm these findings.

Background: Several studies have investigated the efficacy of additional left atrial (LA) roof ablation to pulmonary vein isolation (PVI) using cryoballoon for persistent atrial fibrillation (AF). However, the evidence from randomized controlled trials regarding adjunctive LA roof ablation with cryoballoon remains unclear.

Objective: This study aimed to prospectively evaluate the efficacy and safety of adding LA roof ablation to PVI using cryoballoon in patients with persistent AF.

Methods: A total of 106 patients with persistent AF who underwent an initial catheter ablation using cryoballoon were randomly assigned in a 1:1 ratio to either PVI plus LA roof ablation (53 patients) or PVI alone (53 patients). The primary outcome was freedom from recurrence of atrial tachyarrhythmia lasting ≥ 30 s at 12 months after a single ablation procedure. The secondary outcome was procedure-related complications.

Results: No significant differences were observed in baseline characteristics between the PVI-plus group and the PVI-alone group. PVI was successfully performed in all patients. In the PVI-plus group, LA roof ablation was completed successfully in all cases. There was no significant difference in the recurrence-free rate between the two groups (P = 0.071, log-rank test). In addition, no significant differences were observed in procedure-related complications between the two groups.

Conclusion: The addition of LA roof ablation to PVI did not demonstrate superiority to PVI alone in patients with persistent AF undergoing cryoballoon ablation. However, it did not increase the risk of procedure-related complications.

Aims: Left ventricular heart failure (LVHF) remains a major contributor to morbidity and mortality, with sex-specific differences. This study investigates the influence of sex and New York Heart Association (NYHA) classification on clinical outcomes and healthcare costs.

Methods and results: We analyzed data from 2,616,462 LVHF hospitalization cases in Germany (2014-2022), sourced from the Research Data Centre of the Federal Statistical Office and Statistical Offices of the Federal States (DESTATIS). Cases were stratified by sex and NYHA stages. Baseline characteristics, comorbidities, in-hospital outcomes, and healthcare costs were assessed. Multivariable logistic regression evaluated in-hospital survival. Women were more frequently diagnosed at earlier NYHA stages; men dominated in advanced stages. In-hospital mortality was higher among women (8.34% (108,461) vs. 7.90% (103,883)). However, stratified analyses showed higher mortality rates for men across most age and NYHA groups, except for men aged 80-89 in NYHA I, < 40 in NYHA III, and 40-59 in NYHA IV. Despite being younger and hospitalized for shorter or equal durations, men incurred higher costs in NYHA III (2,931.34 vs. 2,922.67) and NYHA IV (2,960.72 vs. 2,923.36). NYHA stage was the strongest predictor of in-hospital mortality (NYHA II: OR 1.596; NYHA III: OR 5.290; NYHA IV: OR 22.533]; all p < 0.001), while female sex (OR 0.841) and obesity (OR 0.751) were associated with lower mortality.

Conclusion: LVHF outcomes and costs differ by sex and NYHA stage. Though women had higher overall mortality, men showed worse outcomes in most subgroups. These findings stress the importance of sex- and stage-specific LVHF management strategies.

Background: Functional mitral and tricuspid regurgitation (MR and TR) are caused by changes in atrial and/or ventricular geometry. Atrial fibrillation (AF) has been identified as a cause of functional MR and TR, but the arrhythmia may also occur as a consequence of the valvular dysfunction. Data on the success of restoring sinus rhythm (SR) and subsequent MR/TR improvement remain limited. This study reports findings from the prospective Berlin-FMTR registry, which included patients with AF and newly diagnosed moderate or worse functional MR or TR undergoing cardioversion or ablation.

Methods and results: Eighty patients (46% male, median age 73.7 years) with persistent AF and at least moderate MR or TR underwent rhythm control via cardioversion or catheter ablation. Follow-up assessments were conducted at 3 and 12 months. After a mean of 11.6 ± 9 months, 45 patients (56%) remained in SR. At 12 months, 56% of patients with baseline moderate or worse MR improved to mild MR. Among those in SR, this rose to 77% versus 38% with AF recurrence. Only patients in SR showed significant improvements in LVEF, left atrial size, and heart failure symptoms. Similarly, 54% of patients with at least moderate TR at baseline improved to mild TR at 12 months. Among those maintaining SR, 70% showed TR improvement, compared to 35% with recurrent AF. Right ventricular function (TAPSE, RV diameter/volume) improved only in those in SR.

Conclusion: Restoring and maintaining SR led to significant reductions in MR and TR severity and cardiac remodeling. These findings support rhythm control as a key therapeutic strategy in patients with AF and functional MR/TR.

Background: Mavacamten is the first approved myosin inhibitor for symptomatic obstructive hypertrophic cardiomyopathy (oHCM), addressing hypercontractility and left ventricular outflow tract (LVOT) obstruction.

Objectives: This study evaluates left ventricular performance by non-invasive measurements of pressure-strain loops in patients treated with Mavacamten.

Methods: In 36 symptomatic oHCM patients, pressure-strain analysis was performed prior to 3 and 12 months after Mavacamten therapy. Echocardiographic measurements included LVOT gradient, left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), left atrial strain (LAS), peak strain time dispersion (PSD), and myocardial work parameters (global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE)). Clinical status was evaluated using the New York Heart Association (NYHA) class and stress biomarkers (NTproBNP and high-sensitivity troponin I).

