Open Heart最新文献

Background: The role of cyclic guanosine 3',5'-monophosphate (cGMP) after acute myocardial infarction (AMI) is not well understood despite its significance as a second messenger of natriuretic peptides (NPs) in cardiovascular disease. We investigated the association between the NP-cGMP cascade and left ventricular reverse remodelling (LVRR) in anterior AMI.

Methods: 67 patients with their first anterior AMI (median age, 64 years; male, 76%) underwent prospective evaluation of plasma concentrations of the molecular forms of A-type and B-type natriuretic peptide (BNP) and cGMP from immediately after primary percutaneous coronary intervention (PPCI) to 10 months post-AMI. The estimated mature BNP (emBNP) concentration was calculated as the difference between total BNP and prohormone of BNP (proBNP) concentrations. Patients were divided into LVRR and non-LVRR groups on the basis of residuals between observed change in left ventricular end-systolic volume index on MR during the first 11 months after AMI and change adjusted for proBNP concentration immediately post-PPCI, which was calculated with regression. The LVRR group (n=33) had residuals below the median; the non-LVRR group (n=34) had residuals at or above the median.

Results: The LVRR group had higher freedom from major adverse cardiac and cerebrovascular events (MACCEs) than the non-LVRR group during a median follow-up of 9.9 years (p=0.008). The presence of LVRR (HR 0.256; 95% CI 0.081 to 0.809; p=0.028) and peak creatine phosphokinase-myocardial band level (per 100 IU/L) (HR 1.22; 95% CI 1.02 to 1.46; p=0.027) were independent predictors of MACCE after adjusting for age, male sex, infarct size and hypertension. Multivariable analyses identified logarithmic proBNP and emBNP concentrations from 12 hours to 5 days post-AMI and logarithmic cGMP concentration from immediately post-PPCI to 3 days post-AMI as independent predictors of LVRR (p<0.05).

Conclusions: Early-phase BNP-cGMP cascade activation might play a crucial role in LVRR in anterior AMI.

Background: Visual assessment of coronary CT angiography (CCTA) is time-consuming, influenced by reader experience and prone to interobserver variability. This study evaluated a novel algorithm for coronary stenosis quantification (atherosclerosis imaging quantitative CT, AI-QCT).

Methods: The study included 208 patients with suspected coronary artery disease (CAD) undergoing CCTA in Perfusion Imaging and CT Coronary Angiography With Invasive Coronary Angiography-1. AI-QCT and blinded readers assessed coronary artery stenosis following the Coronary Artery Disease Reporting and Data System consensus. Accuracy of AI-QCT was compared with a level 3 and two level 2 clinical readers against an invasive quantitative coronary angiography (QCA) reference standard (≥50% stenosis) in an area under the curve (AUC) analysis, evaluated per-patient and per-vessel and stratified by plaque volume.

Results: Among 208 patients with a mean age of 58±9 years and 37% women, AI-QCT demonstrated superior concordance with QCA compared with clinical CCTA assessments. For the detection of obstructive stenosis (≥50%), AI-QCT achieved an AUC of 0.91 on a per-patient level, outperforming level 3 (AUC 0.77; p<0.002) and level 2 readers (AUC 0.79; p<0.001 and AUC 0.76; p<0.001). The advantage of AI-QCT was most prominent in those with above median plaque volume. At the per-vessel level, AI-QCT achieved an AUC of 0.86, similar to level 3 (AUC 0.82; p=0.098) stenosis, but superior to level 2 readers (both AUC 0.69; p<0.001).

Conclusions: AI-QCT demonstrated superior agreement with invasive QCA compared to clinical CCTA assessments, particularly compared to level 2 readers in those with extensive CAD. Integrating AI-QCT into routine clinical practice holds promise for improving the accuracy of stenosis quantification through CCTA.

Introduction: Conductive disturbances requiring permanent pacemaker (PPM) implantation remain a major concern after transcatheter aortic valve implantation (TAVI).

Aims: To assess the impact of aortic valve calcium score (AVCS) on conductive disturbances requiring PPM after TAVI.

Methods: All patients who underwent TAVI with accessible AVCS from the preprocedural CT scan report were included in this retrospective single-centre study. The primary endpoint was the occurrence of a conductive disturbance requiring PPM at 30 days. The association between PPM and AVCS, with its incremental prognostic value, was analysed using multivariable logistic regression, receiver operating characteristic curve analysis and likelihood ratio (LR) test.

