Search

Aims: Anaemia and iron deficiency (ID) are common comorbidities in cardiovascular patients and are associated with a poor clinical status, as well as a worse outcome in patients with heart failure and acute myocardial infarction (AMI). Nevertheless, data concerning the impact of anaemia and ID on clinical outcomes in patients with cardiogenic shock (CS) are scarce. This study aimed to assess the impact of anaemia and ID on clinical outcomes in patients with CS complicating AMI., Methods and Results: The presence of anaemia (haemoglobin <13 g/dl in men and <12 g/dl in women) or ID (ferritin <100 ng/ml or transferrin saturation <20%) was determined in patients with CS due to AMI from the CULPRIT-SHOCK trial. Blood samples were collected in the catheterization laboratory during initial percutaneous coronary intervention. Clinical outcomes were compared in four groups of patients having neither anaemia nor ID, against patients with anaemia with or without ID and patients with ID only. A total of 427 CS patients were included in this analysis. Anaemia without ID was diagnosed in 93 (21.7%), anaemia with ID in 54 study participants (12.6%), ID without anaemia in 72 patients (16.8%), whereas in 208 patients neither anaemia nor ID was present (48.9%). CS patients with anaemia without ID were older (73 ± 10 years, p = 0.001), had more frequently a history of arterial hypertension (72.8%, p = 0.01), diabetes mellitus (47.8%, p = 0.001), as well as chronic kidney disease (14.1%, p = 0.004) compared to CS patients in other groups. Anaemic CS patients without ID presence were at higher risk to develop a composite from all-cause death or renal replacement therapy at 30-day follow-up (odds ratio [OR] 3.83, 95% confidence interval [CI] 2.23-6.62, p < 0.001) than CS patients without anaemia/ID. The presence of ID in CS patients, with and without concomitant anaemia, did not increase the risk for the primary outcome (OR 1.17, 95% CI 0.64-2.13, p = 0.64; and OR 1.01, 95% CI 0.59-1.73, p = 0.54; respectively) within 30 days of follow-up. In time-to-event Kaplan-Meier analysis, anaemic CS patients without ID had a significantly higher hazard ratio (HR) for the primary outcome (HR 2.11, 95% CI 1.52-2.89, p < 0.001), as well as for death from any cause (HR 1.90, 95% CI 1.36-2.65, p < 0.001) and renal replacement therapy during 30-day follow-up (HR 2.99, 95% CI 1.69-5.31, p < 0.001)., Conclusion: Concomitant anaemia without ID presence in patients with CS at hospital presentation is associated with higher risk for death from any cause or renal replacement therapy and the individual components of this composite endpoint within 30 days after hospitalization. ID has no relevant impact on clinical outcomes in patients with CS., (© 2023 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Importance: Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest (OHCA). The long-term effect of early coronary angiography on patients with OHCA with possible coronary trigger but no ST-segment elevation remains unclear., Objective: To compare the clinical outcomes of early unselective angiography with the clinical outcomes of a delayed or selective approach for successfully resuscitated patients with OHCA of presumed cardiac origin without ST-segment elevation at 1-year follow-up., Design, Setting, and Participants: The TOMAHAWK trial was a multicenter, international (Germany and Denmark), investigator-initiated, open-label, randomized clinical trial enrolling 554 patients between November 23, 2016, to September 20, 2019. Patients with stable return of spontaneous circulation after OHCA of presumed cardiac origin but without ST-segment elevation on the postresuscitation electrocardiogram were eligible for inclusion. A total of 554 patients were randomized to either immediate coronary angiography after hospital admission or an initial intensive care assessment with delayed or selective angiography after a minimum of 24 hours. All 554 patients were included in survival analyses during the follow-up period of 1 year. Secondary clinical outcomes were assessed only for participants alive at 1 year to account for the competing risk of death., Interventions: Early vs delayed or selective coronary angiography and revascularization if indicated., Main Outcomes and Measures: Evaluations in this secondary analysis included all-cause mortality after 1 year, as well as severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure in survivors at 1 year., Results: A total of 281 patients were randomized to the immediate angiography group and 273 to the delayed or selective group, with a median age of 70 years (IQR, 60-78 years). A total of 369 of 530 patients (69.6%) were male, and 268 of 483 patients (55.5%) had a shockable arrest rhythm. At 1 year, all-cause mortality was 60.8% (161 of 265) in the immediate angiography group and 54.3% (144 of 265) in the delayed or selective angiography group without significant difference between the treatment strategies, trending toward an increase in mortality with immediate angiography (hazard ratio, 1.25; 95% CI, 0.99-1.57; P = .05). For patients surviving until 1 year, the rates of severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure were similar between the groups., Conclusions and Relevance: This study found that a strategy of immediate coronary angiography does not provide clinical benefit compared with a delayed or selective invasive approach for patients 1 year after resuscitated OHCA of presumed coronary cause and without ST-segment elevation., Trial Registration: ClinicalTrials.gov Identifier: NCT02750462.

