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Although previous risk models exist for advanced heart failure with reduced ejection fraction (HFrEF), few integrate invasive hemodynamics or support missing data. This study developed and validated a heart failure (HF) hemodynamic risk and phenotyping score for HFrEF, using Machine Learning (ML). Prior to modeling, patients in training and validation HF cohorts were assigned to 1 of 5 risk categories based on the composite endpoint of death, left ventricular assist device (LVAD) implantation or transplantation (DeLvTx), and rehospitalization in 6 months of follow-up using unsupervised clustering. The goal of our novel interpretable ML modeling approach, which is robust to missing data, was to predict this risk category (1, 2, 3, 4, or 5) using either invasive hemodynamics alone or a rich and inclusive feature set that included noninvasive hemodynamics (all features). The models were trained using the ESCAPE trial and validated using 4 advanced HF patient cohorts collected from previous trials, then compared with traditional ML models. Prediction accuracy for each of these 5 categories was determined separately for each risk category to generate 5 areas under the curve (AUCs, or C-statistics) for belonging to risk category 1, 2, 3, 4, or 5, respectively. Across all outcomes, our models performed well for predicting the risk category for each patient. Accuracies of 5 separate models predicting a patient's risk category ranged from 0.896 +/- 0.074 to 0.969 +/- 0.081 for the invasive hemodynamics feature set and 0.858 +/- 0.067 to 0.997 +/- 0.070 for the all features feature set. Novel interpretable ML models predicted risk categories with a high degree of accuracy. This approach offers a new paradigm for risk stratification that differs from prediction of a binary outcome. Prospective clinical evaluation of this approach is indicated to determine utility for selecting the best treatment approach for patients based on risk and prognosis. [ABSTRACT FROM AUTHOR]

Newer therapies have increased heart failure (HF) survival rates, but these therapies are rarely curative. The consequence of increased longevity is the likelihood that patients with HF will experience higher symptom burdens over time. Exercise such as cardiac rehabilitation programs can palliate symptom burdens, but numerous barriers prevent exercise participation and adherence. Small pilot studies indicate short-term beneficial effects of gentle forms of exercise such as yoga to address symptom burdens and accommodate comorbidities. Long-term symptom benefit and adherence to yoga are currently unknown. Therefore, a novel a home-based, gentle-stretching intervention that addresses issues of exercise access and adherence is described in this article. The purpose of this article is to describe the background, design and study methodology of the Getting Into Light Exercise for HF (GENTLE-HF) randomized controlled trial. Gentle-HF will test a gentle stretching and education intervention compared to an education control group concerning symptom burden (dyspnea, exercise, activity adherence, depression, and anxiety) and quality of life. As an exploratory aim, we also will determine whether rurality moderates the relationships between exercise participation and symptom burden as a measure of health equity. We designed a randomized controlled trial study (n = 234) with 2 arms: a gentle stretching intervention arm with HF education and an HF education-only control. Participants will be recruited from U.S. cardiology clinics in the mid-Atlantic and the San Francisco Bay areas. This recruitment strategy will include individuals from urban, suburban and rural areas and individuals that have diverse racial and ethnic backgrounds. All participants will be provided with an iPad set up to access HF educational topics, and the intervention arm will have both educational and gentle-stretching class links. Both arms will access the HF health education icons on their iPads weekly; they correspond to the 6 months (26 weeks) of study participation. Symptom burden (dyspnea, fatigue, exercise intolerance, depression, anxiety) and quality of life will be measured at the study's start and completion. Study adherence will be measured by using attendance rates and number of class minutes attended. The GENTLE-HF study is a randomized study that will test the effect of a home-based, video-conference-delivered gentle stretching and HF education intervention designed for patients with HF. The findings will inform whether gentle stretching can decrease symptom burden and potentially provide access to symptom palliation for a diverse population of patients with HF. [ABSTRACT FROM AUTHOR]

To examine the accuracy of noninvasively-derived peripheral arterial blood pressure (BP) by the Caretaker device (CT) against invasively measured arterial BP and the fidelity of heart rate variability by CT compared with electrocardiogram (ECG)-derived data. Prospective cohort study. Adult surgical and trauma patients admitted to the intensive care unit. Academic tertiary care medical center. In a prospective manner, beat-by-beat BP by CT was recorded simultaneously with invasive arterial BP measured in patients in the intensive care unit. Invasive arterial BPs were compared with those obtained by the CT system. All comparisons among the CT data, arterial catheter data, and ECG data were postprocessed. From 37 enrolled patients, 34 were included with satisfactory data that overlapped between arterial catheter and CT. A total of 87,757 comparative data points were obtained for the 40-minute time window comparisons of the 34 patients, spanning approximately 22.5 hours in total. Systolic BP and diastolic BP correlations (Pearson coefficient), as well as the mean difference (standard deviation), were 0.92 and –0.36 (7.57) mmHg and 0.83 and –2.11 (6.00) mmHg, respectively. The overall interbeat correlation was 0.99, with the mean difference between interbeats obtained with the arterial BP and the CT of –0.056 ms (6.0). This study validated the noninvasive tracking of BP using the CT device, and the pulse decomposition analysis approach is possible within the guidelines of the standard. [ABSTRACT FROM AUTHOR]

Negative-pressure pulmonary edema (NPPE) has become a well-recognized, though uncommon, complication of acute upper airway obstruction. While initially described in the setting of peri-operative endotracheal intubation, NPPE has been increasingly observed in numerous other clinical scenarios. In this report, we describe a case of NPPE that occurred after a scheduled cardioversion and transesophageal echocardiogram (TEE). We suspect the attempt at TEE probe placement inadvertently led to tracheal insertion as suggested by excessive resistance, poor visualization, stridor, and subsequent acute pulmonary edema. While supportive treatment when recognized can lead to rapid improvement, it is important to recognize NPPE as a possible complication of this commonly indicated procedure. Excessive resistance is a common challenge during the transesophageal echocardiogram (TEE) procedure and may be the result of incidental tracheal insertion. Negative-pressure pulmonary edema (NPPE) may result from this acute upper airway obstruction. Thus, NPPE should be on the differential for patients who present with unexplained non-cardiogenic pulmonary edema and should be recognized as a possible complication of the TEE procedure. [ABSTRACT FROM AUTHOR]