Results: We included 761 patients of which 125 (16%) required PPM at 30 days. AVCS score was significantly higher in patients requiring PPM (3788 (2487-5218) vs 3050 (2043-4367) AU, p<0.001). Using multivariable analysis, preprocedural right bundle branch block (RBBB) (OR 6.61, 95% CI 3.82 to 11.5, p<0.001), first atrioventricular block (OR 1.71, 95% CI 1.03 to 2.83, p=0.037), self-expanding valve (OR 3.25, 95% CI 1.17 to 9.09, p=0.025) and AVCS>4510 AU (OR 1.83, 95% CI 1.04 to 3.20, p=0.035) were independently associated with PPM. AVCS had an incremental discriminative value (C-index 0.79 vs 0.77, LR test p=0.036) over and above traditional PPM risk factors. An algorithm was proposed based on the initial presence of RBBB, AVCS and the type of implanted valve.

Conclusion: Even if RBBB remained the strongest predictor of PPM post-TAVI, this study suggests that a high AVCS may help identifying patients at increased risk of PPM after TAVI, especially among those without pre-existing RBBB.

Purpose: We examined whether end-to-end deep-learning models could detect moderate (≥50%) or severe (≥70%) stenosis in the left anterior descending artery (LAD), right coronary artery (RCA) or left circumflex artery (LCX) in iodine contrast-enhanced ECG-gated coronary CT angiography (CCTA) scans.

Methods: From a database of 6293 CCTA scans, we used pre-existing curved multiplanar reformations (CMR) images of the LAD, RCA and LCX arteries to create end-to-end deep-learning models for the detection of moderate or severe stenoses. We preprocessed the images by exploiting domain knowledge and employed a transfer learning approach using EfficientNet, ResNet, DenseNet and Inception-ResNet, with a class-weighted strategy optimised through cross-validation. Heatmaps were generated to indicate critical areas identified by the models, aiding clinicians in understanding the model's decision-making process.

Results: Among the 900 CMR cases, 279 involved the LAD artery, 259 the RCA artery and 253 the LCX artery. EfficientNet models outperformed others, with EfficientNetB3 and EfficientNetB0 demonstrating the highest accuracy for LAD, EfficientNetB2 for RCA and EfficientNetB0 for LCX. The area under the curve for receiver operating characteristic (AUROC) reached 0.95 for moderate and 0.94 for severe stenosis in the LAD. For the RCA, the AUROC was 0.92 for both moderate and severe stenosis detection. The LCX achieved an AUROC of 0.88 for the detection of moderate stenoses, though the calibration curve exhibited significant overestimation. Calibration curves matched probabilities for the LAD but showed discrepancies for the RCA. Heatmap visualisations confirmed the models' precision in delineating stenotic lesions. Decision curve analysis and net reclassification index assessments reinforced the efficacy of EfficientNet models, confirming their superior diagnostic capabilities.

Conclusion: Our end-to-end deep-learning model demonstrates, for the LAD artery, excellent discriminatory ability and calibration during internal validation, despite a small dataset used to train the network. The model reliably produces precise, highly interpretable images.

Background and aims: Hypertrophic cardiomyopathy (HCM) has various aetiologies, including genetic conditions like Fabry disease (FD), a lysosomal storage disorder. FD prevalence in high-risk HCM populations ranges from 0.3% to 11.8%. Early diagnosis of FD is crucial due to available treatments, but its rarity and diverse symptoms complicate identification. Heart-specific FD variants often lead to late diagnoses due to the absence of typical FD symptoms. This prospective study (NCT04943991) was conducted to identify patients with undiagnosed FD using electronic health records (EHR) at a German tertiary-care hospital.

Methods: Over 20 years (2000-2020), 2824 patients with 'left ventricular hypertrophy (LVH)' or 'hypertrophic cardiomyopathy (HCM)' were identified by full-text search. Exclusion criteria were age over 85, other diagnosed cardiomyopathies, significant valvular heart disease, death, active malignancy and prior FD testing. The remaining patients received an invitation for FD genetic testing.

Results: Of the 2824 identified patients, 2626 (93%) fulfilled the exclusion criteria. Among the 198 included patients, 96 responded, and 55 underwent genetic testing, yielding a response rate of 48% and a testing rate of 28%. In one patient (1.8% of tested), FD was diagnosed with the p.N215S variant. Subsequent family screening revealed six additional FD cases, with four initiating FD-specific therapies. Comprehensive clinical evaluations were conducted in five of the seven identified patients.

