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International Journal of Cardiology Sep 2024Extensive ablation in addition to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (AF) has not yielded consistent results, indicating... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Extensive ablation in addition to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (AF) has not yielded consistent results, indicating diversity in their efficacy. Mitral regurgitation (MR) associated with AF may indicate a higher prevalence of arrhythmogenic substrate, suggesting potential benefits of extensive ablation for these patients.
METHODS
This post-hoc analysis of the EARNEST-PVI trial compared PVI alone versus an extensive ablation strategy (PVI-plus) in persistent AF patients, stratified by MR presence. The primary endpoint of the study was the recurrence of AF. The secondary endpoints included death, cerebral infarction, and procedure-related complications.
RESULTS
The trial included 495 eligible patients divided into MR and non-MR groups. The MR group consisted of 192 patients (89 in the PVI-alone arm and 103 in the PVI-plus arm), while the non-MR group had 303 patients (158 in the PVI-alone arm and 145 in the PVI-plus arm). In the non-MR group, recurrence rates were similar between PVI-alone and PVI-plus arms (Log-rank P = 0.47, Hazard ratio = 0.85 [95%CI: 0.54-1.33], P = 0.472). However, in the MR group, PVI-plus was significantly more effective in preventing AF recurrence (Log-rank P = 0.0014, Hazard ratio = 0.40 [95%CI: 0.22-0.72], P = 0.0021). No significant differences were observed in secondary endpoints between the two arms.
CONCLUSIONS
For persistent AF patients with mild or greater MR, receiving PVI-plus was superior to PVI-alone in preventing AF recurrence. Conversely, for patients without MR, the effectiveness of extensive ablation was not demonstrated. These findings suggest tailoring ablation strategies based on MR presence can lead to better outcomes in AF management.
Topics: Humans; Atrial Fibrillation; Male; Female; Mitral Valve Insufficiency; Prospective Studies; Catheter Ablation; Middle Aged; Aged; Treatment Outcome; Pulmonary Veins; Follow-Up Studies; Recurrence
PubMed: 38838745
DOI: 10.1016/j.ijcard.2024.132231 -
European Journal of Heart Failure Jun 2024This study aimed to evaluate the clinical significance of secondary mitral regurgitation (MR) in patients with heart failure with preserved ejection fraction (HFpEF).
Cardiac function, haemodynamics, and valve competence with exercise in patients with heart failure with preserved ejection fraction and mild to moderate secondary mitral regurgitation.
AIMS
This study aimed to evaluate the clinical significance of secondary mitral regurgitation (MR) in patients with heart failure with preserved ejection fraction (HFpEF).
METHODS AND RESULTS
We conducted a prospective study enrolling consecutively evaluated patients with HFpEF undergoing invasive haemodynamic exercise testing with simultaneous echocardiography. Compared to HFpEF without MR (n = 145, 79.7%), those with mild or moderate MR (n = 37, 20.3%) were older, more likely to be women, had more left ventricular (LV) systolic dysfunction, and more likely to have left atrial (LA) myopathy reflected by greater burden of atrial fibrillation, more LA dilatation, and poorer LA function. Pulmonary artery (PA) wedge pressure was higher at rest in HFpEF with MR (17 ± 5 mmHg vs. 20 ± 5 mmHg, p = 0.005), but there was no difference with exercise. At rest, only 2 (1.1%) patients had moderate MR, and none developed severe MR. Pulmonary vascular resistance was higher, and right ventricular (RV)-PA coupling was more impaired in patients with HFpEF and MR at rest and exercise. LV and LA myocardial dysfunction remained more severe in patients with MR during stress compared to those without MR, characterized by greater LA dilatation during all stages of exertion, lower LA emptying fraction and compliance, steeper and rightward-shifted LA pressure-volume relationships, and reduced LV longitudinal contractile function.
