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The conveyed risk of mild diastolic dysfunction (MDD) according to age had not been thoroughly studied. We aimed to investigate the mortality-risk of MDD by age-groups among inpatients with preserved ejection fraction (EF), and determine ranges of diastolic function parameters by prognosis.In a single-center retrospective study we identified inpatients who underwent echocardiography between 2012 and 2018 and had preserved EF without significant valvulopathies. Propensity scores were used to adjust for baseline characteristics and main diagnoses at discharge. Comparisons for all-cause mortality between MDD and normal diastolic function were conducted by age groups. Using classification and regression trees (CART) modeling we determined age-specific cut-offs according to outcome.The cohort consisted of 15,777 inpatients. Mortality rate during a 33.9-months median follow-up was 21.6%. MDD was associated with increased mortality risk among all ages up to 90 years, thereafter no difference was detected. Adjusted hazard ratios inversely related to age - 1.99(95%CI 1.25-3.16, p = 0.004), 1.82(95%CI1.46-2.26, p0.001), 1.88(95%CI1.64-2.15, p0.001), 1.78(95%CI1.59-2.01, p0.001), and 1.32(95%CI0.95-1.83, p = 0.093), for 18-44, 45-59, 60-74, 75-89, and ≥90 years, respectively (Pinteraction = 0.009). New cut-offs of E/e' for ages 75-89(16), e' lateral for ages ≥90(6 cm/s), e' septal for ages 60-74(5 cm/s), and E/A ratio for ages 18-44(1.5), predicted outcome more accurately than guidelines-based recommendations. The remaining cut-offs were not better predictors compared to guidelines-based recommendations.MDD is a consequential finding at all ages up to 90 years among inpatients with preserved EF, although its significance decreases with age. Diastolic function of several age-groups may be better delineated by cut-offs that presage adverse prognoses. Helsinki committee approval number: 0170-17-TLV.

Patients who underwent transcatheter edge-to-edge repair (TEER) for mitral regurgitation with atrial fibrillation (AF) at baseline have higher mortality than those without AF. Data on new-onset AF (NOAF) after TEER are limited. Using the 2016 to 2018 Nationwide Readmissions Database, we identified a cohort of patients who underwent TEER and classified them into 3 groups based on AF presence during the study period. The primary end point was the incidence and timing of NOAF up to 6 months after TEER. Logistic regression modeling identified independent predictors of NOAF at readmission. Of the 6,861patients that underwent TEER, 4,134 (59.9%) had AF at baseline, and 239 (3.5%) developed NOAF. Median time-to-NOAF admission was 47 days (interquartile range 16 to 113), and 37% of patients with NOAF presented within 30 days after TEER. Patients with NOAF experienced costlier and longer index-TEER hospitalization and had more co-morbidities. Chronic kidney disease (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.03 to 2.20), fluid and electrolyte disorders (OR 1.59, 95% CI 1.01 to 2.52), and heart failure (OR 1.86, 95% CI 1.01 to 3.44) were identified as independent predictors of NOAF. Hypertensive complications and heart failure were the leading causes of readmission. In conclusion, those patients that developed NOAF after TEER tended to be an overall sicker group at baseline compared with the remainder of the study cohort. These data, obtained from a nationally representative cohort, highlight a particular group of patients subject to developing NOAF and their association with increased rehospitalization in the post-TEER setting. Predictors of NOAF can be screened for during TEER workup to identify patients at increased risk.

Coronary artery obstruction is a life-threatening complication of transcatheter aortic valve replacement (TAVR) procedures. Current preventive strategies are suboptimal.The aim of this study was to describe bench testing and clinical experience with a novel device that splits valve leaflets that are at risk for causing coronary obstruction after TAVR, allowing normal coronary flow.The ShortCut device was initially tested in vitro and preclinically in a porcine model for functionality and safety. The device was subsequently offered to patients at elevated risk for coronary obstruction. Risk for coronary obstruction was based on computed tomography-based anatomical characteristics. Procedure success was determined as patient survival at 30 days with a functioning new valve, without stroke or coronary obstruction.Following a successful completion of bench testing and preclinical trial, the device was used in 8 patients with failed bioprosthetic valves (median age 81 years; IQR: 72-85 years; 37.5% man) at 2 medical centers. A total of 11 leaflets were split: 5 patients (63.5%) were considered at risk for left main obstruction alone, and 3 patients (37.5%) were at risk for double coronary obstruction. All patients underwent successful TAVR without evidence of coronary obstruction. All patients were discharged from the hospital in good clinical condition, and no adverse neurologic events were noted. Procedure success was 100%.Evaluation of the first dedicated transcatheter leaflet-splitting device shows that the device can successfully split degenerated bioprosthetic valve leaflets. The procedure was safe and successfully prevented coronary obstruction in patients at risk for this complication following TAVR.