Conclusions: Genetic testing of patients with unexplained LVH/HCM using EHR is effective for identifying FD. Subsequent family screening further identified at-risk individuals, promoting regular follow-ups and if needed FD-specific therapies. This approach highlights the potential for broader application in high-risk populations to uncover treatable genetic conditions. The next phase should focus on automating the executed search process.

Trial registration number: NCT04943991.

Background: The majority of functional ischemia tests in patients with suspected chronic coronary syndromes (CCS) yield normal results. Implementing gatekeepers for patient preselection, such as pretest probability (PTP) and/or coronary artery calcium score (CACS), could reduce the number of normal scan results, radiation exposure and costs. However, the efficacy and safety of these approaches remain unclear.

Methods: Three diagnostic algorithms based on PTP, as summarised in the 2019 European Society of Cardiology (ESC) CCS guidelines, were retrospectively applied to 1792 patients with suspected CCS referred for 82Rb-Positron Emission Tomography (⁸²Rb-PET): (1) defer testing if PTP ≤5%; (2) defer if PTP <15%; and (3) defer if PTP ≤5% or PTP 5-15% and CACS 0. The proportion of missed ischemia, number of scans and reduction of normal scan results, radiation exposure and costs were compared with the current gold standard (CACS+PET in every patient). Endpoints were defined as small ischemia (SDS ≥2) and relevant ischemia (≥10% of myocardium).

Results: The mean age of the patients was 65±11 years, and 43% were female. PTP ≤5% and <15% were present in 7.5% and 41.0%, respectively. Algorithm 1 reduced scans, radiation and costs by 7.5% without significantly missing ischemia (sensitivity/negative predictive value (NPV) 98.6%/99.7%). Algorithm 2 showed the largest reduction (41.0%), but sensitivity was significantly reduced (80.2%). Algorithm 3 demonstrated optimal performance, reducing radiation by 17.0% and costs by 17.3% without significantly missing ischemia suggesting excellent safety (sensitivity/NPV 98.0%/99.5%).

Conclusion: Using a diagnostic algorithm combining PTP and CACS (algorithm 3), the number of normal scan results, radiation exposure and costs could be significantly reduced without a significant increase in missed diagnoses suggesting similar outcome and excellent patients safety. Consequently, this approach could help to optimally allocate limited healthcare resources while maintaining patient's safety.

Background: Transcatheter aortic valve replacement (TAVR) is increasingly used for aortic valve replacement instead of surgical aortic valve replacement (sAVR). We aimed to examine the impact of diabetes on 30-day mortality, 30-day readmission and compare outcomes between TAVR and sAVR.

Methods: Data were extracted from the Nationwide Readmissions Database from 2012 to 2017. The primary outcome was 30-day mortality, and the secondary outcome was 30-day readmission.

Results: The study included 110 135 patients who underwent aortic valve replacement. Of these, 59 466 (54.0%) were hospitalised for TAVR, and 50 669 (46.0%) underwent sAVR. Diabetes was present in 36.4% of TAVR patients and 29.1% of sAVR patients. In TAVR patients, the adjusted risk of 30-day readmission and mortality was similar regardless of diabetes status (aHR=0.94 (0.86-1.03); 0.97 (0.84-1.12); respectively). However, sAVR patients with diabetes had a higher adjusted risk of 30-day mortality (aHR=1.13 (1.01-1.25)) but not readmission (aHR=0.92 (0.84-1.01)). When comparing outcomes between TAVR and sAVR in patients with diabetes, TAVR patients were older and had a higher prevalence of chronic kidney disease (CKD). Nevertheless, 30-day readmission and mortality were lower in patients who underwent TAVR (aHR=0.59 (0.53-0.67), aHR=0.29 (0.25-0.34), respectively) compared with sAVR. Coronary artery disease was the most significant predictor of readmission in patients with diabetes. CKD increased the risk of mortality by almost twofold in both techniques.

Conclusion: Diabetes increases the risk of short-term mortality in sAVR but not TAVR. Moreover, the incidence of 30-day mortality and readmission is lower in TAVR compared with TAVR among patients with diabetes.

Background: Valve-related haemolysis is a known complication following prosthetic valve surgery. Haemolysis after transcatheter aortic valve implantation (TAVI) has been reported in some studies, all of which were non-critical. Data related to haemolysis associated with new-generation balloon-expandable valve (BEV) are scarce.