Background: Hospitalizations for acute decompensated heart failure (ADHF) are commonly associated with congestion-related signs and symptoms. Objective and quantitative markers of congestion have been identified, but there is limited knowledge regarding the correlation between these markers., Methods: Patients hospitalized for ADHF irrespective of left ventricular ejection fraction were included in a prospective registry. Assessment of congestion markers (e.g., NT-proBNP, maximum inferior vena cava diameter, dyspnea using visual analogue scale, and a clinical congestion score) was performed systematically on admission and at discharge. Telephone interviews were performed to assess clinical events, i.e., all-cause death or readmission for cardiovascular cause, after discharge. Missing values were handled by multiple imputation., Results: In total, 130 patients were prospectively enrolled. Median length of hospitalization was 9 days (interquartile range 6 to 16). All congestion markers declined from admission to discharge (p < 0.001). No correlation between the congestion markers could be identified, neither on admission nor at discharge. The composite endpoint of all-cause death or readmission for cardiovascular cause occurred in 46.2% of patients. Only NT-proBNP at discharge was predictive for this outcome (hazard ratio 1.48, 95% confidence interval 1.15 to 1.90, p = 0.002)., Conclusion: No correlation between quantitative congestion markers was observed. Only NT-proBNP at discharge was significantly associated with the composite endpoint of all-cause death or readmission for cardiovascular cause. Findings indicate that the studied congestion markers reflect different aspects of congestion., (© 2022. The Author(s).)

Background: Left atrial (LA) reservoir strain provides prognostic information in patients with and without heart failure (HF), but might be altered by atrial fibrillation (AF). The aim of the current study was to investigate changes of LA deformation in patients undergoing cardioversion (CV) for first-time diagnosis of AF., Methods and Results: We performed 3D-echocardiography and strain analysis before CV (Baseline), after 25 ± 10 days (FU-1) and after 190 ± 20 days (FU-2). LA volumes, reservoir, conduit and active function were measured. In total, 51 patients were included of whom 35 were in SR at FU-1 (12 HF and preserved ejection fraction (HFpEF)), while 16 had ongoing recurrence of AF (9 HFpEF). LA maximum volume was unaffected by cardioversion (Baseline vs. FU-2: 41 ± 11 vs 40 ± 10 ml/m 2 ; p = 0.85). Restored SR led to a significant increase in LA reservoir strain (Baseline vs FU-1: 12.9 ± 6.8 vs 24.6 ± 9.4, p < 0.0001), mediated by restored LA active strain (SR group Baseline vs. FU-1: 0 ± 0 vs. 12.3 ± 5.3%, p < 0.0001), while LA conduit strain remained unchanged (Baseline vs. FU-1: 12.9 ± 6.8 vs 13.1 ± 6.2, p = 0.78). Age-controlled LA active strain remained the only significant predictor of LA reservoir strain on multivariable analysis (β 1.2, CI 1.04-1.4, p < 0.0001). HFpEF patients exhibited a significant increase in LA active (8.2 ± 4.3 vs 12.2 ± 6.6%, p = 0.004) and reservoir strain (18.3 ± 5.7 vs. 22.8 ± 8.8, p = 0.04) between FU-1 and FU-2, associated with improved LV filling (r = 0.77, p = 0.005)., Conclusion: Reestablished SR improves LA reservoir strain by restoring LA active strain. Despite prolonged atrial stunning following CV, preserved SR might be of hemodynamic and prognostic benefit in HFpEF., (© 2021. The Author(s).)

Background: Arterial hypertension is the most common comorbidity in patients with heart failure with preserved ejection fraction (HFpEF) and mediates adverse hemodynamics through related aortic stiffness and increased pulsatile load. We aimed to investigate the clinical and hemodynamic implications of renal sympathetic denervation (RDN) in patients with HFpEF and uncontrolled arterial hypertension., Methods: Patients undergoing RDN between 2011 and 2018 in a single-center were retrospectively analyzed and classified as HFpEF (n=99) or no HF (n=65). Stroke volume index and aortic distensibility were measured through cardiac magnetic resonance imaging, and left ventricular (LV) systolic and diastolic properties were assessed echocardiographically., Results: At baseline, patients with HFpEF had higher stroke volume index (median 40 [interquartile range, 33-48] versus 33 [26-40] mL/m 2 , P =0.002), pulse pressure (69 [63-77] versus 61 [55-67] mm Hg, P <0.001), but lower LV-VPES 100mm Hg (18 [10-28] versus 24 [15-40] mL, P =0.007) and aortic distensibility (1.5 [1.1-2.6] versus 2.7 [1.1-3.5] 10 -3 mm Hg -1 , P =0.013) as compared to no-HF patients. Systolic blood pressure decreased comparable in patients with HFpEF and no-HF patients following RDN (-9 [-16 to -2], P <0.001). After RDN stroke volume index (-3 [-9 to +3] mL/m 2 , P =0.011) decreased and aortic distensibility (0.2 [-0.1 to +1.1] 10 -3 mm Hg -1 , P =0.007) and systolic stiffness ( P <0.001) increased in HFpEF patients. LV diastolic stiffness and LV filling pressures as well as NT-proBNP (N-terminal pro-B-type natriuretic peptide) decreased after RDN in patients with HFpEF ( P =0.032, P =0.043, and P <0.001, respectively)., Conclusions: Patients with HFpEF undergoing RDN showed increased stroke volume index, vascular, and LV stiffness as compared to no-HF patients. Following RDN those hemodynamic alterations and reduced systolic and diastolic LV stiffness were partly normalized, implying RDN might be a potential therapeutic strategy for arterial hypertension and HFpEF.