BackgroundSince the beginning of the coronavirus disease 2019 (COVID-19) pandemic in 2019, several countries have reported a substantial drop in the number of patients admitted with non-ST-segment myocardial infarction (NSTEMI).ObjectiveWe aimed to evaluate the changes in admissions, in-hospital management and outcomes of patients with NSTEMI in the COVID-19 era in a nationwide survey.MethodA prospective, multicenter, observational, nationwide study involving 13 medical centers across Israel aimed to evaluate consecutive patients with NSTEMI admitted to intensive cardiac care units over an 8-week period during the COVID-19 outbreak and to compare them with NSTEMI patients admitted at the same period 2 years earlier (control period).ResultsThere were 624 (43%) NSTEMI patients, of whom 349 (56%) were hospitalized during the COVID-19 era and 275 (44%) during the control period. There were no significant differences in age, gender and other baseline characteristics between the two study periods. During the COVID-19 era, more patients arrived at the hospital via an emergency medical system compared with the control period (P = 0.05). Time from symptom onset to hospital admission was longer in the COVID-19 era as compared with the control period [11.5 h (interquartile range, IQR, 2.5–46.7) vs. 2.9 h (IQR 1.7–6.8), respectively, P ConclusionIn contrast to previous reports, admission rates of NSTEMI were similar in this nationwide survey during the COVID-19 era. With longer time from symptoms to admission, but with the same time from hospital admission to reperfusion therapy and with similar in-hospital and 30-day mortality rates. Even in times of crisis, adherence of medical systems to clinical practice guidelines ensures the preservation of good clinical outcomes.

Objectives This study sought to evaluate the long-term effect of transcatheter patent foramen ovale (PFO) closure on migraineurs with and without aura and examine the effect of residual right-to-left shunt. Background Many studies reported improvement in migraine symptoms after PFO closure, yet randomized trials failed to reach its clinical endpoints. Methods The study retrospectively analyzed data from 474 patients who underwent transcatheter PFO closure at Massachusetts General Hospital. Patients completed a migraine burden questionnaire at baseline and at follow-up. Migraine severity is reported as migraine frequency (days/month), average duration (min), and migraine burden (days × min/month). Improvement following closure was defined as complete abolishment of symptoms or >50% reduction in migraine burden. Results A total of 110 migraineurs who underwent PFO closure were included; 77.0% had aura and 23.0% were without aura, and 91.0% had a cryptogenic stroke. During long-term median follow-up of 3.2 (interquartile range: 2.1 to 4.9) years, there was a significant improvement in migraine symptoms in migraineurs with or without aura. Migraine burden was reduced by >50% in 87.0% of patients, and symptoms were completely abolished in 48%. Presence of aura was associated with abolishment of migraine (odds ratio: 4.30; 95% confidence interval: 1.50 to 12.30; p = 0.006). At 6 months after PFO closure, residual right-to-left shunt was present in 26% of patients. Absence of right-to-left shunt was associated with improvement in migraine burden by >50% (odds ratio: 4.60; 95% confidence interval: 1.30 to 16.10; p = 0.017). Conclusions Long-term follow-up after transcatheter PFO closure was associated with significant improvement in migraine burden. Aura was a predictor of abolishing symptoms. Absence of residual right-to-left shunt was a predictor of significant reduction in migraine burden.

While the impact of mitral regurgitation (MR) prior to transcatheter aortic valve replacement (TAVR) has been intensively studied, the implications of post-procedural MR on outcome are unknown. We investigated the clinical and physiological impact of significant MR after TAVR.Clinical and echocardiographic data of 486 patients who underwent TAVR between March 2009 and December 2014 were evaluated. Clinical endpoints included overall mortality and combined endpoint of mortality, heart failure re-hospitalization and new atrial fibrillation. Echocardiographic parameters were analyzed at baseline, 30-day and 6-month after TAVR.MR severity improved in 25%, worsened in 19% and did not change in 56% of patients 30-days post TAVR (p = 0.3). Post TAVR MR grade ≥ moderate was present in 16.1%. Predictive accuracy of post TAVR MR was low (AUC = 0.63). Median follow-up was 4.3 years (interquartile range, 2.5 to 6.1). Post TAVR MR grade ≥ moderate was associated with increased mortality and combined cardiac events (p = 0.013 and p 0.001) even when adjusted for all clinical and echo parameters and when analyzed with propensity score matching. In patients with MR ≥ moderate, LV filling pressure and RV hemodynamics worsened 6 months post TAVR, while improving in patients with less significant post procedural MR.Post procedural, but not pre-procedural MR grade ≥ moderate was independently associated with mortality and adverse cardiac events after TAVR. Significant MR post TAVR resulted in adverse LV and RV remodeling and poor hemodynamic. Our study strengthens the rational for initiating early treatment to reduce post TAVR MR.