Methods: Among 441 patients who underwent TAVI between April 2023 and June 2024, 282 patients treated with new-generation BEV were analysed. Haemolysis was defined based on the lactate dehydrogenase, haemoglobin, reticulocyte and haptoglobin levels. Clinically relevant haemolysis was defined as a case requiring transfusion and/or reintervention.

Results: Clinically relevant haemolysis occurred in 6 of 282 patients (2.1%), with median age of 84 years. Three (50%) received a 20 mm valve, and the oversizing ranged from -6.6% to +2.7%. All patients (100%) exhibited paravalvular leakage at the native commissural sites, with moderate or greater paravalvular leakage in two (33%). Lactate dehydrogenase levels exceeded 1200 IU/L in five (83%), four (67%) required transfusion and three (50%) underwent reintervention: balloon aortic valvuloplasty in one and valve-in-valve procedures in two. Haemolysis regressed in three reintervention cases; however, one patient died 9 days postoperatively due to COVID-19. Among three patients (50%) managed conservatively, one developed prosthetic valve endocarditis, whereas another showed spontaneous regression of haemolysis. Over a median follow-up of 218 days, five patients (83%) survived.

Conclusion: Clinically relevant haemolysis occurred in 2.1% of patients undergoing TAVI with new-generation BEV, with 67% requiring transfusion and 50% undergoing reintervention. Further research is warranted to identify risk factors and optimise management strategies for haemolysis.

Background: Hypoxic pulmonary vasoconstriction leads to an increase in pulmonary artery pressure (PAP) and potentially right heart failure in healthy individuals and patients with respiratory diseases. Previous studies in patients with chronic obstructive pulmonary disease (COPD) exposed to hypobaric hypoxia have shown an increase in PAP, while traditional echocardiographic parameters revealed only minimal changes at high altitude. Speckle-tracking-derived analysis is potentially more sensitive to assess right ventricular (RV) function and we used this method to investigate the impact on RV function of patients with COPD ascending to high altitude and compared the results with the traditional echocardiographic parameters.

Methods: This post hoc analysis evaluates echocardiographic RV free wall strain (RVFWS) in patients with COPD GOLD grade 1-3 travelling from 760 m to 3100 m for a 2-day stay. An RVFWS over -20% was considered as an indicator of RV dysfunction.

Results: A total of 54 patients (57% men, mean±SD age 58±9 years, forced expiratory volume in 1 s (FEV₁ % predicted 77.3±22.5)) with echocardiographs of sufficient quality were included. The mean RVFWS worsened significantly from -26.0±4.9% at 760 m to -23.9±5.4% at 3100 m (p=0.02). The number of patients with relevant RV dysfunction based on RVFWS increased from 7.4% at 760 m to 25.9% at 3100 m (p=0.02), whereas the prevalence of RV dysfunction assessed by traditional indices remained unchanged.

Conclusion: Exposure to hypoxia led to RVFWS impairment in more than one quarter of patients with COPD. Strain analysis is a promising, non-invasive method for evaluating RV dysfunction, even in subclinical cases and might be prognostically relevant in patients with lung diseases.

Trial registration numbers: NCT02450968 and NCT03173508.

Introduction: The impact of sex on coronary artery disease prognosis is debated. It has been postulated that women receive less prompt treatment compared with men, potentially adversely affecting their prognosis by significantly increasing the risk of morbidity and mortality. We aim to investigate the influence of sex on the timing and clinical outcomes of ST-segment elevation myocardial infarction (STEMI) patients using a controlled Swiss registry.

Methods and results: Based on the Fribourg STEMI Fast Track Registry, 1177 patients (288 women, 889 men) with >12 months clinical follow-up were selected. Women had longer first medical contact to reperfusion times (1.31 (1.14-2.00) vs 1.27 (1.09-1.54) hours, p=0.035) but similar total ischaemic times (3.04 (2.15-4.50) vs 2.56 (2.07-4.38) hours, p=0.064). Men had higher rates of diabetes, smoking and dyslipidaemia, while women had higher hypertension and renal insufficiency rates. No significant sex differences in clinical outcomes were observed at 1-year and 5-year follow-ups.

Discussion: The study found sex differences in patient profiles and minor treatment delays for women, which did not significantly affect outcomes. Efforts to improve sex equity in STEMI care are effective, as no significant outcome differences were observed. Disparities are more related to patient characteristics than sex.

Conclusion: Despite slight delays and different risk profiles for women with STEMI, clinical outcomes are similar between sexes. Ongoing efforts are needed to ensure sex equity in acute coronary syndrome management.

Trial registration number: NCT04185285.