Aims: To characterize the prevalence and clinical relevance of malnutrition in patients undergoing transcatheter tricuspid valve edge-to-edge repair (TTVR)., Methods and Results: Overall, 86 consecutive patients (mean age 78 ± 7 years) with moderate-to-severe tricuspid regurgitation (TR) at prohibitive surgical risk were analysed. Mini Nutritional Assessment (MNA), quality of life assessment, 6-min walk test distance and laboratory analyses were performed before and 1 month after TTVR. A total of 43 patients (50%) underwent concomitant transcatheter mitral valve repair. According to MNA, 81 patients (94%) were malnourished or at risk of malnutrition before TTVR. Following TTVR, MNA improved in 64 patients (74%). As compared to patients without MNA improvement, patients with increased MNA score had greater reductions in TR [regurgitation volume -17.0 (interquartile range, IQR -25.0; -7.0) mL vs. -26.4 (IQR -40.3; -14.5) mL, P < 0.001] and inferior vena cava diameter. Only patients with increased MNA score displayed a decrease in N-terminal pro-brain natriuretic peptide levels [-320 (IQR -1294; 105) pg/mL vs. +708 (IQR -342; 2708) pg/mL, P = 0.009], improvements in cholinesterase levels (0.0 ± 11.9 μmoL/L vs. +10.9 ± 16.7 μmoL/L, P < 0.001) and renal function during follow-up. Beneficial effects on quality of life scores and 6-min walk test distance following TTVR were observed exclusively in patients with improvement in MNA. During a median follow-up of 6 months, patients with worsened MNA had an increased risk of death and rehospitalization for heart failure., Conclusion: Nutritional impairment is common and of prognostic importance in patients undergoing TTVR. Hepatorenal function modestly improves after successful TTVR. Further study of extracardiac implications of TR-associated right heart failure is warranted to improve care in this vulnerable patient population., (© 2020 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome with extremely high mortality, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large spectrum of CS presentations resulting from the interaction between an acute cardiac insult and a patient's underlying cardiac and overall medical condition. Phenotyping patients with CS may have clinical impact on management because classification would support initiation of appropriate therapies. CS management should consider appropriate organization of the health care services, and therapies must be given to the appropriately selected patients, in a timely manner, whilst avoiding iatrogenic harm. Although several consensus-driven algorithms have been proposed, CS management remains challenging and substantial investments in research and development have not yielded proof of efficacy and safety for most of the therapies tested, and outcome in this condition remains poor. Future studies should consider the identification of the new pathophysiological targets, and high-quality translational research should facilitate incorporation of more targeted interventions in clinical research protocols, aimed to improve individual patient outcomes. Designing outcome clinical trials in CS remains particularly challenging in this critical and very costly scenario in cardiology, but information from these trials is imperiously needed to better inform the guidelines and clinical practice. The goal of this review is to summarize the current knowledge concerning the definition, epidemiology, underlying causes, pathophysiology and management of CS based on important lessons from clinical trials and registries, with a focus on improving in-hospital management., (© 2020 European Society of Cardiology.)