Transthoracic echocardiography (TTE) is the primary clinical imaging modality for the assessment of patients with isolated aortic regurgitation (AR) in whom TTE’s linear left ventricular (LV) dimension is used to assess disease severity to guide aortic valve replacement (AVR), yet TTE is relatively limited with regards to its integrated semi-quantitative/qualitative approach. We therefore compared TTE and cardiovascular magnetic resonance (CMR) assessment of isolated AR and investigated each modality’s ability to predict LV remodeling after AVR. AR severity grading by CMR and TTE were compared in 101 consecutive patients referred for CMR assessment of chronic AR. LV end-diastolic diameter and end-systolic diameter measurements by both modalities were compared. Twenty-four patients subsequently had isolated AVR. The pre-AVR estimates of regurgitation severity by CMR and TTE were correlated with favorable post-AVR LV remodeling. AR severity grade agreement between CMR and TTE was moderate (ρ = 0.317, P = 0.001). TTE underestimated CMR LV end-diastolic and LV end-systolic diameter by 6.6 mm (P

Background Transcatheter closure of patent foramen ovale (PFO) in patients with cryptogenic stroke reduces the rate of recurrent events. Although presence of thrombophilia increases the risk for paradoxical emboli through a PFO, such patients were excluded from large randomized trials. Objectives We compared the safety and efficacy of percutaneous PFO closure in patients with and without a hypercoagulable state. Methods Data from 800 consecutive patients undergoing percutaneous PFO closure in our medical center were analyzed. All patients were independently evaluated by specialists in neurology, cardiology, hematology, and vascular medicine. A post-procedural treatment of at least 3 months of anticoagulation was utilized in patients with thrombophilia. Follow-up events included death, recurrent neurological events, and the need for reintervention for significant residual shunt. Results A hypercoagulable state was found in 239 patients (29.9%). At median follow-up of 41.9 months, there were no differences in the frequencies of stroke or transient ischemic attack between patients with or without thrombophilia (2.5% in non-hypercoagulable group vs. 3.4% in hypercoagulable group, log-rank test p = 0.35). There were no significant differences in baseline demographics, echocardiographic characteristics, procedural success, or complications between groups. Conclusion Percutaneous PFO closure is a safe and effective therapeutic approach for patients with cryptogenic stroke and an underlying hypercoagulable state.

Background Transcatheter closure of patent foramen ovale (PFO) in patients with cryptogenic stroke reduce the rate of recurrent events. Although presence of thrombophilia increases the risk for paradoxical emboli through a PFO, such patients were excluded from the large randomized studies. Purpose To examine the effect of hypercoagulable state on clinical outcomes after PFO closure. Methods We retrospectively analyzed data of 800 consecutive patients undergoing percutaneous PFO closure at the Massachusetts general hospital. We compared the safety and efficacy of the procedure in patients with and without a hypercoagulable state. Periprocedural treatment included 3 months of anticoagulation followed by low dose aspirin. Results A hypercoagulable disorder was found in 239 patients (29.9%). There were no significant differences in baseline demographics, echocardiographic characteristics, procedural success rate, or complication rate between both groups. At median follow-up of 41.9 months there were no differences in the rate of stroke/transient ischemic attack (2.5% in non-hypercoagulable group vs. 3.4% in hypercoagulable group, log-rank test p=0.349). Survival analysis of composite outcome that included: ischemic neurologic event, reintervention and procedural or neurologic death did not show significant difference between groups (Log-rank p=0.122). Conclusion Percutaneous PFO closure is a safe and effective therapeutic approach for patients with cryptogenic stroke and an underlying hypercoagulable state Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Research funds of the Massachusetts general hospital

Background There is a shortage of data concerning the natural history of patients with moderate aortic stenosis (AS). The aim of this study was to assess the effect of moderate AS on mortality in the general population and in the subgroups of patients with moderate AS and reduced ejection fractions (EF) and patients with moderate AS and low aortic valve gradients. The study was not designed to address the applicability of treatment in this population. Methods Outcomes were compared between patients with moderate AS and a propensity-matched cohort (1:3 ratio) without AS. The primary outcome was survival until end of follow-up. Results Among approximately 40,000 patients who underwent echocardiographic evaluations between 2011 and 2016, 952 had moderate AS. Median follow-up duration was 181 weeks (interquartile range, 179–182 weeks) for the entire cohort and 174 weeks (interquartile range, 169–179 weeks) for the propensity-matched groups. Propensity matching successfully balanced most preexisting clinical differences. Increased mortality was observed in the group of patients with moderate AS before propensity matching and persisted following propensity matching (median survival 4.1 vs 5.2 years, P = .008). Survival rates and corresponding standard errors at 1, 2, 3, and 5 years were 80 ± 1% versus 82 ± 0.7%, 70 ± 1.5% versus 74 ± 0.8%, 62 ± 1.7% versus 66 ± 0.9%, and 47 ± 2.4% versus 52 ± 1.3%, respectively. A survival difference was similarly observed for the subgroup analyses of moderate AS and reduced ejection fraction (P = .028) and moderate AS and low aortic valve gradients (P = .039). Conclusions Moderate AS is associated with increased mortality. The increased mortality was also observed in the subgroups of patients with either reduced ejection fraction or low aortic valve gradients.