Background: The prognostic importance of trajectories of neurohormones relative to left ventricular function over time in heart failure with reduced and mid-range EF (HFrEF and HFmrEF) is poorly defined.Objective: To evaluate left ventricular ejection fraction (LVEF) and B-type natriuretic peptide (BNP) trajectories in HFrEF and HFmrEF.Methods: Analyses of LVEF and BNP trajectories after incident HF admissions presenting with abnormal LV systolic function were performed using 3 methods: a Cox proportional hazards model with time-varying covariates, a dual longitudinal-survival model with shared random effects, and an unsupervised analysis to capture 3 discrete trajectories for each parameter.Results: Among 1,158 patients (68.9 ± 13.0 years, 53.3% female), both time-varying LVEF measurements (P=.001) and log-transformed BNP measurements (p-values=2 × 10-16) were independently associated with survival during 6 years after covariate adjustment. In the dual longitudinal/survival model, both LVEF and BNP trajectories again were independently associated with survival (P<.0001 in each model); however, LVEF was more dynamic than BNP (P <.0001 for time covariate in LVEF longitudinal model versus P=.88 for the time covariate in BNP longitudinal model). In the unsupervised analysis, 3 discrete LVEF trajectories (dividing the cohort into approximately thirds) and 3 discrete BNP trajectories were identified. Discrete LVEF and BNP trajectories had independent prognostic value in Kaplan-Meier analyses (P<.0001), and substantial membership variability across BNP and LVEF trajectories was noted.Conclusion: Although LVEF trajectories have greater temporal variation, BNP trajectories provide additive prognostication and an even stronger association with survival times in heart failure patients with abnormal LV systolic function. [ABSTRACT FROM AUTHOR]

The objective was to determine the feasibility and effectiveness of cardiac magnetic resonance (CMR) cine and strain imaging before and after cardiac resynchronization therapy (CRT) for assessment of response and the optimal resynchronization pacing strategy. CMR with cardiac implantable electronic devices can safely provide high-quality right ventricular/left ventricular (LV) ejection fraction (RVEF/LVEF) assessments and strain. CMR with cine imaging, displacement encoding with stimulated echoes for the circumferential uniformity ratio estimate with singular value decomposition (CURE-SVD) dyssynchrony parameter, and scar assessment was performed before and after CRT. Whereas the pre-CRT scan constituted a single "imaging set" with complete volumetric, strain, and scar imaging, multiple imaging sets with complete strain and volumetric data were obtained during the post-CRT scan for biventricular pacing (BIVP), LV pacing (LVP), and asynchronous atrial pacing modes by reprogramming the device outside the scanner between imaging sets. 100 CMRs with a total of 162 imaging sets were performed in 50 patients (median age 70 years [IQR: 50-86 years]; 48% female). Reduction in LV end-diastolic volumes (P = 0.002) independent of CRT pacing were more prominent than corresponding reductions in right ventricular end-diastolic volumes (P = 0.16). A clear dependence of the optimal CRT pacing mode (BIVP vs LVP) on the PR interval (P = 0.0006) was demonstrated. The LVEF and RVEF improved more with BIVP than LVP with PR intervals ≥240 milliseconds (P = 0.025 and P = 0.002, respectively); the optimal mode (BIVP vs LVP) was variable with PR intervals <240 milliseconds. A lower pre-CRT displacement encoding with stimulated echoes (DENSE) CURE-SVD was associated with greater improvements in the post-CRT CURE-SVD (r = −0.69; P < 0.001), LV end-systolic volume (r = −0.58; P < 0.001), and LVEF (r = −0.52; P < 0.001). CMR evaluation with assessment of multiple pacing modes during a single scan after CRT is feasible and provides useful information for patient care with respect to response and the optimal pacing strategy. [Display omitted] [ABSTRACT FROM AUTHOR]

Social vulnerability index (SVI) measures social factors that impact clinical outcomes for a county or census tract, particularly cardiovascular disease outcomes. Over the last decade, Transcatheter aortic valve replacement (TAVR) has improved clinical outcomes for patients with Aortic Stenosis (AS). However, despite data suggesting a strong relationship between SVI and cardiovascular diseases and procedures, it is currently unknown whether SVI is associated with the urgency of receiving TAVR in AS. SVI is associated with urgency of TAVR in AS. Using Optum's de-identified Clinformatics® Data Mart Database (CDM, which includes U.S. patients with commercial insurance or Medicare Advantage) 26,252 admissions for TAVR were recorded between January 2018 and March 2022. We included patients who met the following eligibility criteria: TAVR as primary cause of admission, a previous diagnosis of AS, 12 months of prior insurance enrollment, and consistent ZIP codes during the study. We classified patient hospital admissions as either urgent or non-urgent according to CDM claims codes. SVI was cross-referenced to patients using patient ZIP codes and stratified into SVI quintiles. Generalized linear mixed-effects models were used to predict the probability of a TAVR admission being urgent based on SVI quintiles, adjusting for patient- and hospital-level covariates. Among 6680 admissions eligible for final analysis, 567 (8.5%) were classified as urgent, with proportions similar across SVI quintiles (ranging from 7.0% in the lowest SVI quintile, to 9.7% in the highest quintile). After adjusting for patient- and hospital-level variables, there was no significant differences in the odds of urgent admission for TAVR based on the SVI quintiles (OR for the highest to lowest SVI quintile: 1.29, 95% CI 0.90 - 1.85). Among commercially insured patients with AS who underwent TAVR in the CDM, social vulnerability index was not associated with the urgency of TAVR procedure. Future research should include investigating the relationship between SVI and urgency of TAVR for AS among patients with public insurance and no insurance. [ABSTRACT FROM AUTHOR]

To compare the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score with the established Society of Thoracic Surgeons (STS) and EuroSCORE II risk prediction models regarding mortality discrimination after aortic and mitral valve surgery. Retrospective cohort study. Single tertiary academic medical center. A total of 259 patients who underwent open aortic valve replacement or open mitral valve repair/replacement from 2009-2014. Retrospective chart review. MAGGIC, STS, and EuroSCORE II risk scores for each patient were studied using binary logistic regression and receiver operating characteristic analysis for the primary endpoint of one-year mortality and secondary endpoint of 30-day mortality. One-year mortality C-statistics were similar across risk scores (STS 0.709, 95% confidence interval [CI] 0.578-0.841; MAGGIC 0.673, 95% CI 0.547-0.799; EuroSCORE II 0.642, 95% CI 0.521-0.762; p = 0.56 between STS and MAGGIC; p = 0.20 between STS and EuroSCORE II; and p = 0.69 between MAGGIC and EuroSCORE II). Thirty-day mortality C-statistics also were similar between STS (0.797, 95% CI 0.655-0.939; p < 0.0001 v null hypothesis), MAGGIC (0.721, 95% CI 0.581-0.860; p = 0.33 v STS), and EuroSCORE II (0.688, 95% CI 0.557-0.818; p = 0.06 v STS; p = 0.68 v MAGGIC). The MAGGIC risk score performs similarly to STS and EuroSCORE II risk models in mortality discrimination after aortic and mitral valve surgery, albeit in a small sample size. This finding has important implications in establishing MAGGIC as a viable prognostic model in this population subset, with fewer variables and ease of use representing key advantages over STS and EuroSCORE II. [ABSTRACT FROM AUTHOR]

