Cardiology

Vemmou, E., Alaswad, K., Patel, M., Mahmud, E., Choi, J.W., Jaffer, F.A., Doing, A.H., Dattilo, P., Karmpaliotis, D., Krestyaninov, O., Khelimskii, D., Nikolakopoulos, I., Karacsonyi, J., Xenogiannis, I., Garcia, S., Burke, M.N., Abi Rafeh, N., ElGuindy, A., Goktekin, O., Abdo, A., Rangan, B.V., Abdullah, S. and Brilakis, E.S. (2021). “Chronic total occlusion percutaneous coronary intervention in octogenarians and nonagenarians.” J Am Geriatr Soc Feb 16. [Epub ahead of print].

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OBJECTIVE: The outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in octogenarians and nonagenarians have received limited study. METHODS: We compared in-hospital outcomes of CTO PCI between patients ≥80 vs. <80-years-old in 6233 CTO PCIs performed between 2012 and 2020 at 33 U.S. and international centers. RESULTS: There were 415 octogenarians and nonagenarians in our study (7% of the total population). Compared with younger patients, octo- and nonagenarians were less likely to be men (73% vs. 83.2%, p < 0.0001) and more likely to have atrial fibrillation (27% vs. 12%, p < 0.0001) and prior coronary artery bypass graft surgery (CABG) (43% vs. 29%, p < 0.0001). They were more likely to have CTOs with moderate/severe calcification (71% vs. 46%, p < 0.0001), but had similar mean J-CTO scores (2.5 ± 1.3 vs. 2.4 ± 1.3, p = 0.08). They had lower technical and procedural success (82.2% vs. 86.3%, p = 0.0201; 80.3% vs. 84.8%, p = 0.016, respectively) and higher incidence of in-hospital major adverse cardiovascular events (3.4% vs. 1.8%, p = 0.021). On multivariable analysis PCI in octo- and nonagenarians was not independently associated with technical and procedural success or with in-hospital MACE. CONCLUSION: CTO PCI is feasible in octo- and nonagenarians, although success rates are lower, and the risk of complications is higher compared with younger patients, likely related to more comorbidities and higher coronary lesion complexity.

Fam, N.P., von Bardeleben, R.S., Hensey, M., Kodali, S.K., Smith, R.L., Hausleiter, J., Ong, G., Boone, R., Ruf, T., George, I., Szerlip, M., Näbauer, M., Ali, F.M., Moss, R., Bapat, V., Schnitzler, K., Kreidel, F., Ye, J., Deva, D.P., Mack, M.J., Grayburn, P.A., Peterson, M.D., Leon, M.B., Hahn, R.T. and Webb, J.G. (2021). “Transfemoral Transcatheter Tricuspid Valve Replacement With the EVOQUE System: A Multicenter, Observational, First-in-Human Experience.” JACC Cardiovasc Interv Feb 5;S1936-8798(20)32387-6. [Epub ahead of print].

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OBJECTIVES: The purpose of this observational first-in-human experience was to investigate the feasibility and safety of the EVOQUE tricuspid valve replacement system and its impact on short-term clinical outcomes. BACKGROUND: Transcatheter tricuspid intervention is a promising option for selected patients with severe tricuspid regurgitation (TR). Although transcatheter leaflet repair is an option for some, transcatheter tricuspid valve replacement (TTVR) may be applicable to a broader population. METHODS: Twenty-five patients with severe TR underwent EVOQUE TTVR in a compassionate-use experience. The primary outcome was technical success, with NYHA (NYHA) functional class, TR grade, and major adverse cardiac and cerebrovascular events assessed at 30-day follow-up. RESULTS: All patients (mean age 76 ± 3 years, 88% women) were at high surgical risk (mean Society of Thoracic Surgeons risk score 9.1 ± 2.3%), with 96% in NYHA functional class III or IV. TR etiology was predominantly functional, with mean tricuspid annular diameter of 44.8 ± 7.8 mm and mean tricuspid annular plane systolic excursion of 16 ± 2 mm. Technical success was 92%, with no intraprocedural mortality or conversion to surgery. At 30-day follow-up, mortality was 0%, 76% of patients were in NYHA functional class I or II, and TR grade was ≤2+ in 96%. Major bleeding occurred in 3 patients (12%), 2 patients (8%) required pacemaker implantation, and 1 patient (4%) required dialysis. CONCLUSIONS: This first-in-human experience evaluating EVOQUE TTVR demonstrated high technical success, acceptable safety, and significant clinical improvement. Larger prospective studies are needed to confirm durability and safety and the impact on long-term clinical outcomes.

Ilardi, F., Santoro, C., Maréchal, P., Dulgheru, R., Postolache, A., Esposito, R., Giugliano, G., Sannino, A., Avvedimento, M., Leone, A., Cirillo, P., Stabile, E., Lancellotti, P. and Esposito, G. (2021). “Accuracy of global and regional longitudinal strain at peak of dobutamine stress echocardiography to detect significant coronary artery disease.” Int J Cardiovasc Imaging Jan 12;1-11. [Epub ahead of print]. 1-11.