Aims: Treating patients with acute decompensated heart failure (ADHF) presenting with volume overload is a common task. However, optimal guidance of decongesting therapy and treatment targets are not well defined. The inferior vena cava (IVC) diameter and its collapsibility can be used to estimate right atrial pressure, which is a measure of right-sided haemodynamic congestion. The CAVA-ADHF-DZHK10 trial is designed to test the hypothesis that ultrasound assessment of the IVC in addition to clinical assessment improves decongestion as compared with clinical assessment alone., Methods and Results: CAVA-ADHF-DZHK10 is a randomized, controlled, patient-blinded, multicentre, parallel-group trial randomly assigning 388 patients with ADHF to either decongesting therapy guided by ultrasound assessment of the IVC in addition to clinical assessment or clinical assessment alone. IVC ultrasound will be performed daily between baseline and hospital discharge in all patients. However, ultrasound results will only be reported to treating physicians in the intervention group. Treatment target is relief of congestion-related signs and symptoms in both groups with the additional goal to reduce the IVC diameter ≤21 mm and increase IVC collapsibility >50% in the intervention group. The primary endpoint is change in N-terminal pro-brain natriuretic peptide from baseline to hospital discharge. Secondary endpoints evaluate feasibility, efficacy of decongestion on other scales, and the impact of the intervention on clinical endpoints., Conclusions: CAVA-ADHF-DZHK10 will investigate whether IVC ultrasound supplementing clinical assessment improves decongestion in patients admitted for ADHF., (© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Aims: Patients with heart failure and severe mitral regurgitation (MR) have a poor prognosis and carry an increased risk for ventricular arrhythmias. The present study evaluates the impact of transcatheter mitral valve repair using the MitraClip on the potential reduction of ventricular arrhythmias., Methods and Results: Patients undergoing MitraClip implantation were prospectively enrolled into the present study and received 24 h Holter ECG assessment prior to and 6 months after the procedure. In addition, left ventricular dimensions and function were assessed at baseline and follow-up. A total of 50 patients with mainly functional MR (82%) were included. Non-sustained or sustained ventricular tachycardia (nsVT and/or sVT) occurred in 32% of patients and was reduced to 14% at follow-up (P = 0.01). Also, premature ventricular complex (PVC) burden ≥5% decreased from 16% to 4% (P = 0.04). Patients with persistent (n = 6) or new (n = 1) nsVT and/or sVT at follow-up showed a significant decrease in left ventricular ejection fraction from 38% (interquartile range 26-45%) to 33% (interquartile range 22-44%; P = 0.03)., Conclusions: In this prospective study, transcatheter mitral valve repair using MitraClip was associated with a reduced prevalence of ventricular arrhythmias. The subset of patients with persistent or new ventricular arrhythmias after MitraClip implantation showed progression of left ventricular dysfunction., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Rationale: Remote ischemic conditioning (RIC) or ischemic postconditioning (PostC) may protect the myocardium from ischemia-reperfusion injury in patients with ST-segment-elevation myocardial infarction., Objective: To determine whether combined intrahospital RIC and PostC or PostC alone in addition to primary percutaneous coronary intervention (PCI) reduce long-term clinical events after ST-segment-elevation myocardial infarction., Methods and Results: The present study is a post hoc analysis of a prospective trial which randomized 696 ST-segment-elevation myocardial infarction patients with symptoms <12 hours 1:1:1 to either combined RIC and PostC in addition to primary PCI, PostC alone in addition to primary PCI, or conventional PCI (control). Three cycles of RIC were performed by inflation of an upper arm blood pressure cuff for 5 minutes followed by deflation for 5 minutes. PostC was performed after primary PCI via 4 cycles of 30 seconds balloon occlusions followed by 30 seconds of reperfusion. Major adverse cardiac events consisting of cardiac death, reinfarction, and new congestive heart failure were assessed during long-term follow-up. Follow-up data were obtained in 97% of patients in median 3.6 years after the index event (interquartile range, 2.9-4.2 years). Major adverse cardiac events occurred in 10.2% of patients in the combined RIC and PostC group and in 16.9% in the control group (odds ratio, 0.56; 95% CI, 0.32-0.97; P=0.04). The difference was driven by a significantly reduced rate of new congestive heart failure in the RIC and PostC group (2.7% versus 7.8%; odds ratio, 0.32; 95% CI, 0.13-0.84; P=0.02). In contrast, PostC alone did not reduce major adverse cardiac events compared with controls (14.1% versus 16.9%; odds ratio, 0.81; 95% CI, 0.48-1.35; P=0.41), and the reduction of new congestive heart failure was not statistically significant (3.5% versus 7.8%; odds ratio, 0.43; 95% CI, 0.18-1.03; P=0.05)., Conclusions: Cardioprotection by combined intrahospital RIC and PostC in addition to primary PCI significantly reduced the rate of major adverse cardiac events and new congestive heart failure after ST-segment-elevation myocardial infarction., Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02158468.

Inferior vena cava (IVC) diameter can be used to approximate right atrial pressure in patients admitted for acute decompensated heart failure (ADHF). Recent studies linked IVC dilation to an increased risk of early re-admission and short-term mortality. Moreover, renal insufficiency (RI) is an established risk factor for mortality in ADHF and is associated with congestion. We hypothesized that the IVC diameter is a marker of all-cause mortality but its prognostic impact may be influenced by kidney function. We analyzed data of 1101 patients admitted for ADHF with available echocardiography of the IVC by chart review and death registry linkage. Patients were dichotomized according to a cut-off value of 21 mm. Cox proportional hazards model was used to identify mortality predictors. A dilated IVC was detected in 474 (43.1%) patients. Overall, 400 (36.3%) patients died within 3 years. All-cause mortality was significantly higher in patients with dilated IVC [hazard ratio 1.45 (confidence interval 1.21-1.74); p < 0.001]. However, a dilated IVC was only associated with all-cause mortality in patients with RI function [hazard ratio 1.60 (confidence interval 1.26-2.03); p < 0.001] but not in patients with a preserved kidney function [hazard ratio 1.04 (confidence interval 0.72-1.50); P = 0.84]. IVC diameter was identified as an independent predictor for all-cause mortality in a Cox proportional hazards model with a significant interaction between IVC diameter and baseline kidney function. In conclusion, IVC dilation is a marker of high mortality risk in patients admitted for ADHF. However, this observation was confined to patients with RI.