Results: Mavacamten therapy significantly reduced LVOT gradients at rest and under provocation. Gradients decreased from 69 ± 36 to 24 ± 27 mmHg (p < 0.001) at 3 months and further to 11 ± 6 mmHg (p = 0.003) at 12 months. Provoked gradients decreased from 113 ± 33 to 50 ± 31 mmHg (p < 0.001) at 3 months and to 31 ± 19 mmHg (p = 0.01) at 12 months. Clinical symptoms also improved. LVEF was 68 ± 6% at baseline and decreased mildly to 62 ± 5% (p = 0.003), while GLS and LAS remained unchanged. PSD decreased mildly from 116 ± 56 to 97 ± 36 ms and further to 93 ± 38 ms, but this was not statistically significant (p = 0.07). Under Mavacamten, GWE remained stable. In contrast, GWI, GCW, and GWW decreased significantly from baseline to 3 months (GWI, 2098 ± 700 to 1610 ± 440 mmHg%, p < 0.001; GCW, 2514 ± 776 to 1951 ± 466 mmHg%, p < 0.001; GWW, 312 ± 163 to 249 ± 177 mmHg%, p = 0.003), with only mild, non-significant further reductions at 12 months (1538 ± 402, 1901 ± 380, and 207 ± 124 mmHg%, respectively; p = 0.67, p = 0.74, p = 0.30).

Conclusion: Myocardial work indices derived from non-invasive pressure-strain analysis were feasible to obtain in patients with oHCM in this study. Mavacamten therapy decreases workload index, constructive and wasted work, and synchronizes myocardial contractility, reflecting normalization of myocardial energetics. These findings reinforce the role of Mavacamten as a targeted therapy in oHCM.

Background: Carditis (myocarditis, pericarditis, and endocarditis) is a rare but serious complication of SARS-CoV-2 infection. While COVID-19 has been associated with heightened long-term cardiovascular risk, the long-term prognosis of survivors with clinically confirmed carditis remains poorly characterized.

Methods: In this observational cohort study, we analyzed electronic health records from the Montefiore Health System (2016-2024) to evaluate long-term outcomes of patients who developed carditis during COVID-19. We compared three groups: COVID+ patients with carditis within 30 days of infection (n = 226), COVID+ patients without carditis (n = 42,758), and pre-pandemic carditis controls (n = 2107). Major adverse cardiovascular events (MACE) and all-cause mortality 30 days to up to 5 years post index were assessed using multivariate Cox regression adjusted for demographics, comorbidities, and social determinants.

Results: Over a median follow-up of 22 months, COVID+  carditis+  patients had a significantly higher risk of MACE compared to COVID+  carditis- patients (adjusted HR 2.99 [95% CI 2.18, 4.10]) and higher all-cause mortality than pre-pandemic carditis + patients (adjusted HR 2.75 [1.93, 3.91]). Among COVID+  patients, myocarditis cases exhibited the lowest left ventricular ejection fraction and highest troponin elevations during acute illness, followed by patients with endocarditis and then pericarditis.

Conclusion: Survivors of COVID-19-associated carditis are at higher risk of all-cause mortality than non-COVID-19 carditis patients and at higher risk of MACE than non-carditis COVID-19 patients up to 5-year follow-up. These findings highlight the need for longitudinal surveillance and tailored cardiovascular care in survivors of COVID-19-associated carditis.

Background: Transcatheter aortic valve replacement (TAVR) has become a well-established therapy for aortic stenosis (AS). With rising TAVR numbers, appropriate patient selection becomes more important. Identifying patients with the highest long-term benefit from the procedure is especially challenging in this elderly patient cohort. Barthel Index (BI) is a commonly used tool to assess the patients' capability of activities of daily life.

Methods and results: In this single-center study, we analyzed BI of patients receiving TAVR for severe symptomatic AS at our center in 2018 and 2019. BI had been collected by nursing personnel during clinical routine and 475 patients could be analyzed. Median BI was 90 points and was used as cut-off to define two groups of patients: lesser frail patients with higher BI (≥ 90; n = 255) and more frail patients with lower BI (< 90; n = 220). Patients with lower BI were older (83 vs. 80 years; p < 0.01) with higher surgical risk score (STS-score 4.1% vs. 2.5%; p < 0.01), and worse renal function (CKD in 49.5% vs. 31.8%; p < 0.01). Long-term survival differed significantly: only 117 patients (53.1%) in the low BI group were still alive 4-years after TAVR vs. 204 patients (80.0%) in the higher BI group. Further analyses revealed that combining STS score and BI significantly improved mortality prediction (C index for STS score 0.626; C index for combined STS score and BI 0.683; p < 0.01).

Conclusions: This is the first analysis evaluating the prognostic value of BI on long-term survival after TAVR. Albeit assessing only the patient's functional status and no detailed medical history, BI is a strong discriminator for frail patients. Moreover, it allows identification of patients at higher risk of mortality within the first 4 years after TAVR and should therefore be considered for evaluation of patients with severe AS.