Background Mixed valvular disease (MVD), mitral regurgitation (MR) from pre‐existing disease in conjunction with paravalvular leak (PVL) following transcatheter aortic valve replacement (TAVR), is one of the most important stimuli for left ventricle (LV) dysfunction, associated with cardiac mortality. Despite the prevalence of MVD, the quantitative understanding of the interplay between pre‐existing MVD, PVL, LV, and post‐TAVR recovery is meager. Methods and Results We quantified the effects of MVD on valvular‐ventricular hemodynamics using an image‐based patient‐specific computational framework in 72 MVD patients. Doppler pressure was reduced by TAVR (mean, 77%; N=72; P Conclusions PVL limits the benefit of TAVR by increasing LV load and worsening of MR and heart failure. Post‐TAVR, most MVD patients (75% of N=72; P P

Background Radiologists and cardiologists have a remarkably different approach to the clinical importance and to the need for prophylactic treatment of contrast-induced acute kidney injury (CI-AKI). Objectives To evaluate the efficacy of forced diuresis with matched controlled hydration (FMH) in a real-world, high risk population. Methods This is an investigator-driven, single-center, retrospective analysis of prospectively collected data. A total of 150 consecutive patients undergoing coronary angiography, angioplasty or TAVR who were treated with FMH were compared to a matched historical control cohort. Results In the FMH treated patients, eGFR improved following the procedure from 37ml/min per 1.73m 2 at baseline to 39ml/min per 1.73m 2 ( p p 2 to 33.2ml/min per 1.73m 2 post procedurally ( p p p Conclusions In patients undergoing coronary angiography, angioplasty or TAVR, who are considered high risk to develop post procedural AKI, forced diuresis with matched controlled hydration resulted in a significant net creatinine decrease, eGFR increase and a decrease in the incidence of AKI.

IMPORTANCE: Pulmonary hypertension (pHTN) is associated with increased risk of mortality after mitral valve surgery for mitral regurgitation. However, its association with clinical outcomes in patients undergoing transcatheter mitral valve repair (TMVr) with a commercially available system (MitraClip) is unknown. OBJECTIVE: To assess the association of pHTN with readmissions for heart failure and 1-year all-cause mortality after TMVr. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study analyzed 4071 patients who underwent TMVr with the MitraClip system from November 4, 2013, through March 31, 2017, across 232 US sites in the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy registry. Patients were stratified into the following 4 groups based on invasive mean pulmonary arterial pressure (mPAP): 1103 with no pHTN (mPAP

Aortic stenosis (AS) management is classically guided by symptoms and valvular metrics. However, the natural history of AS is dictated by coupling of the left ventricle, aortic valve, and vascular system. We investigated whether metrics of ventricular and vascular state add to the appreciation of AS state above valve gradient alone. Seventy patients with severe symptomatic AS were prospectively followed from baseline to 30 days after transcatheter aortic valve replacement (TAVR). Quality of life (QOL) was assessed using the Kansas City Cardiomyopathy Questionnaire. Left ventricular stroke work (SW[subscript LV]) and vascular impedance spectrums were calculated noninvasively using in-house models based on central blood pressure waveforms, along with hemodynamic parameters from echocardiograms. Patients with higher preprocedural SW[subscript LV] and lower vascular impedance were more likely to experience improved QOL after TAVR. Patients fell into two categories: those who did and those who did not exhibit increase in blood pressure after TAVR. In patients who developed hypertension (19%), vascular impedance increased and SW[subscript LV] remained unchanged (impedance at zeroth harmonic: Z[subscript 0], from 3964.4 to 4851.8 dyne·s/cm[superscript 3], P = 0.039; characteristic impedance: Z[subscript c], from 376.2 to 603.2 dyne·s/cm[superscript 3], P = 0.033). SW[subscript LV] dropped only in patients who did not develop new hypertension after TAVR (from 1.58 to 1.26 J; P < 0.001). Reduction in valvular pressure gradient after TAVR did not predict change in SW[subscript LV] (r = 0.213; P = 0.129). Reduction of SW[subscript LV] after TAVR may be an important metric in management of AS, rather than relying solely on the elimination of transvalvular pressure gradients.