Background: Data on the prognostic value of the shock index in patients with ST-elevation myocardial infarction (STEMI) are scarce. Furthermore, the relationship of the shock index with myocardial damage is unknown. The aim of this study was to evaluate the association of the shock index with markers of myocardial damage and clinical outcome in patients with STEMI., Methods and results: This multicenter study analyzed 791 patients. Patients were categorized in 2 groups according to the admission shock index (optimized cut-off=0.62). Infarct severity was determined by cardiac magnetic resonance (CMR) imaging. Patients with cardiogenic shock that were unable to undergo CMR acquisition were excluded. Major adverse cardiac events (MACE) were defined as a composite of death, reinfarction and congestive heart failure within 12 months. Patients with elevated admission shock index (n=321 [40.6%]) had a significantly larger area-at-risk (37.6 [27.8-50.4] % of left ventricular volume [LV] vs. 34.3 [24.5-46.0] % LV, P=0.02), larger infarct size (19.5 [10.7-28.0] % LV vs. 14.9 [7.7-22.3] % LV, P<0.001), lower myocardial salvage index (46.2 [27.9-64.5] vs. 53.5 [36.5-75.2], P<0.001), and a larger extent of microvascular obstruction (0.3 [0.0-2.2] % LV vs. 0.0 [0.0-1.4] % LV, P=0.01). An elevated shock index was associated with reduced MACE-free survival (P<0.001). Furthermore, the admission shock index was identified as an independent predictor of MACE (hazard ratio=2.92 [1.24-4.22], P<0.01)., Conclusions: STEMI patients with an elevated admission shock index had more pronounced myocardial and microvascular damage. Moreover, the shock index was independently associated with MACE at 12 months.

Aims: Angiopoietin-2 (Ang-2) is a mediator of capillary leakage, and increased Ang-2 levels were associated with poor in-hospital outcome in a pilot study in cardiogenic shock (CS). In this larger study, we followed this hypothesis and aimed at assessing the predictive role of Ang-2 on short- and long-term mortality, investigating the effect of intra-aortic balloon pump (IABP) treatment on Ang-2 levels, and identifying clinical and procedural predictors of increased Ang-2., Methods and Results: In the IABP-SHOCK II-trial, 600 patients with CS complicating acute myocardial infarction were assigned to therapy with or without IABP. This substudy included 189 randomized patients with serial blood sampling performed at days 1, 2, and 3. No significant differences in Ang-2 levels were found between patients with or without IABP. The Ang-2 levels above the median at day 1 were associated with 30-day [hazard ratio (HR) 1.98, 95% confidence interval (CI) 1.26-3.10, P = 0.002) and 1-year mortality (HR 2.21, 95% CI 1.49-3.27, P < 0.001). Stratification of patients according to Ang-2 levels at day 3 increased these associations (30 days HR 5.15, 95% CI 2.80-9.45, P < 0.001; 1 year HR 5.24, 95% CI 3.19-8.58, P < 0.001). The Ang-2 concentrations were independent predictors for mortality in multivariate analysis (30 days HR 4.82, 95% CI 1.52-15.23, P = 0.007; 1 year HR 2.01, 95%CI 1.24-3.24, P = 0.005). Predictors of increased Ang-2 levels at day 3 were baseline Ang-2, development of acute kidney injury, bleeding events or transfusion, and impaired reperfusion., Conclusion: In CS, high levels of Ang-2 are independently associated with poor short- and long-term outcome and associated with the reperfusion success as well as complications., Clinical Trial Registration: URL: www.clinicaltrials.gov; unique identifier: NCT00491036., (© 2015 The Authors European Journal of Heart Failure © 2015 European Society of Cardiology.)

Background: Both infarct size and microvascular obstruction (MO) assessed by cardiac magnetic resonance imaging (CMR) are known to be predictors for adverse clinical outcome after ST-elevation myocardial infarction (STEMI). We hypothesized that a ratio of MO and infarct size (MO/infarct size) might be an even stronger predictor for outcome after STEMI, which has not been investigated yet., Methods: STEMI patients reperfused by primary angioplasty (n = 438) within 12 h after symptom onset underwent contrast-enhanced CMR at a median of 3 days (interquartile range [IQR] 2;4) after the index event. MO and infarct size were measured 15 min after intravenous gadolinium injection. Follow-up was conducted after 19 months (IQR 10;27). The primary end point was defined as a composite of death, non-fatal myocardial reinfarction and congestive heart failure (major adverse cardiac events [MACE])., Results: The extent of MO was only weakly correlated with infarct size (r = 0.21, p < 0.001). In a first multivariate analysis including extent of MO, infarct size, ejection fraction, end-systolic and end-diastolic volume, the extent of MO was independently associated with MACE (hazard ratio [HR] 1.03, 95%CI 1.02–1.05, p < 0.001). In a second multivariate analysis including MO/infarct size on top of the extent of MO, infarct size, ejection fraction, end-systolic and end-diastolic volume, MO/infarct size was identified as the strongest independent predictor for MACE (HR 2.22 [95%CI 1.60–3.08, p < 0.001])., Conclusions: In contrast to infarct size, MO is associated with adverse clinical outcome after STEMI even after adjustment for other CMR parameters. However, MO/infarct size is a more powerful predictor for long-term outcome after STEMI than either parameter alone.