CONCLUSIONS
Patients with HFpEF and mild or moderate MR have more severe LV systolic dysfunction, LA myopathy, RV-PA uncoupling, and more severe pulmonary vascular disease. Mitral valve incompetence in this setting is a phenotypic marker of more advanced disease but is not a causal factor in development of HFpEF.
PubMed: 38837599
DOI: 10.1002/ejhf.3322 -
JAMA Jun 2024Rheumatic heart disease (RHD) remains a public health issue in low- and middle-income countries (LMICs). However, there are few large studies enrolling individuals from...
IMPORTANCE
Rheumatic heart disease (RHD) remains a public health issue in low- and middle-income countries (LMICs). However, there are few large studies enrolling individuals from multiple endemic countries.
OBJECTIVE
To assess the risk and predictors of major patient-important clinical outcomes in patients with clinical RHD.
DESIGN, SETTING, AND PARTICIPANTS
Multicenter, hospital-based, prospective observational study including 138 sites in 24 RHD-endemic LMICs.
MAIN OUTCOMES AND MEASURES
The primary outcome was all-cause mortality. Secondary outcomes were cause-specific mortality, heart failure (HF) hospitalization, stroke, recurrent rheumatic fever, and infective endocarditis. This study analyzed event rates by World Bank country income groups and determined the predictors of mortality using multivariable Cox models.
RESULTS
Between August 2016 and May 2022, a total of 13 696 patients were enrolled. The mean age was 43.2 years and 72% were women. Data on vital status were available for 12 967 participants (94.7%) at the end of follow-up. Over a median duration of 3.2 years (41 478 patient-years), 1943 patients died (15% overall; 4.7% per patient-year). Most deaths were due to vascular causes (1312 [67.5%]), mainly HF or sudden cardiac death. The number of patients undergoing valve surgery (604 [4.4%]) and HF hospitalization (2% per year) was low. Strokes were infrequent (0.6% per year) and recurrent rheumatic fever was rare. Markers of severe valve disease, such as congestive HF (HR, 1.58 [95% CI, 1.50-1.87]; P < .001), pulmonary hypertension (HR, 1.52 [95% CI, 1.37-1.69]; P < .001), and atrial fibrillation (HR, 1.30 [95% CI, 1.15-1.46]; P < .001) were associated with increased mortality. Treatment with surgery (HR, 0.23 [95% CI, 0.12-0.44]; P < .001) or valvuloplasty (HR, 0.24 [95% CI, 0.06-0.95]; P = .042) were associated with lower mortality. Higher country income level was associated with lower mortality after adjustment for patient-level factors.
CONCLUSIONS AND RELEVANCE
Mortality in RHD is high and is correlated with the severity of valve disease. Valve surgery and valvuloplasty were associated with substantially lower mortality. Study findings suggest a greater need to improve access to surgical and interventional care, in addition to the current approaches focused on antibiotic prophylaxis and anticoagulation.
PubMed: 38837131
DOI: 10.1001/jama.2024.8258 -
JTCVS Techniques Apr 2024The Ross operation is a widely accepted option for aortic valve replacement in children, and evidence shows its excellent results in terms of hemodynamics and...
OBJECTIVE
The Ross operation is a widely accepted option for aortic valve replacement in children, and evidence shows its excellent results in terms of hemodynamics and durability. However, indications are still limited due to the fact that it is a technically demanding procedure, only performed by specialized surgeons. On top of that, and despite numerous techniques being applied, autograft dilatation remains a key disadvantage, which can lead to graft failure. In recent years, the ExoVasc Personalized External Aortic Root Support (PEARS) has proven to be a safe and effective option to prevent aortic root dilatation in various aortopathies and is a technique that lends itself to support the pulmonary autograft in the Ross operation.