This study sought to determine if combining the Seattle Heart Failure Model (SHFM-D) and cardiac magnetic resonance (CMR) provides complementary prognostic data for patients with cardiac resynchronization therapy (CRT) defibrillators. The SHFM-D is among the most widely used risk stratification models for overall survival in patients with heart failure and implantable cardioverter-defibrillators (ICDs), and CMR provides highly detailed information regarding cardiac structure and function. CMR Displacement Encoding with Stimulated Echoes (DENSE) strain imaging was used to generate the circumferential uniformity ratio estimate with singular value decomposition (CURE-SVD) circumferential strain dyssynchrony parameter, and the SHFM-D was determined from clinical parameters. Multivariable Cox proportional hazards regression was used to determine adjusted hazard ratios and time-dependent areas under the curve for the primary endpoint of death, heart transplantation, left ventricular assist device, or appropriate ICD therapies. The cohort consisted of 100 patients (65.5 [interquartile range 57.7 to 72.7] years; 29% female), of whom 47% had the primary clinical endpoint and 18% had appropriate ICD therapies during a median follow-up of 5.3 years. CURE-SVD and the SHFM-D were independently associated with the primary endpoint (SHFM-D: hazard ratio: 1.47/SD; 95% confidence interval: 1.06 to 2.03; p = 0.02) (CURE-SVD: hazard ratio: 1.54/SD; 95% confidence interval: 1.12 to 2.11; p = 0.009). Furthermore, a favorable prognostic group (Group A, with CURE-SVD <0.60 and SHFM-D <0.70) comprising approximately one-third of the patients had a very low rate of appropriate ICD therapies (1.5% per year) and a greater (90%) 4-year survival compared with Group B (CURE-SVD ≥0.60 or SHFM-D ≥0.70) patients (p = 0.02). CURE-SVD with DENSE had a stronger correlation with CRT response (r = −0.57; p < 0.0001) than CURE-SVD with feature tracking (r = −0.28; p = 0.004). A combined approach to risk stratification using CMR DENSE strain imaging and a widely used clinical risk model, the SHFM-D, proved to be effective in this cohort of patients referred for CRT defibrillators. The combined use of CMR and clinical risk models represents a promising and novel paradigm to inform prognosis and device selection in the future. [ABSTRACT FROM AUTHOR]

Mavacamten improves left ventricular outflow tract obstruction (LVOT), exercise capacity, symptoms, and health status versus placebo in patients with symptomatic obstructive hypertrophic cardiomyopathy (HCM). As mavacamten is used in clinical practice, generating data in the real-world setting becomes important to understand its safety and effectiveness. DISCOVER-HCM (NCT05489705) is an observational, multicenter, prospective registry study to assess patient characteristics, treatment patterns, and longitudinal outcomes in patients receiving mavacamten and/or other treatments for symptomatic obstructive HCM. Up to 1500 patients from 65 sites in the US and Puerto Rico will be enrolled over approximately 2 years. Inclusion and exclusion criteria are outlined in the Table. The study will include 2 years of retrospective and 5 years of prospective data collection (Figure). The primary objective is to estimate the incidence of new/worsening heart failure due to systolic dysfunction (symptomatic left ventricular ejection fraction <50%). Secondary and exploratory objectives include evaluation of treatment effectiveness (e.g., LVOT gradients), additional safety endpoints (e.g., occurrences of arrhythmias and major adverse cardiovascular events), and quality of life outcomes (e.g., Kansas City Cardiomyopathy Questionnaire 23). A sub-study will assess longitudinal cardiac biomarkers to characterize markers of response over time. DISCOVER-HCM is the first real-world prospective registry study to characterize use, health outcomes, effectiveness, safety and other markers of health in patients with obstructive HCM receiving mavacamten and other therapies. [ABSTRACT FROM AUTHOR]

Estimated pulse wave velocity (ePWV) is a known indicator of arterial stiffness, which is an established predictor of hypertension and cardiovascular disease. The Dietary Approaches to Stop Hypertension (DASH) diet has been shown to lower blood pressure, but its effect on arterial stiffness remains unclear. We hypothesize that the DASH diet will change arterial stiffness, as measured by ePWV, in participants enrolled in the DASH trial. This post hoc secondary analysis of the DASH trial (n=459) compared the effects of the DASH diet, a control diet, and a fruit and vegetable diet on ePWV. ePWV was calculated using mean blood pressure (MBP) and Age using the equation: 9.587 - 0.402 х age + 4.560 х 10-3 х age2 - 2.621 х 10-5 х age2 х MBP + 3.176 х 10-3 х age х MBP - 1.832 х 10-2 х MBP. MBP was calculated from diastolic blood pressure (DBP) and systolic blood pressure (SBP) using the equation: (DBP) + 0.4(SBP - DBP). Responders and non-responders were analyzed separately, and multiple hypothesis testing was adjusted. Among 459 participants, the mean age was 44±10years in the DASH diet, 45±11years in the fruits and vegetables, and 44±11years in the control diets group, while the mean ePWV was 7.99 ± 0.13m/s, 8.19 ± 0.09 m/s, 8.24 ± 0.05m/s for participants in the DASH diet, fruits and vegetable, control diets respectively. A significant difference in ePWV was found between the three diet groups (p=0.002, q=0.042). The DASH diet significantly reduced ePWV compared to the control diet (-0.27 m/s, 95% CI [-0.38, -0.17], p<0.0001) and the fruit and vegetable diet (-0.12 m/s, 95% CI [-0.23, -0.02], p=0.02). The reduction in ePWV becomes statistically significant after three weeks of being on the DASH diet and continues to proportionally decrease over time. Participants with hypertension experienced a numerically greater reduction in ePWV on the DASH diet, compared to participants without hypertension. This study shows that the DASH diet may improve ePWV, suggesting decrease arterial stiffness and better cardiovascular health, particularly in individuals with hypertension. These findings align with previous research that the DASH diet effectively lowers blood pressure and improves cardiovascular health. The current study extends this body of literature by specifically examining the effect of the DASH diet on arterial stiffness. More studies are needed to further evaluate the role of diet, ePWV, and cardiovascular outcomes. [ABSTRACT FROM AUTHOR]

Mechanisms underlying heart failure with preserved ejection (HFpEF) are not fully understood, but arterial stiffness due to a proinflammatory milieu and hypertension play dominant roles. Estimated pulse wave velocity (ePWV) is a measure of arterial stiffness, which is closely associated with hypertension. There is a paucity of studies examining the role of ePWV in HFpEF. Here, we evaluated the role of ePWV in HFpEF in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial. We hypothesized that increased ePWV would be associated with increased mortality in patients with HFpEF enrolled in the TOPCAT trial. A post hoc analysis of the TOPCAT trial (n = 3441) was conducted to evaluate ePWV in patients with HFpEF and its effect on mortality. ePWV was calculated using mean blood pressure (MBP) and age using the equation: 9.587 - 0.402 х age + 4.560 х 10-3 х age2 - 2.621 х 10-5 х age2 х MBP + 3.176 х 10-3 х age х MBP - 1.832 х 10-2 х MBP. MBP was calculated using diastolic blood pressure (DBP) and systolic blood pressure (SBP) using the equation DBP + 0.4 (SBP - DBP). Utilizing the Cox regression model, the risk of increased ePWV on mortality was determined using hazard ratios (HR) for 1 m/s increases in ePWV and 95% confidence intervals (CI). Of the 3441 patients included in this analysis, the mean age was 68.6 ± 9.6. The mean ePWV of all patients was 11.06 m/s ± 1.80. ePWV was significantly associated with all-cause mortality: HR 1.47, 95% CI 1.02-2.12, p=0.04. ePWV was also significantly associated with cardiovascular mortality: HR 1.21, 95% CI 1.14-1.28, p<0.0001. These findings were independent of whether patients received spironolactone or placebo. This post hoc analysis suggests that increased ePWV is associated with increased all-cause mortality and cardiovascular mortality in patients with HFpEF. This association between ePWV and mortality supports the role of ventricular-arterial interactions in HFpEF. Future studies are needed in this population to identify the mechanism underlying ePWV and adverse outcomes in HFpEF. [ABSTRACT FROM AUTHOR]