Objective Determine the rates, reasons, predictors, and costs of 30-day readmissions following transcatheter mitral valve repair (TMVR) versus surgical mitral valve repair (SMVR) in the United States. Background Data on 30-day readmissions after TMVR are limited. Methods High-risk patients with mitral regurgitation (MR) undergoing TMVR or SMVR were identified from the 2014-2015 Nationwide Readmissions Databases. Multivariable stepwise regression models were used to identify independent predictors of 30-day readmission. Risk of 30-day readmission was compared between the two groups using univariate and propensity score adjusted regression models. Results Among 8,912 patients undergoing mitral valve repair during 2014-2015 (national estimate 17,809), we identified 7,510 (84.7%) that underwent SMVR and 1,402 (15.3%) that underwent TMVR. Thirty-day readmission rates after SMVR and TMVR were 10.7% and 11.7%, respectively (unadjusted OR 1.11, 95% CI 0.89-1.39, p = .35). After propensity score adjustment, TMVR was associated with a lower risk of 30-day readmissions compared with SMVR (adjusted OR 0.70, 95% CI 0.51-0.95, p = .02). Heart failure and arrhythmias were the leading cardiac reasons for readmission. Anemia and fluid and electrolyte disorder were independent predictors of 30-day readmission after TMVR. Demographics, comorbidities, and length of stay were independent predictors of 30-day readmission after SMVR. Conclusions One in 10 patients are readmitted within 30 days following TMVR or SMVR. Approximately half of the readmissions are for cardiac reasons. The predictors of 30-day readmission are different among patients undergoing TMVR and SMVR, but can be easily screened for to identify patients at highest risk for readmission.

Intravascular optical coherence tomography (OCT) provides high-resolution images of arterial cross-sections, offering rich information on vessel morphology and disease state. The detection of the media layer is crucial for improving quantitative analyses, including plaque characterization. Manual annotation of vessel layers for analysis and quantification, however, is laborious and requires substantial expertise. We therefore sought to automatically delineate the intima-media and media-adventitia layers simultaneously even when the delineated features are not fully visible, as is often seen with atherosclerotic disease. We validated our approach with a 105-frame image sequence from a single patient with severe atherosclerosis. Delineations automatically generated by the algorithm matched annotations by human experts in most regions; the media thickness deviated on average by 0.038 mm (standard deviation: 0.029 mm). These promising results could improve characterization of vessel wall plaque, quantitative assessment of patient health, and longitudinal monitoring of disease progression.

Aims Acute kidney injury (AKI) is a common complication following transcatheter aortic valve implantation (TAVI) and is associated with increased risk for short- and long-term mortality. In patients undergoing percutaneous coronary intervention (PCI), forced diuresis with matched hydration has been shown to reduce the incidence of AKI by ∼50%. The aim of the present study was to evaluate whether forced diuresis with matched intravenous hydration reduces AKI in patients undergoing TAVI. Methods and results Reducing Acute Kidney Injury (REDUCE-AKI) was a single-centre, prospective, randomized, double-blind sham-controlled clinical trial, designed to examine the effect of an automated matched saline infusion with urine output for the prevention of AKI in patients undergoing TAVI. A total of 136 TAVI patients were randomized, 68 in each group. Mean age was 83.9 ± 5 years and 41.2% were males. There were no differences in baseline characteristics between the two groups. The rate of AKI was not statistically different between the groups (25% in the active group vs. 19.1% in the sham group, P = 0.408). There was a significant increase in long-term mortality in the active group (27.9% vs. 13. 2% HR 3.744, 95% CI 1.51–9.28; P = 0.004). The study was terminated prematurely by the Data Safety Monitoring Board for futility and a possible signal of harm. Conclusions Unlike in PCI, forced diuresis with matched hydration does not prevent AKI in patients undergoing TAVI, and might be associated with increased long-term mortality. Future studies should focus on understanding the mechanisms behind these findings. Clinicaltrials.gov registration NCT01866800, 30 April 2013.

Optical coherence tomography (OCT) is a fiber-based intravascular imaging modality that produces high-resolution tomographic images of artery lumen and vessel wall morphology. Manual analysis of the diseased arterial wall is time consuming and sensitive to inter-observer variability; therefore, machine-learning methods have been developed to automatically detect and classify mural composition of atherosclerotic vessels. However, none of the tissue classification methods include in their analysis the outer border of the OCT vessel, they consider the whole arterial wall as pathological, and they do not consider in their analysis the OCT imaging limitations, e.g. shadowed areas. The aim of this study is to present a deep learning method that subdivides the whole arterial wall into six different classes: calcium, lipid tissue, fibrous tissue, mixed tissue, non-pathological tissue or media, and no visible tissue. The method steps include defining wall area (WAR) using previously developed lumen and outer border detection methods, and automatic characterization of the WAR using a convolutional neural network (CNN) algorithm. To validate this approach, 700 images of diseased coronary arteries from 28 patients were manually annotated by two medical experts, while the non-pathological wall and media was automatically detected based on the Euclidian distance of the lumen to the outer border of the WAR. Using the proposed method, an overall classification accuracy 96% is reported, indicating great promise for clinical translation.