Aims Patients with diastolic dysfunction (DD) experience worse outcomes after transcatheter aortic valve replacement (TAVR). We investigated the prognostic value and clinical utility of left atrial reservoir strain (LARS) in patients undergoing TAVR for aortic stenosis (AS). Methods and results All consecutive patients undergoing TAVR between January 2018 and December 2018 were included if discharge echocardiography and follow-up were available. LARS was derived from 2D-speckle-tracking. Patients were grouped into three tertiles according to LARS. DD was analysed using the ASE/EACVI-algorithm. The primary outcome was a composite of all-cause death and readmission for worsening heart failure 12 months after TAVR. Overall, 606 patients were available [age 80 years, interquartile range (IQR) 77–84], including 53% women. Median LARS was 13.0% (IQR 8.4–18.3). Patients were classified by LARS tertiles [mildly impaired 21.4% (IQR 18.3–24.5), moderately impaired 13.0% (IQR 11.3–14.6), severely impaired 7.1% (IQR 5.4–8.4), P < 0.0001]. The primary outcome occurred more often in patients with impaired LARS (mildly impaired 7.4%, moderately impaired 13.4%, and severely impaired 25.7%, P < 0.0001). On adjusted multivariable Cox regression analysis, LARS tertiles [hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.44–0.86, P = 0.005] and higher degree of tricuspid regurgitation (HR 1.82, 95% CI 1.23–2.98, P = 0.003) were the only significant predictors of the primary endpoint. Importantly, DD was unavailable in 56% of patients, but LARS assessment allowed for reliable prognostication regarding the primary endpoint in subgroups without DD assessment (HR 0.64, 95% CI 0.47–0.87, P = 0.003). Conclusion Impaired LARS is independently associated with worse outcomes in patients undergoing TAVR. LARS allows for risk stratification at discharge even in patients where DD cannot be assessed by conventional echocardiographic means. [ABSTRACT FROM AUTHOR]

Cardiomyopathies are a heterogeneous group of structural, mechanical, and electrical heart muscle disorders which often correlate with life-threatening arrhythmias and progressive heart failure accounting for significant cardiovascular morbidity and mortality. Currently, cardiomyopathies still represent a leading reason for heart transplantation worldwide. The last years have brought remarkable advances in the field of cardiomyopathies especially in terms of understanding the molecular basis as well as the diagnostic evaluation and management. Although most cardiomyopathy treatments had long focused on symptom management, much of the current research efforts aim to identify and act on the disease-driving mechanisms. Regarding risk assessment and primary prevention of sudden cardiac death, additional data are still pending in order to pave the way for a more refined and early patient selection for defibrillator implantation. This review summarizes the current knowledge of hypertrophic, dilated and arrhythmogenic cardiomyopathy with a particular emphasis on their pathophysiology, clinical features, and diagnostic approach. Furthermore, the relevant ongoing studies investigating novel management approaches and main gaps in knowledge are highlighted. [ABSTRACT FROM AUTHOR]

Aims Patients with pulmonary hypertension (PHT) are often excluded from surgical therapies for tricuspid regurgitation (TR). Transcatheter tricuspid valve repair (TTVR) with the MitraClip™ technique is a novel treatment option for these patients. We aimed to assess the role of PHT in severe TR and its implications for TTVR. Methods and results A total of 243 patients underwent TTVR at two centres. One hundred twenty-one patients were grouped as iPHT+ [invasive systolic pulmonary artery pressures (PAPs) ≥50 mmHg]. Patients were similarly stratified according to echocardiographic PAPs (ePHT). The occurrence of the combined clinical endpoint (death, heart failure hospitalization, and reintervention) was investigated during a follow-up of 330 (interquartile range 175–402) days. iPHT+ patients were at higher preoperative risk (P  < 0.01), had more severe symptoms (P  = 0.01), higher N-terminal pro-B-type natriuretic peptide levels (P  < 0.01), more impaired right ventricular (RV) function (P  < 0.01), and afterload corrected RV function (P  < 0.01). Procedural TTVR success was similar in iPHT+ and iPHT− patients (84 vs. 84%, P  = 0.99). The echocardiographic diagnostic accuracy to detect iPHT was only 55%. During follow-up, 35% of patients reached the combined clinical endpoint. The discordant diagnosis of iPHT+/ePHT− carried the highest risk for the combined clinical endpoint [HR 3.76 (CI 2.25–6.37), P  < 0.01], while iPHT+/ePHT+ patients had a similar survival-free time from the combined endpoint compared to iPHT− patients (P  = 0.48). In patients with isolated tricuspid procedure (n  = 131) a discordant iPHT+/ePHT− diagnosis and an impaired afterload corrected RV function (P  < 0.01 for both) were independent predictors for the occurrence of the combined endpoint. Open in new tab Download slide Open in new tab Download slide Conclusion The discordant echocardiographic and invasive diagnosis of PHT in severe TR predicts outcomes after TTVR. [ABSTRACT FROM AUTHOR]