There is a growing need for risk stratification of patients with pulmonary hypertension (PH) using non-invasive modalities. We investigated the prognostic value of the echocardiogram-derived index pulmonary artery systolic pressure to right atrial volume index ratio (PASP/RAVi) vs pulmonary artery pulsatility index (PAPi) in patients with PH. We used logistic regression models to evaluate the association between PASP/RAVi and survival. The models used the variables as either continuous or dichotomized by the median. Among 121 patients (age 61.8 +/- 12.7 years, 68.6% female), 17 patients (14%) died during follow-up. The median PASP/RAVi was 2.05 (IQR 1.56-2.83) and the median PAPi was 4.0 (IQR 3.0-6.0). In a logistic regression model, patients with PASP/RAVi greater than the median had an OR for death of 0.26 (95% CI 0.07-0.80, p=0.028), and the AUC was 65.2% (95% CI 53.7%-76.6%) (Panel A). The model with PASP/RAVi as a continuous variable (as opposed to dichotomization by the median) also showed improved survival with increasing PASP/RAVi with a trend p-value of​ 0.14 (OR 0.65, 95% CI 0.35-1.08). This was compared to the PAPi, which did not predict survival either as a continuous parameter (p=0.85) or as a median-dichotomized parameter (p=0.65). The corresponding AUC is shown in Panel B. Lower PASP/RAVi was associated with increased mortality in patients with PH. This novel non-invasive index may be used as a prognostic indicator. [ABSTRACT FROM AUTHOR]

Background: Right ventricular failure (RVF) portends poor outcomes after left ventricular assist device (LVAD) implantation. Although numerous RVF predictive models have been developed, there are few independent comparative analyses of these risk models.Methods and Results: RVF was defined as use of inotropes for >14 days, inhaled pulmonary vasodilators for >48 hours or unplanned right ventricular mechanical support postoperatively during the index hospitalization. Risk models were evaluated for the primary outcome of RVF by means of logistic regression and receiver operating characteristic curves. Among 93 LVAD patients with complete data from 2011 to 2016, the Michigan RVF score (C = 0.74 [95% CI 0.61-0.87]; P = .0004) was the only risk model to demonstrate significant discrimination for RVF, compared with newer risk scores (Utah, Pitt, EuroMACS). Among individual hemodynamic/echocardiographic metrics, preoperative right ventricular dysfunction (C = 0.72 [95% CI 0.58-0.85]; P = .0022) also demonstrated significant discrimination of RVF. The Michigan RVF score was also the best predictor of in-hospital mortality (C = 0.67 [95% CI 0.52-0.83]; P = .0319) and 3-year survival (Kaplan-Meier log-rank 0.0135).Conclusions: In external validation analysis, the more established Michigan RVF score-which emphasizes preoperative hemodynamic instability and target end-organ dysfunction-performed best, albeit modestly, in predicting RVF and demonstrated association with in-hospital and long-term mortality. [ABSTRACT FROM AUTHOR]

Objectives Pulmonary hypertension portends worse outcomes in cardiac valve surgery; however, isolated pulmonary artery pressures may not reflect patients' global cardiac function accurately. To better account for the interventricular relationship, the authors hypothesized that patients with greater pulmonary-systemic ratios (mean pulmonary arterial pressure)/(mean systemic arterial pressure) would correlate with worse outcomes after valve surgery. Design Retrospective cohort study. Setting Single academic hospital. Participants The study comprised 314 patients undergoing valve surgery with or without coronary artery bypass grafting (2004-2016) with Society of Thoracic Surgeons predicted risk scores and preoperative right heart catheterization. Interventions None. Measurements and Main Results The pulmonary-systemic ratio was calculated as follows: mean pulmonary arterial pressure/mean systemic arterial pressure. Patients were stratified by pulmonary-systemic ratio quartile. Logistic regression was used to assess the risk-adjusted association between pulmonary-systemic ratio or mean pulmonary arterial pressure. Median pulmonary-systemic ratio was 0.33 (Q1-Q3: 0.23-0.65); median pulmonary arterial pressure was 29 (21-30) mmHg. Patients with the highest pulmonary-systemic ratio had the highest rates of morbidity and mortality (p < 0.0001). A high pulmonary-systemic ratio was associated with longer duration in the intensive care unit (p < 0.0001) and hospital (p < 0.0001). After risk-adjustment, pulmonary-systemic ratio and pulmonary arterial pressure were independently associated with morbidity and mortality, but the pulmonary-systemic ratio (odds ratio 23.88, p = 0.008, Wald 7.1) was more strongly associated than the pulmonary arterial pressure (odds ratio 1.035, p = 0.011, Wald 6.5). Conclusions The pulmonary-systemic ratio is more strongly associated with risk-adjusted morbidity and mortality in valve surgery than pulmonary arterial pressure. By integrating ventricular interactions, this metric may better characterize the risk of valve surgery. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the association of preoperative invasive hemodynamic parameters with mortality in valvular heart surgery. Design Retrospective cohort study. Setting Single tertiary academic medical center. Participants A total of 382 patients who underwent preoperative right and/or left heart catheterization before open aortic valve replacement (AVR), open mitral valve repair/replacement (MVR), or combined AVR and MVR, from July 2009 to December 2014. Interventions Retrospective chart review. Measurements and Main Results Common hemodynamic indices derived from direct catheterization measurements were assessed, including pulmonary artery systolic pressure (PASP), pulmonary artery pulse pressure (PPP), mean pulmonary capillary wedge pressure (mPCWP), pulmonary artery pulsatility index, diastolic pressure gradient, left ventricular work index, and right ventricular work index. Bivariable and multivariable associations of these measures with survival were determined using Cox proportional hazards regression. Kaplan–Meier survival curves were generated using the log-rank test. The median age of the cohort was 69 years (interquartile range 60-79 years), and 162 (42.4%) of the patients were female. Elevated PASP (hazard ratio [HR] 1.32 per 10 mmHg, p < 0.0001), elevated PPP (HR 1.48 per 10 mmHg, p < 0.0001), and elevated mPCWP (HR 1.95 per 10 mmHg, p < 0.0001) were all associated with decreased survival, as was decreased diastolic blood pressure (DBP) (p = 0.005). The combination of elevated PPP and decreased DBP was associated with the worst outcomes. Conclusions PASP, PPP, mPCWP, and DBP were significantly associated with mortality in valvular heart surgery patients. These hemodynamic parameters may be useful in risk stratification of this population subset. [ABSTRACT FROM AUTHOR]