Direct mechanical compression of the frame struts on the adjacent bundle branch with local inflammatory reaction might cause conduction system disturbances and need for pacemaker implantation following transcatheter aortic valve implantation (TAVI). We assessed the impact of preprocedural anti-inflammatory steroid therapy on the occurrence of conduction disturbances following TAVI.From a cohort of 324 patients who underwent transfemoral TAVI, 39 (12%) were pretreated with steroids because of iodine allergy (n=29) or active obstructive pulmonary disease (n=10). We compared the rate of occurrence of new conduction disturbances and pacemaker implantation between TAVI patients with (n=39) and without (n=285) steroid treatment, using Cox logistic regression estimates and proportional hazards models. The overall occurrence of new conduction defects and the need for new pacemaker implantation were similar among steroid and non-steroid-treated patients (38.4% vs 37.5% and 25.6% vs 25.3%, respectively). New conduction disturbances were more prevalent in patients treated with CoreValve prosthesis, low implantation, and smaller aortic annulus diameter (P

Background The Norton scale is traditionally used to assess the risk of pressure ulcers. However, recent studies have shown its prognostic utilization in elderly patients with diverse medical conditions. The association between low admission Norton scale scores (ANSS), complications, and mortality in elderly patients following trans-catheter aortic valve implantation (TAVI) has never been studied. We aimed to determine if low ANSS (≤16) is associated with complications and 30-day and 1-year mortality in elderly patients undergoing TAVI. Methods The medical charts of elderly (≥70 years) TAVI patients at the Tel-Aviv Medical Center, a tertiary medical center, were studied for the following measurements: ANSS, demographics, co-morbidities, complications during hospitalization, and 30-day and 1-year mortality. Complications included: an atrio-ventricular block, stroke, and vascular complications. Results The cohort included 302 elderly patients: 179 (59.3%) were women; the mean age was 83.3 ± 5.1 years. Following TAVI, 112 (37.1%) patients had complications other than pressure ulcers, 10 (3.3%) patients died within 30 days, and 42 (13.9%) patients died within one year. Overall, 36 (11.9%) patients had low ANSS. 1-year mortality rates were almost three times higher in patients with low ANSS relative to patients with high ANSS (27.8% vs. 12.0%; the relative risk 1.1; p = 0.018). A stepwise logistic regression analysis showed that ANSS was independently inversely associated with 1-year mortality (p = 0.018). Complications and 30-day mortality rates were similar in both groups. Conclusions Low ANSS are associated with 1-year mortality after TAVI. The Norton scale may therefore be used as an additional tool for elderly patient selection before TAVI.

Objectives: Previous studies investigating the prognostic value of HbA1c in patients undergoing coronary angiography reported a mixed pattern of results. Therefore, we aimed to better define the prognostic power of HbA1c among coronary catheterized patients. Methods: Patients undergoing coronary angiography (n = 3,749) were divided into four groups according to HbA1c levels (7%). Cox regression models assessed long-term mortality after adjusting for multiple covariates. Results: Baseline clinical profiles differed in HbA1c groups, with a higher prevalence of comorbidities in the groups with higher HbA1c levels. Median follow-up was 1,745 days (interquartile range 1,007-2,171). A J-shaped association curve was observed between HbA1c levels and all-cause mortality rates, with patients in the lowest and highest HbA1c groups suffering from significantly higher mortality rates compared to in-between groups (hazard ratio 1.9, 95% CI 1.32-2.74, p = 0.001, and hazard ratio 1.58, 95% CI 1.29-1.95, p < 0.001, for the lowest and highest HbA1c groups, respectively). This association persisted after adjustment for anemia, nutritional status, renal function, cardiovascular risk factors and inflammatory biomarkers. Conclusions: HbA1c levels 7% are predictors of all-cause mortality in patients undergoing coronary angiography.

There is much debate in the literature surrounding the effects of heart rate on aortic regurgitation (AR). Despite the contradictory information, it is still widely believed that an increase in heart rate is beneficial due to the disproportionate shortening of the duration of diastole relative to systole, permitting less time for the left ventricle to fill from regurgitation. This in vitro work investigates how a change in heart rate affects the left ventricular fluid dynamics in the absence and presence of acute AR. The experiments are performed on a novel double-activation left heart simulator previously used for the study of chronic AR. The intraventricular velocity fields are acquired via time-resolved planar particle image velocimetry (PIV) in a clinically relevant plane. Considering fluid dynamic factors, an increase in heart rate was observed to have a limited benefit in the case of mild AR and a detrimental effect for more severe AR. With increasing heart rate, mild AR was associated with a decrease in regurgitant volume, a negligible change in regurgitant volume per diastolic second, and a limited reduction in the fraction of retained regurgitant inflow. More severe AR was accompanied by an increase in both regurgitant volume and the fraction of retained regurgitant inflow, implying a less effective pumping efficiency and a longer relative residence time of blood in the ventricle. Globally, the left ventricle's capacity to compensate for the increase in energy dissipation associated with an increase in heart rate diminishes considerably with severity, a phenomenon which may be exploited further as a method of noninvasive assessment of the severity of AR. These findings may affect the clinical belief that tachycardia is preferred in acute AR and should be investigated further in the clinical setting.