METHODS
During the past 7 years, we have used the ExoVasc PEARS graft, manufactured from the patients' pulmonary artery measurements from computed tomography scan data, to support the pulmonary autograft in the Ross operation. This graft (manufactured by Exstent Ltd, UK) is implanted at the same time as the autograft. We have reviewed all the patients who underwent this surgery, including demographic data, aorta measurements, operative data, and follow-up assessment consisting of periodic echocardiograms and magnetic resonance imaging scans.
RESULTS
Fifty patients were included in the study. Mean age at the time of the operation was 29.84 years, the youngest patient was 9 years-old. Nineteen patients (38%) had previous sternotomies; 11 of them having had a previous aortic valve replacement. Seventy-two percent of patients had initially a bicuspid aortic valve. Mean diameter of the ascending aorta was 3.83 cm. Forty-four percent of patients required a concomitant reduction aortoplasty due to mismatch sizes between the ascending aorta and the autograft. Mean bypass and crossclamp times were 200.66 and 151.14 minutes, respectively. Median length of stay was 6 days. Mean follow-up was 16.88 months. Two patients required subsequent aortic valve replacement (1 had rheumatic valve disease and the other had iatrogenic damage in his autograft valve leaflet). Ascending aorta dimensions remain stable when compared with immediate postoperative studies. There were no deaths.
CONCLUSIONS
The ExoVasc PEARS graft has proven to be an excellent support in the Ross operation to prevent the autograft failure related to autograft dilatation that can offer several advantages compared with other existing techniques. With this type of support, we believe the Ross indications can be expanded to multiple clinical scenarios, given the good long-term results this operation offers in terms of durability, life expectancy, and hemodynamics.
PubMed: 38835595
DOI: 10.1016/j.xjtc.2024.02.004 -
JTCVS Techniques Apr 2024In select patients with borderline ventricular hypoplasia, we adopted a strategy of initial single-ventricle palliation followed by staged or direct biventricular...
OBJECTIVE
In select patients with borderline ventricular hypoplasia, we adopted a strategy of initial single-ventricle palliation followed by staged or direct biventricular conversion by 2 years of age.
METHODS
Between 2018 and 2023, 14 newborns with borderline hypoplastic heart disease deemed high risk for primary biventricular repair underwent palliative procedures as a neonate/infant, followed by staged or direct biventricular conversion.
RESULTS
Of the 14 patients, 6 had borderline left ventricles and 8 had borderline right ventricles. Index neonatal operations were performed in 12 patients and included the Norwood operation (n = 5), pulmonary artery band (n = 3), ductal stent (n = 3), and hybrid Norwood (n = 1). Five patients underwent direct biventricular conversion, and the remaining 9 patients underwent staged ventricular recruitment operations at a mean age of 6 months (range, 3-11 months). Ventricular recruitment operations included atrial septation with or without ventricular rehabilitation, atrioventricular valve repair, or outflow tract operations. At a mean duration of 8 months (range, 4-10 months) after ventricular recruitment, there was a significant increase in chamber volume, aortic valve, and mitral valve size in patients with borderline left ventricles, and a normalization of the right ventricle:left ventricle end-diastolic volume ratio in patients with borderline right ventricles. To date, 13 of 14 patients have undergone successful biventricular conversion at a mean age of 16 months (range, 4-31 months).
CONCLUSIONS
In select newborns with borderline hypoplastic heart disease, single-ventricle palliation followed by staged or direct biventricular conversion may increase infant survival while allowing for early attainment of a biventricular circulation.
PubMed: 38835569
DOI: 10.1016/j.xjtc.2024.02.006 -
JTCVS Techniques Apr 2024Infants with single ventricle heart disease and severe atrioventricular valve regurgitation have poor outcomes following conventional staged palliation. As such,...
BACKGROUND
Infants with single ventricle heart disease and severe atrioventricular valve regurgitation have poor outcomes following conventional staged palliation. As such, ventricular assist device (VAD) placement along with hybrid stage 1 palliation has been proposed as a bridge to heart transplant. We present a novel surgical technique for VAD implantation concurrent with hybrid stage 1 that avoids cardiopulmonary bypass.