Background: The objective of this work was to determine the impact of improving right ventricular versus left ventricular stroke work indexes (RVSWI vs LVSWI) during therapy for acute decompensated heart failure (ADHF).Methods and Results: Cox proportional hazards regression and logistic regression were used to analyze key factors associated with outcomes in 175 patients (mean age 56.7 ± 13.6 years, 29.1% female) with hemodynamic data from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial. In this cohort, 28.6% and 69.7%, respectively, experienced the outcomes of death, transplantation, or ventricular assist device implantatation (DVADTX) and DVADTX or HF rehospitalization (DVADTXHF) during 6 months of follow-up. Increasing RVSWI (ΔRVSWI) from baseline to discharge was associated with a decrease in DVADTXHF (hazard ratio [HR] 0.923, 95% confidence interval [CI] 0.871-0.979) per 0.1 mm Hg⋅L⋅m-2 increase); however, increasing LVSWI (ΔLVSWI) had only a nonsignificant association with decreased DVADTXHF (P = .11) In a multivariable model, patients with ΔRVSWI ≤1.07 mm Hg⋅L⋅m-2 and ΔLVSWI ≤4.57 mm Hg⋅L⋅m-2 had a >2-fold risk of DVADTXHF (HR 2.05, 95% CI 1.23-3.41; P = .006).Conclusion: Compared with left ventricular stroke work, increasing right ventricular stroke work during treatment of ADHF was associated with better outcomes. The results promise to inform optimal hemodynamic targets for ADHF. [ABSTRACT FROM AUTHOR]

Left atrial coupling index (LACi) is a novel imaging metric that integrates left atrial and ventricular functions. We performed a secondary analysis of the TOPCAT trial based on the LACi. LACi was calculated as the left atrial volume index divided by the tissue doppler late myocardial velocity (a' velocity). Survival analysis methods included Cox proportional hazards regression and reverse Kaplan-Meier survival curves by quartile of LACi. Among 359 patients from the TOPCAT trial with available echocardiographic data for calculation of the LACi (age 69.2 +/- 9.7 years; 42.6% female), quartiles of the LACi were 0.01-0.025,0.25-0.38,0.38-0.54, and 0.54-3.10, respectively. LACi was associated with both age-adjusted all-cause mortality (HR 1.07 per 0.10 increase in LACi, 95% CI 1.003-1.14, p=0.04) and age-adjusted heart failure hospitalizations (HR 1.10, 95% CI 1.04-1.16, p=0.001). Patients with LACi in the quartile 4 had greater mortality during five years of follow-up (p=0.025; Figure Panel A), and patients with LACi greater than the median had increased heart failure hospitalizations during five years of follow-up (p=0.013; Figure Panel B). The LACi was associated with increased mortality and increased heart failure hospitalizations independent of age in the TOPCAT trial. [ABSTRACT FROM AUTHOR]

Systemic arterial pulsatility index (SAPi), a surrogate hemodynamic index for ventriculo-arterial coupling (VAC), has been shown to be predictive of adverse events in advanced heart failure patients. A hallmark of AS in the setting of LV dysfunction is marked left ventricular contractile-aortic afterload mismatch. Given the heightened sensitivity of the left ventricle to loading conditions in severe AS, we sought to evaluate whether SAPi would be predictive of adverse outcomes in patients with concomitant HFrEF. We hypothesized that lower SAPi would be associated with increased mortality. Patients with LVEF <40% and severe AS undergoing TAVR at the University of Virginia (UVA) between 2012 and 2016 were retrospectively observed. SAPi was calculated using the equation (SBP-DBP)/LVEDP using both pre- and post-valve deployment invasive hemodynamics. These two groups were then stratified based on median SAPi. Survival data was collected from time of TAVR until October 2021. Kaplan-Meier curve was performed for all-cause mortality. Among 128 patients with LVEF <40%, 56 patients (mean age 76.92 years, 38% female) had complete invasive hemodynamic data and a follow-up period of at least 5 years. The median pre-valve deployment SAPi was 2.72 (IQR 1.61-3.33). Post-valve deployment SAPi median was 2.95 (IQR 2.31-4.13). Decreased pre-TAVR SAPi was associated with increased mortality as shown in Figure [1, A] with a p=0.0045. There is no statistically significant change in mortality with decreased post-TAVR SAPi as indicated in Figure [1, B] with a p=0.24. In patients with severe aortic stenosis and HFrEF, decreased SAPi prior to TAVR was associated with higher mortality compared to those with increased SAPi, and may be a useful prognostic indicator in this subset of patients. [ABSTRACT FROM AUTHOR]

Allocation of ventricular assist devices (VAD) has been associated with patient race and a presumed higher severity of heart failure (HF) in African American patients. Data has demonstrated that patients with ambulatory HF (INTERMACS profiles 4-7) may benefit from VAD. It is unclear if there are racial/ethnic differences in VAD implantation rates and survival among patients with ambulatory HF. We hypothesized that VAD implantation rates among White patients with ambulatory HF were higher than rates among African American and Hispanic patients and that survival post VAD was similar across groups. Using the INTERMACS database from 2012-2017, we examined annual census-adjusted VAD implantation rates using negative binomial models with quadratic effect of time among patients with ambulatory HF by race and ethnicity. Survival was evaluated via Kaplan-Meier estimates as well as Cox models adjusted for demographics, device strategy, comorbidities, and laboratory values and an interaction of time with race/ethnicity to account for non-proportionality of the hazards. Rates of implantation peaked between 2013-2015 before declining in all populations (Figure 1A). From 2012-2017 implantation rates were higher for African American and White patients than Hispanic patients, but rates were similar for African American and White patients. Kaplan-Meier curves were significantly different among the three groups (log rank test, p-value=0.0067), with estimated survival among African American patients higher than among White patients by nine months (9-month survival: African American 92% [95% CI:88-94%]; White 86% [95% CI:84-87%]. Low sample size for Hispanic patients resulted in imprecise survival estimates (9-month survival 86% [95% CI:78-91%]. Cox models demonstrated that Hazard Ratios for African American and Hispanic vs. White patients declined over time, with estimated Hazard Ratios less than 1 for both groups by 4 months (Figure 1B). Rates of VAD implantation for patients with ambulatory HF are lower than expected, particularly for African American and Hispanic patients who have higher prevalence of HF than White patients. Estimated survival was higher among African American compared to White patients by nine months. Further investigation is needed to understand the drivers of lower VAD implantation rates in African American and Hispanic patients. [ABSTRACT FROM AUTHOR]