Automated analysis of vascular imaging techniques is limited by the inability to precisely determine arterial borders. Intravascular optical coherence tomography (OCT) offers unprecedented detail of artery wall structure and composition, but does not provide consistent visibility of the outer border of the vessel due to the limited penetration depth. Existing interpolation and surface fitting methods prove insufficient to accurately fill the gaps between the irregularly spaced and sometimes unreliably identified visible segments of the vessel outer border. This paper describes an intuitive, efficient, and flexible new method of 3D surface fitting and smoothing suitable for this task. An anisotropic linear-elastic mesh is fit to irregularly spaced and uncertain data points corresponding to visible segments of vessel borders, enabling the fully automated delineation of the entire inner and outer borders of diseased vessels in OCT images for the first time. In a clinical dataset, the proposed smooth surface fitting approach had great agreement when compared with human annotations: areas differed by just 11 ± 11% (0.93 ± 0.84 mm2), with a coefficient of determination of 0.89. Overlapping and non-overlapping area ratios were 0.91 and 0.18, respectively, with a sensitivity of 90.8 and specificity of 99.0. This spring mesh method of contour fitting significantly outperformed all alternative surface fitting and interpolation approaches tested. The application of this promising proposed method is expected to enhance clinical intervention and translational research using OCT., U.S. National Institutes of Health (Grant GM 49039).

Objectives To evaluate initial and long term results of coronary perforation treatment with pericardial covered stent. Background Iatrogenic coronary perforation is a rare life threatening complication of percutaneous coronary interventions (PCI) occurring in 0.1–0.8% of cases. Covered stents are the mainstay of therapy for coronary perforation. However, polytetrafluoroethylene covered stents are bulky with limited flexibility and thus may not be easy to deliver in difficult anatomy. Therefore, they are reserved to perforations in proximal or mid straight segments where their delivery is relatively easy. The pericardial covered stent is a highly deliverable fully covered stent that may be used to treat coronary perforations. Only a single case has been reported of the use of this stent in its previous version for the treatment of coronary perforation. Methods The electronic databases of four tertiary medical centers were retrospectively reviewed for cases of coronary perforations in which PCS was used. During a five years period, between 2008 and 2013, 18,364 patients underwent PCI in these centers. Nine cases of perforations for which balloon dilatation was not sufficient and pericardial covered stent was used were recorded. Results All nine cases were successfully treated with pericardial covered stent. Six of the patients underwent repeated angiography at 2–15 months, and in two of them instent restenosis that warranted repeated angioplasty was observed. One of them was catheterized for NSTEMI 3 months after the covered stent implantation, and stent thrombosis was demonstrated. Conclusions Pericardial covered stents offer a safe and effective therapy for coronary perforation when balloon inflation and reversal of anticoagulation are insufficient. © 2015 Wiley Periodicals, Inc.

Background The worsening of serum creatinine (sCr) level is a frequent finding among ST-segment elevation MI (STEMI) patients undergoing primary percutaneous coronary intervention (PCI), associated with adverse short-term and long-term outcomes. No information is present, however, regarding the incidence and prognostic implications associated with an improvement in sCr levels throughout hospitalization, as compared with admission levels. Hypothesis Reversible renal impairment prior to PCI is not associated with adverse outcomes. Methods We retrospectively studied 1260 STEMI patients undergoing primary PCI. The incidence of in-hospital complications and long-term mortality was compared between patients having stable, worsened (>0.3 mg/dL increase), or improved (>0.3 mg/dL decrease) sCr levels throughout hospitalization. Results Overall, 127 patients (10%) had worsening in sCr levels, whereas 44 (3.5%) had an improvement of sCr compared with admission levels. Patients with worsening sCR had more complications during hospitalization, higher 30-day (13% vs 1%; P < 0.001) and up to 5-year all-cause mortality (28% vs 5%; P < 0.001) compared with those with stable sCR. No significant difference was found regarding complications and mortality between patients having an improvement in sCr and stable sCr. Compared with patients with stable sCr, the adjusted hazard ratio for all-cause mortality in patients with worsened sCr was 6.68 (95% confidence interval: 2.1-21.6, P = 0.002). Conclusions In STEMI patients undergoing primary PCI, renal impairment prior to PCI is a frequent finding. In contrast to post-PCI sCr worsening, this entity is not associated with adverse short-term and long-term outcomes.