METHODS
We performed a retrospective review of our institutional experience with this novel surgical technique.
RESULTS
Three patients (weight, 2.7-3.5 kg; age, 3 to 5 days) underwent hybrid stage 1 with VAD placement, consisting of bilateral 3.5-mm expandable polytetrafluoroethylene (PTFE) pulmonary artery bands, a ductal stent, a 6-mm Berlin Heart outflow cannula onto the main pulmonary trunk with a 10-mm graft, a 6-mm Berlin Heart outflow cannula onto the right atrium, and a 10-mL Berlin Heart pump. In patients with severe aortic arch hypoplasia or coarctation, a 4-mm PTFE graft was sewn from the VAD outflow graft to the innominate artery to protect coronary and cerebral perfusion. Procedures were performed off bypass with minimal blood product use. Patients were extubated on postoperative days 2, 2, and 5. There were no procedural complications. All patients were transferred out of the intensive care unit and demonstrated appropriate weight gain. Anticoagulation strategy was bivalirudin and antiplatelet therapy. The patients underwent transplantation after 149 days, 157 days, and 288 days of support.
CONCLUSIONS
Off-pump single ventricle VAD placement is technically feasible and can be done at the time of hybrid stage 1 palliation with minimal operative morbidity as a bridge to transplant.
PubMed: 38835568
DOI: 10.1016/j.xjtc.2023.10.022 -
European Journal of Cardio-thoracic... Jun 2024Lung volume reduction surgery (LVRS) is a clinically effective palliation procedure for patients with chronic obstructive pulmonary disease. LVRS has recently been...
OBJECTIVES
Lung volume reduction surgery (LVRS) is a clinically effective palliation procedure for patients with chronic obstructive pulmonary disease. LVRS has recently been commissioned by the NHS England. In this study, a costing model was developed to analyse cost and resource implications of different LVRS procedures.
METHODS
Three pathways were defined by their surgical procedures: bronchoscopic endobronchial valve insertion (EBV-LVRS), video-assisted thoracic surgery LVRS and robotic-assisted thoracic surgery LVRS. The costing model considered use of hospital resources from the LVRS decision until 90 days after hospital admission. The model was calibrated with data obtained from an observational study, electronic health records and expert opinion. Unit costs were obtained from the hospital finance department and reported in 2021 Euros.
RESULTS
Video-assisted thoracic surgery LVRS was associated with the lowest cost at €12 896 per patient. This compares to the costs of EBV-LVRS at €15 598 per patient and €13 305 per patient for robotic-assisted thoracic surgery LVRS. A large component of EBV-LVRS costs were accrued secondary to complications, including revision EBV-LVRS.
CONCLUSIONS
This study presents a comprehensive model framework for the analysis of hospital-related resource use and costs for the 3 surgical modalities. In the future, service commissioning agencies, hospital management and clinicians can use this framework to determine their modifiable resource use (composition of surgical teams, use of staff and consumables, planned length of stay and revision rates for EBV-LVRS) and to assess the potential cost implications of changes in these parameters.
Topics: Humans; Pneumonectomy; Tertiary Care Centers; Thoracic Surgery, Video-Assisted; Pulmonary Disease, Chronic Obstructive; Robotic Surgical Procedures; England; Male; Cost-Benefit Analysis; Bronchoscopy
PubMed: 38833683
DOI: 10.1093/ejcts/ezae222 -
Frontiers in Cardiovascular Medicine 2024To explore the clinical value of echocardiography in detecting fetal cardiac axis abnormalities during middle pregnancy for diagnosing conus arteriosus malformation, and...
Relationship between diagnosis of conus arteriosus malformation and genetic diagnosis results in fetal cardiac axis abnormalities by echocardiography during middle pregnancy.