Background: This study evaluated the novel index pulmonary arterial proportional pulse pressure (PAPP) in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial.Methods and Results: Multivariable Cox proportional hazards and logistical regression were used to model 6-month death; death, transplantation, or left ventricular assist device (DTLVAD); and DTLVAD or heart failure rehospitalization (DTLVADHF) with respect to PAPP. Among 175 patients with final hemodynamic data, 15.5% and 33.9%, respectively, died in optimal PAPP (PAPP >0.50) and nonoptimal PAPP (PAPP ≤0.50) groups (P = .008), and PAPP was independently associated with death, DTLVAD, and DTLVADHF (P < .01 for all outcomes). The hypothesized logistic regression model with pulmonary capillary wedge pressure, creatinine, and nonoptimal PAPP had an area under the curve of 0.818 (P < .0001) for death. Furthermore, PAPP as a continuous variable was the most powerful predictor of DTLVADHF (hazard ratio 0.793 per 0.1 increase in PAPP [95% confidence interval 0.659-0.955], chi square 8.80; P = .01) in the Cox model, with no other clinical, laboratory, or hemodynamic parameters significant after adjustment for PAPP.Conclusions: PAPP, a novel parameter for right-sided proportional pulse pressure, is an independent and powerful predictor of adverse clinical outcomes in advanced HF. Increased PAPP promises to be a useful therapeutic target in patients with pulmonary arterial pressure assessment. [ABSTRACT FROM AUTHOR]

Systemic Arterial Pulsatility Index, (SAPi), [systemic pulse pressure]/Left ventricular end diastolic pressure, (LVEDP)] has emerged as a useful prognostic tool. We evaluated the predictive value of SAPi in pre-transcatheter aortic valve replacement (TAVR) patients using measurements from cardiac catheterization (SAPi-Cath) vs trans-thoracic echocardiography (SAPi-TTE). SAPi was calculated using two methods. SAPi-Cath, using invasive hemodynamics while SAPi-TTE using Nagueh formula (PCWP = 1.24 X (E/e') +1.9), as surrogate for LVEDP. Pulse pressure was obtained from the blood pressure taken at the time of the TTE. Correlational and hierarchical comparisons of SAPi with pre-TAVR five-meter walk times (5MWT) were made using R software. Among 110 pre-TAVR patients (mean age 77.3, 56% female), the median SAPi-Cath was 3.05 (IQR 2.22-3.94). In 94/110 (85.5%) patients with a 5MWT and SAPi-Cath assessment, the pre-TAVR SAPi-Cath was significantly associated with the pre-TAVR 5MWT (r=0.32, p=0.0015); shown in Figure 1. In 74/110 (67.3%) patients who had a pre-TAVR TTE to calculate TTE-SAPi, the correlation was not significant (r=0.144, p=0.219). An exploratory analysis based on machine learning with hierarchical clustering demonstrated two distinct clusters (Figure 2); group A had 79 patients, and group B had 15 patients. The 5MWT (14.1 [B] v. 5.8 [A], p=0.0002) and the SAPi-Cath (4.9 [B] v 2.8 [A]; p<0.0001) were substantially more favorable in Group B, while SAPi-TTE was similar in the two groups (p=0.36). All four patients who died during follow-up were in cluster A (no deaths in cluster B). SAPi-Cath was significantly associated with five-meter walk time in pre-TAVR patients. SAPi derived from TTE was not associated with 5MWT, nor was it correlated with SAPi-cath. Further studies on the applications of SAPi in risk stratification of patients are warranted. [ABSTRACT FROM AUTHOR]

Background: Assessment of diffuse right ventricular (RV) fibrosis is of particular interest in pulmonary hypertension (PH) and heart failure (HF). Current cardiovascular magnetic resonance (CMR) T1 mapping techniques such as Modified Look-Locker inversion recovery (MOLLI) imaging have limited resolution, but accelerated and navigator-gated Look-Locker imaging for cardiac T1 estimation (ANGIE) is a novel CMR sequence with spatial resolution suitable for T1 mapping of the RV. We tested the hypothesis that patients with PH would have significantly more RV fibrosis detected with MRI ANGIE compared with normal volunteers and patients having HF with reduced (LV) ejection fraction (HFrEF) without co-existing PH, independent of RV dilitation and dysfunction. Methods: Patients with World Health Organization group 1 or group 4 PH, patients with HFrEF without PH, and normal volunteers were recruited to undergo contrast-enhanced CMR. RV and LV extracellular volume fractions (RV-ECV and LV-ECV) were determined using pre-contrast and post-contrast T1 mapping using ANGIE (RV and LV) and MOLLI (LV only). Results: Thirty-two participants (53.1 % female, median age 52 years, IQR 26-65 years) were enrolled, including n =1 2 with PH, n = 10 having HFrEF without co-existing PH, and n = 10 normal volunteers. ANGIE ECV imaging was of high quality, and ANGIE measurements of LV-ECV were highly correlated with those of MOLLI (r = 0.91; p < 0.001). The RV-ECV in PH patients was 27.2 % greater than the RV-ECV in normal volunteers (0.341 v. 0.268; p < 0.0001) and 18.9 % greater than the RV-ECV in HFrEF patients without PH (0.341 v. 0.287; p < 0.0001). RV-ECV was greater than LV-ECV in PH (RV-LV difference = 0.04), but RV-ECV was nearly equivalent to LV-ECV in normal volunteers (RV-LV difference = 0.002) (p < 0.0001 for RV-LV difference in PH versus normal volunteers). RV-ECV was linearly associated with both increasing RVEDVI (p = 0.049) and decreasing RVEF (p = 0.04) in a multivariable linear model, but PH was still associated with greater RV-ECV even after adjustment for RVEDVI and RVEF. Conclusions: Pre- and post-contrast ANGIE imaging provides high-resolution ECV determination for the RV. PH is independently associated with increased RV-ECV even after adjustment for RV dilatation and dysfunction, consistent with an independent effect of PH on fibrosis. ANGIE RV imaging merits further clinical evaluation in PH. [ABSTRACT FROM AUTHOR]

Transcatheter mitral valve repair is a favorable option in patient care for treating functional mitral regurgitation (FMR). We report 2-year outcomes from the FMR group of the multicenter, prospective, single arm CLASP study with the PASCAL transcatheter valve repair system. Patients with symptomatic FMR ≥3+ deemed candidates for transcatheter repair by the local heart team were eligible. Follow-up was conducted to two years with echocardiographic outcomes evaluated by the core laboratory at all timepoints; other outcomes included major adverse events (MAEs) evaluated by an independent clinical events committee to one year (site-reported thereafter); six-minute walk distance (6MWD) and quality of life evaluated to one year. Eighty-five FMR patients were treated; mean age 72 years, 55% male, 65% in NYHA Class III-IVa, mean LVEF 37%, and 100% ≥3+ MR. Successful implantation was achieved in 96% of patients. MAEs included one cardiovascular mortality (1.2%) and one conversion to mitral valve replacement surgery (1.2%) at 30 days, and two reinterventions between 30 days and two years. Kaplan-Meier (KM) estimates for survival were 88% at one year and 72% at two years. Freedom from heart failure (HF) rehospitalization was 81% at one year and 78% at two years. Reduction in annualized HF hospitalization rate was 81% (p<0.001). MR ≤1+ was achieved in 73% of patients at 30 days, 75% at one year, and 84% at two years; MR ≤2+ was achieved in 96% of patients at 30 days, 100% at one year, and 95% at two years (all p<0.001). Mean LVEDV of 199 mL at baseline decreased by 9 mL at 30 days (p=0.039), 29 mL at one year (p<0.001), and 31 mL at two years (p<0.001). NYHA class I-II was achieved in 87% of patients at 30 days, 86% at one year, and 88% at two years (all p<0.001). Average 6MWD improved by 22 m at 30 days (p=0.004) and 40 m at one year (p=0.003). Kansas City Cardiomyopathy Questionnaire (KCCQ) score improved by 16 points at 30 days and one year (all p<0.001). : The PASCAL transcatheter valve repair system demonstrated sustained favorable outcomes at two years in patients with FMR. Results showed a high survival rate of 72% and freedom from HF rehospitalization of 78% with an 81% reduction in annualized HF hospitalization rate. Sustained MR reduction of MR ≤2+ was achieved in 95% and MR ≤1+ in 84% of patients, with evidence of left ventricular reverse remodeling. Improvements in functional status were clinically significant and durable. The CLASP IIF randomized pivotal trial (NCT03706833) is ongoing. [ABSTRACT FROM AUTHOR]

