Canadian Journal of Cardiology最新文献

Background: Degeneration is an inevitable outcome for bioprosthetic heart valves. In the setting of transcatheter aortic valve replacement (TAVR), calcifications and leaflet thickening have implications for feasibility and outcomes of repeat interventions, including leaflet modification techniques. This study aimed to investigate the frequency and pattern of leaflet calcification and thickening in explanted transcatheter aortic valves (TAVs) to inform repeat interventions.

Methods: TAV explants were obtained from the Explanted THV registry and clinical institutions. Micro-computed tomography imaging and histology evaluated TAV calcium volume, distribution, and leaflet thickening.

Results: Twenty TAV explants were analyzed: 11 self-expanding CoreValve/Evolut TAVs, 8 balloon-expandable SAPIEN 3 TAVs, and 1 mechanically-expandable Lotus TAV. Median patient age at explant was 73.0 years (IQR, 63.0-81.0 years), with a median time to explant of 3 years and 3 months (1 year and 10 months - 4 years and 10 months). Eleven TAVs (55%) were found to have leaflet calcification (77.9 mm³; 24.7 - 336.1 mm³) and 9 TAVs (45%) had no calcium by micro-CT. Calcified TAVs had an increased leaflet thickness compared to non-calcific samples (1.02 mm; 0.81 - 1.59 mm vs 0.64 mm; 0.47-0.89 mm; p=0.006). Leaflet thickness had a positive correlation with implant duration. Calcium distribution was heterogenous within each individual leaflet but also among leaflets of an individual TAV. Calcium pattern appeared to differ between TAV models.

Conclusions: Calcified TAVs tend to have thicker leaflets and calcium distribution appears to vary according to TAV type. These findings may have important clinical implications when considering redo-TAVR and leaflet modification techniques.

Background: Although post-transplant cyclophosphamide (PT-Cy) is currently widely used to prevent graft-versus-host disease following allogeneic hematopoietic stem cell transplantation (alloHSCT), concerns remain regarding its cardiotoxicity. The aim was to investigate the association between early cardiotoxicity occurring within the first 100 days post-transplant and PT-Cy.

Methods: We conducted a monocentric retrospective observational study including all consecutive patients who underwent alloHSCT at Saint-Louis University Hospital between July 2011 and July 2023. The primary endpoint was a composite of early cardiotoxicity, including cardiovascular death, heart failure (HF), myocarditis, pericardial disease, cardiac arrhythmias, and acute arterial events. A propensity-score matching was performed to balance characteristics between patients who received post-transplant PT-Cy and those who did not. Predictors of early cardiotoxicity were analyzed using Fine-and-Gray subdistribution hazard models.

Results: Among 1,381 patients, 143 (10%) experienced early cardiotoxicity within 100 days post-transplant. The most frequent events were HF (53%), cardiac arrhythmias (20%), and pericardial disease (19%). Age (subdistribution hazard ratio [sHR] 1.01; 95%CI: 1.00-1.03; p=0.028), prior HF (sHR 2.02; 95%CI: 1.04-3.93; p=0.037), prior cancer therapy-related cardiac dysfunction (sHR 4.24; 95%CI: 2.05-8.78; p<0.001), hypertension (sHR 1.54; 95%CI: 1.00-2.36; p=0.047), and PT-Cy (sHR 1.62; 95%CI: 1.07-2.44; p=0.022) were independently associated with early cardiotoxicity. After 1:1 propensity score-matching, the administration of PT-Cy remained associated with cardiotoxicity (HR=2.00; 95%CI: 1.05-3.80; p=0.035).

Conclusion: The administration of PT-Cy was independently associated with an increased risk of early cardiotoxicity, particularly HF. These results underscore the need for early cardiovascular risk assessment and tailored surveillance, particularly in patients receiving PT-Cy.

Background: Conventionally, cardiovascular trials evaluate impact on morbid and mortal events. 'Win ratio' analyses adding symptom relief and quality of life endpoints can assess broader intervention effects. Applying 'win-ratio' principles, we conducted a post-hoc analysis of ADVENT-HF trial findings.