OBJECTIVE
To explore the clinical value of echocardiography in detecting fetal cardiac axis abnormalities during middle pregnancy for diagnosing conus arteriosus malformation, and to compare and analyze the genetic diagnosis results, in order to provide evidence for clinical diagnosis and intervention.
METHODS
Four hundred twenty-one fetuses with conus arteriosus malformation from January 2020 to October 2023 were included as the conus arteriosus malformation group, and 917 healthy fetuses (all single fetuses) matched at the same gestational age were selected as the healthy group.
RESULTS
There was no significant difference in gestational weeks between two groups ( > 0.05). The age of pregnant women in conus arteriosus malformation group was lower compared to healthy group ( < 0.05), and the fetal cardiac axis in conus arteriosus malformation group was significantly higher compared to healthy group ( < 0.05). Among the fetuses with conus arteriosus malformation, tetralogy of Fallot (TOF), transposition of the great arteries (TGA) and double outlet right ventricle (DORV) had the highest proportions, accounting for 38.00%, 18.29% and 17.58%, respectively. Among all types of conus arteriosus malformations, atresia pulmonary valve syndrome associated with TOF, persistent truncus arteriosus and DORV exhibited higher proportions of fetal cardiac axis abnormalities, at 75.00%, 36.84% and 27.03%, respectively, while TGA and interrupted aortic arch associated with B-type interruption had lower proportions of fetal cardiac axis abnormalities, at 2.60% and 4.55%, respectively. Genetic testing was conducted on 73 cases (17.34%) of fetuses with conus arteriosus malformation in this study. Among them, fetal cardiac axis abnormalities were considered positive for genetic results due to factors such as aneuploidy, copy number abnormalities, and single-gene pathogenicity. A total of 31 cases tested positive for genetic anomalies, with a positive rate of approximately 42.47%.
CONCLUSION
In the middle pregnancy, the fetal cardiac axis in cases of conus arteriosus malformation was significantly higher than in normal fetuses. Moreover, there were variations in fetal cardiac axis among different types of conus arteriosus malformations, and these differences were notably associated with genetic diagnostic results.
PubMed: 38832316
DOI: 10.3389/fcvm.2024.1377095 -
Respirology (Carlton, Vic.) Jun 2024
PubMed: 38831347
DOI: 10.1111/resp.14769 -
Saudi Medical Journal Jun 2024To evaluate the relationship between severity of tricuspid regurgitation (TR) and pulmonary hypertension.
OBJECTIVES
To evaluate the relationship between severity of tricuspid regurgitation (TR) and pulmonary hypertension.
METHODS
Cross-sectional study of 118 patients with pulmonary hypertension was carried out at a single center in Jeddah, Saudi Arabia, between 2018-2021. Patients who had pulmonary or tricuspid valves organic diseases, previously undergone tricuspid or pulmonary valve surgeries, had permanent pacemakers or critically ill were excluded.
RESULTS
A high proportion of patients were women (n=100, 85%) and obese (n=57, 48%). Patients with more than mild TR had higher systolic pulmonary artery pressure (sPAP) than those with trivial or mild regurgitation (<0.001). There was a significant association between severity of TR (<0.001) and right chambers size (=0.001). Furthermore, pulmonary artery pressure (PAP) was significantly higher in patients with mild right ventricular impairment (=0.001).
CONCLUSION
Increase in degree of TR and right atrial size were predictors of elevated sPAP. Our findings highlight the interplay among TR, right heart size, ventricular function, and PAP. Understanding these associations can aid in risk stratification, monitoring disease progression, and potentially guiding treatment in those patients.
Topics: Humans; Tricuspid Valve Insufficiency; Female; Male; Hypertension, Pulmonary; Cross-Sectional Studies; Middle Aged; Severity of Illness Index; Adult; Saudi Arabia; Ventricular Dysfunction, Right; Aged; Heart Atria; Obesity; Echocardiography
PubMed: 38830663
DOI: 10.15537/smj.2024.45.6.20240071