Background: Coronary CT angiography (CCTA) is a relatively new technique whose role has yet to be fully defined. The initial appropriateness criteria (AC) guidelines published in 2006 have already been revised. There is paucity of data on the effect of the AC on the use of CCTA at academic centers and none for the private sector. Methods: All CCTA studies ordered at one institution (a large community hospital with internal medicine and cardiovascular training programs) from 2006 to 2008 were retrospectively evaluated, and the ordering indications were categorized per the published AC for both 2006 and 2010. Results: There were 384 studies, of which 243 were included in this study. The majority of the studies were ordered for chest pain (67.1% of patients). A significant proportion of studies (43.2%) were classified as inappropriate on the basis of the 2006 published criteria. Uncertain indications made up 39.1%, and appropriate indications were a minority. There was a significant regrading of appropriateness using the 2010 guidelines. Inappropriate testing remained similar at 48.1%, but uncertain cases decreased to only 2.8%, while appropriateness increased to 49.0% (P = .0001 for trend). Conclusions: The updated 2010 AC guidelines for CCTA resulted in a significant reclassification of the indications for ordering CCTA from the previous 2006 guidelines. This shift in the AC reflects increased familiarity and confidence with this new technology across the imaging community. A large proportion of CCTA studies were ordered for inappropriate indications using both sets of criteria. Further research and enhanced education are needed to disseminate the appropriate role of CCTA in cardiovascular imaging. [ABSTRACT FROM AUTHOR]

Palliative care can improve heart failure (HF) symptoms, however many HF patients lack access. Likewise, standard exercise programs can improve symptoms in HF patients, however participation rates are low due to poor access and patient-specific barriers, such as high symptom burden. Further, measurement of physical function at home is uncommon. It is unknown whether gentle exercise via remote live-video conferencing is feasible in patients with HF. The purpose of this study, PALL-HEART was to pilot test a live, gentle exercise intervention delivered via group video-conference, compared to an education/control group, on: 1) feasibility/adherence; 2) participant satisfaction; and, 3) utility of home-based measurement of physical function. This 8-week randomized controlled trial included participants (N=20) recruited from an academic health system HF clinic. Both the intervention group (IG) and the health education (HE) group received a tablet computer preloaded with HF education topics, while the IG group participated in live 60-minute gentle exercise classes via video-conference twice weekly. The HE group was instructed to explore the education resources and called weekly to ascertain office visits or hospitalizations. Outcomes measured: 1) intervention feasibility using adherence (number of attended sessions, number of minutes attended), technological issues (ease of tablet use; number of technological disruptions; 2) satisfaction with intervention; and, 3) utility of home-based physical function measures (strength [arm curls, chair stands], balance [1 leg stand], hip flexibility [sit and reach], endurance [2 minute step test], agility [timed get up and go]). Effect sizes were calculated using Cohen's d by group. Twenty (IG=10, HE=10) participated, with a mean age of 68.7 years (SD = 12.7), 17 (85%) male gender, 16 (80%) white, and mean BMI of 29.4 (SD = 5.1). The trial design was feasible with 100% participation in classes, 100% of minutes attended, zero technological disruptions, and 100% participant satisfaction ratings. Further, some participants joined classes more often than we instructed (>100% adherence). Physical function measures were conveniently assessed at home (within 15 minutes) with small to moderate preliminary effect sizes in the intervention group at 8 weeks on: hip flexibility (sit to reach; d = 0.25), leg strength (chair stands; d = 0.16), endurance (two-minute-step test; d = 0.13), and balance (get up and go; d = 0.31). Our novel approach to home exercise is highly feasible with very high adherence rates, satisfaction, and easily adapted home-based physical function measures. Testing for improvements in physical function and psychological measures is now needed. These findings are especially critical now as we seek suitable platforms for remote access to health care. [ABSTRACT FROM AUTHOR]

Transcatheter mitral valve repair has emerged as a viable option for treating functional mitral regurgitation (FMR). We report results for the FMR cohort from the multicenter, prospective, single arm CLASP study with the PASCAL transcatheter valve repair system (Edwards Lifesciences, Irvine, CA). Eligible patients had clinically significant and symptomatic MR ≥3+ and were deemed candidates for transcatheter repair by the local heart team. The study outcomes were evaluated by an independent clinical events committee and echocardiographic core lab. The primary safety endpoint was a composite MAE rate at 30 days of cardiovascular mortality, stroke, MI, new need for renal replacement therapy, severe bleeding, and re-intervention for study device-related complications. Of the 109 patients enrolled (intent to treat/ITT and roll-in), 73 (67%) had FMR as determined by the core lab. Mean age was 73 years, 55% male, 60% NYHA Class III/IV with 100% MR grade ≥3+. Successful implantation was achieved in 96% of patients. At 30 days, the MAE rate was 11.0% including one cardiovascular mortality, one stroke, and one conversion to mitral valve replacement surgery. At 30 days, 88% of patients were in NYHA Class I/II (p<0.001), MR grade was ≤1+ in 77% of patients and ≤2+ in 96% of patients. Improvements in 6MWD (+23 m, p=0.009) and KCCQ (+15 points, p<0.001) were observed. These outcomes were sustained at six-months. In addition, we report one-year follow up of the first 38 FMR patients (ITT): 89% one-year survival rate (KM estimate) with 80% freedom from HF hospitalization and no late strokes. At 1 year, MR grade was ≤1+ in 79% of patients and ≤2+ in 100% of patients. 83% of patients were in NYHA Class I/II (p<0.001), 6MWD improved by 24 m (p=0.261) and KCCQ improved by 13 points (p=0.002). This study demonstrates that the PASCAL repair system is safe and results in remarkable MR reduction in patients with FMR. 100% of patients achieved MR ≤2+, and ∼ 80% achieved MR ≤1+, sustained at one year. Results show a high survival rate, low complications, and sustained improvements in functional status, exercise capacity, and quality of life at one year. [ABSTRACT FROM AUTHOR]