Aims: Patients with heart failure and severe mitral regurgitation (MR) have a poor prognosis and carry an increased risk for ventricular arrhythmias. The present study evaluates the impact of transcatheter mitral valve repair using the MitraClip on the potential reduction of ventricular arrhythmias.Methods and Results: Patients undergoing MitraClip implantation were prospectively enrolled into the present study and received 24 h Holter ECG assessment prior to and 6 months after the procedure. In addition, left ventricular dimensions and function were assessed at baseline and follow-up. A total of 50 patients with mainly functional MR (82%) were included. Non-sustained or sustained ventricular tachycardia (nsVT and/or sVT) occurred in 32% of patients and was reduced to 14% at follow-up (P = 0.01). Also, premature ventricular complex (PVC) burden ≥5% decreased from 16% to 4% (P = 0.04). Patients with persistent (n = 6) or new (n = 1) nsVT and/or sVT at follow-up showed a significant decrease in left ventricular ejection fraction from 38% (interquartile range 26-45%) to 33% (interquartile range 22-44%; P = 0.03).Conclusions: In this prospective study, transcatheter mitral valve repair using MitraClip was associated with a reduced prevalence of ventricular arrhythmias. The subset of patients with persistent or new ventricular arrhythmias after MitraClip implantation showed progression of left ventricular dysfunction. [ABSTRACT FROM AUTHOR]

Cardiogenic shock (CS) remains the most common cause of death in patients admitted with acute myocardial infarction (AMI) and mortality remained nearly unchanged in the range of 40–50% during the last two decades. Early revascularization, vasopressors and inotropes, fluids, mechanical circulatory support, and general intensive care measures are widely used for CS management. However, there is only limited evidence for any of the above treatment strategies except for revascularization and the relative ineffectiveness of intra-aortic balloon pumping. This updated review will outline the management of CS complicating AMI with major focus on state-of-the art treatment. Download slide Download slide [ABSTRACT FROM AUTHOR]

This study sought to examine the impact of chronic right ventricular (RV) volume overload and implications of tricuspid regurgitation (TR) reduction on biventricular function. Severe TR is a major determinant of adverse outcomes in advanced heart failure patients. The understanding of TR pathophysiology and implications of correction is still limited. Transcatheter tricuspid edge-to-edge repair (TTVR) is a new treatment option in patients at high surgical risk and provides a unique pathophysiological model without confounding effects of cardiac surgery. Twenty-nine patients (78 ± 4 years of age) with severe isolated TR and high surgical risk underwent TTVR using the MitraClip system, and of these 18 underwent repeated cardiac magnetic resonance. Clinical follow-up was realized at 1 and 6 months after the intervention. TR fraction was reduced from 41% to 21% (p < 0.01) without increase in RV afterload (p = 0.52) and RV end-diastolic volume (p < 0.01), and RV stroke volume decreased (p = 0.03), whereas RV effective forward flow increased (p = 0.03). Left ventricular (LV) filling improved with an increase in LV end-diastolic volume (p = 0.01) and LV stroke volume (p = 0.02), leading to an augmentation of cardiac indices (2.2 ± 0.6 l/min/m2 vs. 2.7 ± 0.6 l/min/m2; p < 0.01) with similar results at 6 months follow-up. After TTVR, New York Heart Association functional class significantly improved (p < 0.01), peripheral edema decreased (p = 0.01), and 6-min walk distance increased by 20% and 22% after 1 and 6 months, respectively (p < 0.01). TTVR reduces chronic RV volume overload without increase in RV afterload, improves RV performance and LV filling, and enhances cardiac output. These changes translate into symptomatic and functional improvement. These implications for biventricular physiology and clinical status are maintained at 6 months follow-up. [ABSTRACT FROM AUTHOR]

Background--Atrial fibrillation (AF) is frequently observed in patients with ST-segment-elevation myocardial infarction and associated with worse clinical outcome. However, the mechanisms for this increased risk are not fully understood. The purpose of this study was to investigate the relationship of the presence of AF to cardiac magnetic resonance (CMR) derived myocardial salvage and damage as well as clinical outcomes. Methods and Results--This multicenter CMR study enrolled 786 patients with ST-segment-elevation myocardial infarction. CMR parameters (infarct size, myocardial salvage index, microvascular obstruction, and myocardial function) were assessed 3 (interquartile range [IQR], 2-4) days post-ST-segment-elevation myocardial infarction and compared between patients with or without AF during hospitalization. Major adverse cardiac events were assessed as a composite of allcause death, reinfarction, and new congestive heart failure at 12 months. AF was documented in 48 (6.1%) patients. There was no significant difference in infarct size (18 [IQR, 9-29]% versus 17 [IQR, 9-25]% of left ventricular mass; P=0.340), myocardial salvage index (51 [IQR, 34-69] versus 51 [IQR, 33-69]; P=0.830), or microvascular obstruction (0.6 [IQR, 0-2.0]% versus 0.0 [IQR, 0-1.8]% of left ventricular mass; P=0.340) between groups. Patients with AF had significantly lower left ventricular (47 [IQR, 34-54]% versus 51 [IQR, 44-58]%; P=0.003) and left atrial (42 [IQR, 17-57]% versus 53 [IQR, 45-59]%; P<0.001) ejection fraction. AF was associated with major adverse cardiac events, even when adjusting for clinical risk factors (odds ratio, 2.48 [95% confidence interval, 1.22-5.03]; P=0.0120) or CMR prognosis markers (odds ratio, 3.77 [95% confidence interval, 1.83-7.79]; P=0.001). Conclusions--This CMR study found no major differences in myocardial salvage, infarct size, or microvascular damage in patients with ST-segment-elevation myocardial infarction or without AF. AF was, however, associated with cardiac dysfunction and independently related to major adverse cardiac events. [ABSTRACT FROM AUTHOR]