Methods: ADVENT-HF examined the impact of treating obstructive or central sleep apnea (OSA, CSA) using peak flow triggered adaptive servo-ventilation (ASV_PF) in patients with heart failure with reduced ejection fraction (HFrEF). After pre-randomization stratification into OSA (n=533) or CSA (n=198) cohorts, participants were randomly allocated to standard care (n=375) or standard care plus ASV_PF (n=356). The following trial endpoints were compared over shared follow-up time of pairs of treated and control participants in a descending hierarchical order: 1) all-cause death; 2) cardiovascular hospitalizations; 3) improvement from baseline at 1 year, in 2 or more of the Epworth Sleepiness Scale, Minnesota Living with Heart Failure Quality of Life, or the NYHA class scores; 4) change from baseline in the sum of stage N3 and rapid eye movement (REM) sleep stage duration; and 5) change from baseline in arousals.

Results: The win ratio calculated on sequential addition of outcomes to the hierarchy was 1.18 (1.00-1.39). The win difference was 7.6%. The principal contributions to the latter were quality of life (4.2%) and time in stage 3 plus REM sleep (2.1%). Ranking quality of life second increased the win ratio to 1.22 (1.04-1.43) and the win difference to 9.1%.

Conclusions: A win-ratio analysis incorporating ADVENT-HF clinical and patient-relevant endpoints favors overall ASV_PF treatment benefit. ASV_PF appeared more effective in the CSA cohort with respect to adherence, sleep structure and quality of life. (NCT01128816).

Transcatheter edge-to-edge repair (TEER) has emerged as an important therapeutic option for patients with significant tricuspid regurgitation (TR), yet procedural success and long-term durability remain variable. Early TR reduction is influenced by anatomic complexity, leaflet coaptation mechanics, and device-related factors, whereas late recurrence is often driven by ongoing right-sided chamber remodeling and leaflet-clip interactions. Although contemporary registries demonstrate sustained TR improvement in many patients, a notable subset experiences recurrent TR with adverse clinical outcomes. A comprehensive understanding of the determinants of procedural success, mechanisms of residual or recurrent TR, and their downstream impact on heart failure, renal function, and survival is essential to refining patient selection and optimizing timing of intervention.

Background: Cerebral complications in patients with infective endocarditis (IE) are common and worsen prognosis. Determining the optimal timing for cardiac surgery in this context remains challenging. This study aimed to describe the characteristics and outcomes of IE patients with cerebral complications, managed either surgically or medically.

Methods: We analyzed all consecutive patients with IE-related cerebral complications enrolled in a prospective cohort in Aquitaine, France (2013-2021). Patients were classified as operated or non-operated. The primary outcome was all-cause mortality at 1 month; secondary outcomes included all-cause mortality up to 1 year and the impact of cerebral lesion type and surgical timing.

Results: Among 1,230 IE patients, 288 had cerebral complications (age 65±14 years, 74% male). Ischemic and hemorrhagic cerebral lesions occurred in 76% and 19%, respectively. Severe valvular damages were present in 43% and cardiac surgery was indicated in 86% of cases. One month mortality was significantly higher among non-operated versus operated patients (27% vs. 5.9%, p<0.001). Multivariate analysis identified heart failure, coma and cardiac surgery (OR 0.24; 95% CI [0.10-0.56]; p<0.001) as independent predictors of mortality. Neither the type of cerebral lesion nor surgical timing appeared to affect prognosis.

Conclusions: When indicated, cardiac surgery should be systematically discussed in IE patients with cerebral complications. Early intervention guided by a multidisciplinary Endocarditis Team including neurology expertise may improve outcomes.

Transcatheter edge-to-edge repair (TEER) is increasingly used as rescue therapy for severe mitral regurgitation (MR) in patients with prohibitive surgical risk. Although procedural success has been reported even in cardiogenic shock, complications related to leaflet fragility in acute structural MR remain poorly recognized. We report a fatal case in which repeated leaflet grasping during TEER caused perforation and fragmentation of a fragile leaflet, resulting in embolization of native mitral leaflet tissue and acute coronary artery occlusion. Autopsy and histopathology confirmed the embolic material to be mitral leaflet tissue. This case highlights an unrecognized mechanism of coronary obstruction during TEER.