Background: P wave indices represent electrocardiographic marker of left atrial pathology. We hypothesized that P wave would be more abnormal in patients presenting with ischemic stroke than a comparable group without ischemic stroke.Methods: We compared P wave terminal force in V1 (PTFV1) between patients admitted with ischemic stroke (case) and patients followed in cardiology clinic (control) at a single medical center. Using logistic regression models, we tested for an association between abnormal PTFV1 (> 4000 µV ms) and ischemic stroke. We also defined several optimal cut-off values of PTFV1 using a LOESS plot and estimated odds ratio of ischemic stroke when moving from one cut-point level to the next higher-level.Results: A total of 297 patients (case 147, control 150) were included. PTFV1 was higher in patients with vs. those without ischemic stroke (median 4620 vs 3994 µV ms; p=0.006). PTFV1 was similar between cardioembolic/cryptogenic and other stroke subtypes. In multivariable analyses adjusting for sex, obesity, age, and hypertension, the association between abnormal PTFV1 and ischemic stroke ceased to be significant (OR 1.53 [0.95, 2.50], p=0.083). Increase to the next cutoff level of PTFV1 (900, 2000, 3000, 4000, 5000, and 6000 µV ms) was associated with 18% increase in odds of having ischemic stroke (vs. no ischemic stroke) (OR 1.18 [1.02, 1.36], p=0.026).Conclusion: Patients presenting with acute ischemic stroke are more likely to have abnormal PTFV1. These findings from a real-world clinical setting support the results of cohort studies that left atrial pathology manifested as abnormal PTFV1 is associated with ischemic stroke. [ABSTRACT FROM AUTHOR]

Increased QRS duration (QRSd) and left ventricular dyssynchrony are associated with worse outcomes in heart failure (HF). The implication of QRSd on left ventricular ejection fraction (LVEF) trajectories among patients with severe decompensated systolic HF is unclear. Patients hospitalized with HF between 2014-2018 with an LVEF ≤ 35% and at least two echocardiograms with LVEF assessments were included. Patients received guideline-directed medical and device therapies. Survival was assessed for up to 4 years after the index admission. LVEF trajectory was defined as the difference between the lowest LVEF and the highest LVEF, multiplied by -1 if the lowest LVEF was more recent than the highest LVEF. Linear regression was used to evaluate the association between LVEF trajectory and QRSd, and logistic regression was used to assess survival based on QRSd and LVEF trajectory. Among 1,674 patients (65.3 ± 14.2 years, 35.9 % female), 39% had QRSD > 120 ms. The lowest LVEF was 26.7% ± 9.7%, the highest LVEF was 45.5% ± 14.5%, and the LVEF trajectory had a median of 5% with an interquartile range of -10% to +25%. The frequency of QRSd less than 120 ms, 120-149 ms, and greater than or equal to 150 ms were 60.5%, 20.5%, and 19.5% respectively. Increasing QRSd was associated with more negative LVEF trajectories (r = -0.24, p < 0.0001). Median LVEF trajectories (panel A) and mortality rates (panel B) in the three QRS duration groups are shown in the Figure (p<0.0001 for both comparisons). Although LVEF trajectory and QRSd had a moderate correlation, both were still independently associated with survival in a multivariable logistic regression model (OR 1.08 per 10 ms for QRSd, 95% CI 1.04-1.12, p < 0.0001; OR 0.92 per 5% LVEF trajectory units, 95% CI 0.90-0.95, p < 0.0001). Increasing QRS duration in HF is associated with worsening LVEF trajectories and increased mortality despite contemporary guideline-directed medical and device therapy. The effect of QRS duration on survival appears to be mediated both by its impact on LVEF trajectory and mechanisms independent of the LVEF trajectory. [ABSTRACT FROM AUTHOR]

Ventricular-arterial (VA) coupling has previously been shown to have physiologic importance in heart failure (HF). We hypothesized that a decreased systemic arterial pulsatility index (SAPi = [systemic systolic pressure - systemic diastolic pressure] / pulmonary capillary wedge pressure) would be associated with the adverse clinical outcomes in patients with systolic heart failure in cardiogenic shock (CS). This was a retrospective study from a tertiary academic center. Patients with CS admitted to the coronary care unit (wedge pressure ≥15, cardiac index ≤2.2, and systolic blood pressure ≤90) were included. Using logistic regression analysis, we evaluated the association of SAPi to the outcomes of death or left ventricular assist device (LVAD). Among 119 patients with complete data (mean age 60.3 ± 14.7 years, 29% female), the median SAPi was 1.24 (IQR 0.91-1.68). Decreasing SAPi was strongly associated with outcome of death or LVAD [OR 0.52 (95% CI 0.29-0.95, chi square 4.54, p=0.03)]. Receiver operating characteristic curve analysis yielded an area under the curve (AUC) of 0.62 ± 0.06 (95% CI 0.490.73). SAPi, an index of VA coupling, integrates pulse pressure and a proxy of left ventricular end-diastolic pressure. A decreased SAPi is strongly associated with adverse clinical outcomes in patients with CS and warrants consideration as a risk stratification tool. [ABSTRACT FROM AUTHOR]

Severe mitral regurgitation (MR) may lead to an impaired prognosis if left untreated. Transcatheter treatment options have emerged as an alternative to surgery and an adjunct to medical therapy. We report the six-month results of the PASCAL transcatheter valve repair system in treating patients with MR enrolled in the multicenter, prospective, single arm CLASP study. The PASCAL system is a leaflet repair therapy that uses clasps and paddles to place a woven Nitinol spacer between the native valve leaflets to fill the regurgitant orifice via a transseptal approach. Eligible patients had clinically significant MR despite optimal medical therapy and were deemed candidates for transcatheter mitral repair by the local Heart Team. All major adverse events (MAE) were adjudicated by an independent clinical events committee and echocardiographic images were assessed by a core lab. The MAE rate was defined as the composite of cardiovascular mortality, stroke, MI, new need for renal replacement therapy, severe bleeding, and re-intervention for study device-related complications. 62 patients were enrolled worldwide for transcatheter mitral valve reconstruction using the PASCAL system. The mean age was 76.5 years. All patients had MR grade ≥3+ and 51.6% of patients were in NYHA Class III/IV. Successful implantation of the PASCAL device was achieved in 95% of patients. At discharge, 95% of patients had MR grade ≤2+ with 81% grade ≤1+. The MAE rate was 4.8%. At 30-day follow-up, 98% of patients had MR grade ≤2+ with 81% grade ≤1+ and 88% were in NYHA Class I/II (p<0.01). The 6MWD improved by 38.9 m (p<0.01) and was accompanied by average improvements in KCCQ and EQ5D scores by 14.1 points (p<0.01) and 8.3 points (p<0.01), respectively. The six-month data will be available for presentation. In this early device experience, the PASCAL device resulted in significant MR grade reduction, which was associated with clinically and statistically significant improvements in functional status, exercise capacity, and quality of life. Continued follow-up is warranted to validate these initial promising results. [ABSTRACT FROM AUTHOR]