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Dobutamine stress echocardiography (DSE) is sensitive but subjective diagnostic tool to detect inducible ischemia. Nowadays, speckle tracking allows an objective quantification of regional wall function. We aimed to investigate the feasibility and accuracy of global (GLS) and regional longitudinal strain (RLS) during DSE to detect significant coronary stenosis (SCS). We conducted a prospective observational multicenter study including patients undergoing DSE for suspected SCS. 50 patients with positive DSE underwent coronary angiography. Besides visual regional wall motion score index (WMSI), GLS and RLS were determined at rest and at peak stress by Automated Function Imaging. DSE GLS feasibility was 96%. Among 35 patients with SCS, 12 patients were affected by multivessel disease, 18 had stenosis of left anterior descending artery (LAD), 18 of left circumflex (LCX) and 15 of right coronary artery (RCA). At peak stress, both GLS reduction (p = 0.037) and WMSI worsening (p = 0.04) showed significant agreement with coronary angiography for detecting SCS. When single lesion was considered, peak stress GLS and LAD RLS were lower in the obstructed LAD regions than in normo-perfused territories (17.4 ± 5.5 vs. 20.5 ± 4.4%, p = 0.03; 17.1 ± 7.6 vs. 21.6 ± 5.5%, p < 0.02, respectively). Furthermore, the addition of RLS to regional WMSI was able to improve accuracy in LAD SCS prediction (AUC 0.68, p = 0.037). Conversely, in presence of LCX or RCA SCS, LS was less accurate than WMSI at peak stress. In conclusion, DSE strain analysis is feasible and may improve prediction of LAD SCS, whereas regional WMSI assessment performs better in presence of SCS of LCX and RCA.

Patel, R.B., Ter Maaten, J.M., Ferreira, J.P., Mc Causland, F.R., Shah, S.J., Rossignol, P., Solomon, S.D., Vaduganathan, M., Packer, M., Thompson, A., Stockbridge, N. and Zannad, F. (2021). “Challenges of Cardio-Kidney Composite Outcomes in Large-Scale Clinical Trials.” Circulation Jan 7.[ Epub aheaad of print].

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Patients with chronic cardiovascular or metabolic diseases, including diabetes, hypertension, obesity, and heart failure, often have comorbid kidney disease. Indeed, long-term outcomes are worse in the setting of both cardiac and kidney disease compared with either disease in isolation. In addition, the clinical presentations of certain acute cardiovascular events (such as heart failure) and worsening kidney function are overlapping and may be challenging to distinguish. Recently, certain novel treatments have demonstrated beneficial effects on both cardiac and kidney outcomes. Sodium-glucose cotransporter-2 inhibitors have exhibited concordant risk reduction and clinically important benefits in chronic kidney disease with and without diabetes, diabetes and established cardiovascular disease or multiple atherosclerotic vascular disease risk
factors, and heart failure with reduced ejection fraction with and without diabetes mellitus. In addition, primary trial results have revealed that sacubitril-valsartan therapy improves cardiovascular outcomes in patients with chronic heart failure with reduced ejection fraction and post-hoc analyses suggest favorable kidney effects. A concordant pattern of kidney benefit with sacubitril-valsartan has also been observed in chronic heart failure with preserved ejection fraction. Given the complex interplay between cardiac and kidney disease and the possibility that treatments may show concordant cardio-kidney benefits, there has been recent interest to acknowledge formally, define, and utilize composite cardio-kidney outcomes in future cardiovascular trials. This review describes potential challenges in utilization of such outcomes that should be considered and addressed prior to their incorporation into such trials.

Ehteshami-Afshar, S., Mooney, L., Dewan, P., Desai, A.S., Lang, N.N., Lefkowitz, M.P., Petrie, M.C., Rizkala, A.R., Rouleau, J.L., Solomon, S.D., Swedberg, K., Shi, V.C., Zile, M.R., Packer, M., McMurray, J.J.V., Jhund, P.S. and Hawkins, N.M. (2021). “Clinical Characteristics and Outcomes of Patients With Heart Failure With Reduced Ejection Fraction and Chronic Obstructive Pulmonary Disease: Insights From PARADIGM-HF.” J Am Heart Assoc 10(4): e019238.

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Background Chronic obstructive pulmonary disease (COPD) is a common comorbidity in heart failure with reduced ejection fraction, associated with undertreatment and worse outcomes. New treatments for heart failure with reduced ejection fraction may be particularly important in patients with concomitant COPD. Methods and Results We examined outcomes in 8399 patients with heart failure with reduced ejection fraction, according to COPD status, in the PARADIGM-HF (Prospective Comparison of Angiotensin Receptor Blocker-Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial. Cox regression models were used to compare COPD versus non-COPD subgroups and the effects of sacubitril/valsartan versus enalapril. Patients with COPD (n=1080, 12.9%) were older than patients without COPD (mean 67 versus 63 years; P<0.001), with similar left ventricular ejection fraction (29.9% versus 29.4%), but higher NT-proBNP (N-terminal pro-B-type natriuretic peptide; median, 1741 pg/mL versus 1591 pg/mL; P=0.01), worse functional class (New York Heart Association III/IV 37% versus 23%; P<0.001) and Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score (73 versus 81; P<0.001), and more congestion and comorbidity. Medical therapy was similar in patients with and without COPD except for beta-blockade (87% versus 94%; P<0.001) and diuretics (85% versus 80%; P<0.001). After multivariable adjustment, COPD was associated with higher risks of heart failure hospitalization (hazard ratio [HR], 1.32; 95% CI, 1.13-1.54), and the composite of cardiovascular death or heart failure hospitalization (HR, 1.18; 95% CI, 1.05-1.34), but not cardiovascular death (HR, 1.10; 95% CI, 0.94-1.30), or all-cause mortality (HR, 1.14; 95% CI, 0.99-1.31). COPD was also associated with higher risk of all cardiovascular hospitalization (HR, 1.17; 95% CI, 1.05-1.31) and noncardiovascular hospitalization (HR, 1.45; 95% CI, 1.29-1.64). The benefit of sacubitril/valsartan over enalapril was consistent in patients with and without COPD for all end points. Conclusions In PARADIGM-HF, COPD was associated with lower use of beta-blockers and worse health status and was an independent predictor of cardiovascular and noncardiovascular hospitalization. Sacubitril/valsartan was beneficial in this high-risk subgroup.