Background--Cardiac magnetic resonance (CMR) demonstrated great potential for the prediction of major adverse cardiac events (MACE) in ST-segment-elevation myocardial infarction. The aim of this study was to develop and validate a CMR-based risk score for ST-segment-elevation myocardial infarction patients. Methods and Results--The scoring model was developed and validated on ST-segment-elevation myocardial infarction cohorts from 2 independent randomized controlled trials (n=738 and n=458 patients, respectively) and included left ventricular (LV) ejection fraction, infarct size, and microvascular obstruction. Primary end point was the 12-month MACE rate consisting of death, reinfarction, and new congestive heart failure. In the derivation cohort, LV ejection fraction ≤7%, infarct size ≥19%LV, and microvascular obstruction ≥1.4%LV were identified as the best cutoff values for MACE prediction. According to the hazard ratios in multivariable regression analysis, the CMR risk score was created by attributing 1 point for LV ejection fraction ≤47%, 1 point for infarct size ≥19%LV, and 2 points for microvascular obstruction ≥1.4%LV In the validation cohort, the score showed a good prediction of MACE (area under the curve: 0.76). Stratification into a low (0/1 point) and high-risk group (≥2 points) resulted in significantly higher MACE rates in high-risk patients (9.0% versus 2.2%; P=0.001). Inclusion of the CMR score in addition to a model of clinical risk factors led to a significant increase of C statistics from 0.74 to 0.83 (P=0.037), a net reclassification improvement of 0.18 (P=0.009), and an integrated discriminative improvement of 0.04 (P=0.010). Conclusions--Our approach integrates the prognostic information of CMR imaging into a simple risk score that showed incremental prognostic value over clinical risk factors in ST-segment-elevation myocardial infarction patients. Clinical Trial Registration--URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00712101 and NCT02158468. [ABSTRACT FROM AUTHOR]

Objective: ST-elevation myocardial infarction (STEMI) is frequently associated with reciprocal ST-segment depression in contralateral ECG leads. However, the relationship of the resolution of ST-segment depression (STD-R) with myocardial damage is unknown and the potential prognostic value incompletely understood. We sought to evaluate the association between STD-R and markers of myocardial injury as well as to determine the prognostic impact of STD-R in patients with acute reperfused STEMI.Methods: We enrolled 611 patients with STEMI in this multicentre cardiac magnetic resonance (CMR) study. STD-R, defined as either worsened (<0%), incomplete (0-50%) or complete (≥50%), was determined 90 min after primary percutaneous coronary intervention (PCI). Patients underwent CMR in median 3 (2-4) days after infarction. Major adverse cardiac events (MACE) were defined as a composite of death, reinfarction and new congestive heart failure within 12 months after enrollment.Results: Patients with worsened or incomplete STD-R (n=148 (24.2%)) had a significantly larger area at risk (42 (31-50) vs 37 (29-52) vs 34 (24-46) %LV, p=0.001), larger infarct size (20 (13-30) vs 17(10-26) vs 16 (8-24) %LV, p=0.003), larger extent of microvascular obstruction (0.6(0-3.4) vs 0.4 (0-2.4) vs 0.0 (0-1.4) %LV, p=0.003), and a lower LVEF (46 (39-54) vs 48 (40-56) vs 52 (45-58) %, p<0.001). MACE rate (n=37 (6%)) was significantly higher in patients with worsened (n=10 (19%)) or incomplete STD-R (n=7 (7%)) than in patients with complete STD-R (n=20 (4%), p<0.001). In multivariate Cox regression analysis, categorised STD-R emerged as an independent predictor of MACE at 12 months after adjusting for clinical variables (p=0.007).Conclusions: Patients with acute STEMI and worsened or incomplete STD-R after PCI show a more pronounced myocardial as well as microvascular damage as detected by CMR with subsequent independent prognostic information on MACE over a 12-month follow-up period. [ABSTRACT FROM AUTHOR]

Cardiogenic shock (CS) remains the most common cause of death in patients with acute myocardial infarction although mortality could be reduced from formerly ∼80% to 40-50%. In addition to percutaneous coronary intervention or coronary artery bypass grafting, catecholamines, fluids, intraaortic balloon pumping (IABP), and also active assist devices are widely used for CS management. However, there is only limited evidence for any of the above treatments except for early revascularization and the relative ineffectiveness of IABP. This updated reviewwill therefore outline the management of CS complicating acute myocardial infarction with major focus on evidence-based revascularization techniques, intensive care unit treatment including ventilation, transfusion regimens, adjunctive medication, and mechanical support devices. [ABSTRACT FROM AUTHOR]