Background Obesity is a major risk factor for cardiovascular morbidity and mortality. A considerable number of studies, however, showed better outcomes for overweight patients undergoing cardiovascular interventions—the so called obesity paradox. Hypothesis Increased body mass index (BMI) is independently associated with improved survival following transcatheter aortic valve implantation (TAVI). Methods We analyzed the data of 409 consecutive patients undergoing TAVI in our medical center. Patients were categorized into 4 groups according to BMI: underweight (≤18.4 kg/m2), normal weight (18.5–24.9 kg/m2), overweight (25–29.9 kg/m2), and obese (≥30 kg/m2). Procedure-related complications were recorded, as well as 30-day and 1-year all-cause mortality rates. Results Obese patients had a higher prevalence of comorbidities and higher incidence of vascular complications compared with the normal-weight patients (16% vs 7%, P = 0.013). Nevertheless, 30-day mortality was similar among the groups, whereas 1-year mortality was lower among the overweight and obese patients (BMI >25) (P = 0.038). After adjusting for differences in baseline characteristics, increase in BMI was found to be independently associated with improved survival following TAVI (hazard ratio: 0.94, confidence interval: 0.89-0.99, P = 0.043). Conclusions In our single-center study, obesity and overweight were independently associated with better outcome, supporting the obesity paradox in the TAVI population.

Background Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) is frequent and is associated with adverse outcomes. Past studies have attributed AKI to impaired kidney function at baseline, amount of contrast medium used, major bleeding, and hemodynamic instability during the procedure. Because major bleeding might play a role in the development of AKI, we analyzed the relationship between periprocedural bleeding and the development of AKI and assessed the impact of these 2 important procedure-related complications on outcome. Methods Consecutive patients undergoing transfemoral TAVI for severe aortic stenosis were prospectively recruited. AKI and bleeding events during hospitalization were recorded, defined, and classified according to the Valve Academic Research Consortium 2 definitions. Logistic and Cox regression was used for predictor and survival analyses. Results We recruited 422 consecutive patients who underwent TAVI; the mean follow-up duration was 576 ± 400 days. AKI occurred in 66 (15.6%) patients. No patient required dialysis. Fifty patients (12%) had major or life-threatening bleeding. Periprocedural major or life-threatening bleeding was a strong predictor of the development of AKI (odds ratio, 3.19; 95% confidence interval [CI], 1.38-7.1; P = 0.006). Major bleeding was a strong independent predictor for both 30-day and long-term mortality (hazard ratio [HR], 6.67; 95% CI, 2.2-19.8; P = 0.001 and HR, 3.3, 95% CI, 1.2-9.0; P = 0.02, respectively), whereas AKI was not independently associated with increased mortality after TAVI. Conclusions In patients undergoing transfemoral TAVI, periprocedural bleeding is a strong risk factor for the development of AKI and a major determinant of short- and long-term mortality.

Vascular complications (VC) after transcatheter aortic valve implantation (TAVI) are reported using various criteria and several access site approaches. We aimed to describe them in a solely percutaneous transfemoral TAVI approach and their association with survival using both the updated Valve Academic Research Consortium (VARC)-2 criteria and the former VARC-1 criteria. From March 2009 to September 2013, 403 consecutive patients at a mean age (±SD) of 83 ± 6 years underwent percutaneous transfemoral TAVI. VC were defined by both VARC-1 and VARC-2 criteria and analyzed separately. Cox proportional hazard ratio models for all-cause mortality were adjusted separately as defined by each criteria. VARC-1-defined and VARC-2-defined VC occurred in 71 (18%) and 78 (19%) patients, respectively, with 15 (4%) and 33 (8%) defined as major VC. The difference in frequency of major and minor VC was mainly driven by VARC-2 implementation of major bleeding events. With either VARC definition, patients with minor VC had similar mortality and complications rates as those patients without VC. In multivariate analyses, referenced to patients with minor or no VC, only VARC-1-defined major VC were significantly associated with increased mortality (hazard ratio 3.52; confidence interval 1.5 to 8.4; p = 0.005), whereas VARC-2-defined major VC were found to be only marginally significant (hazard ratio 1.9; confidence interval 0.9 to 3.9; p = 0.08). In conclusion, the implementation of the VARC-2 criteria resulted in a higher rate of reported major VC after TAVI compared with VARC-1 criteria, mainly by the inclusion of major bleeding events and a reduced association with patient mortality.

Acute kidney injury (AKI) is associated with adverse outcomes after acute ST elevation myocardial infarction (STEMI). The recently proposed AKI network (AKIN) suggested modifications to the consensus classification system for AKI known as the risk, injury, failure, loss, end-stage (RIFLE) criteria. The aim of the current study was to compare the incidence and mortality (early and late) of AKI diagnosed by RIFLE and AKIN criteria in the STEMI patients undergoing primary percutaneous intervention (PCI). We retrospectively studied 1,033 consecutive STEMI patients undergoing primary PCI. Recruited patients were admitted between January 2008 and November 2012 to the cardiac intensive care unit with the diagnosis of acute STEMI. We compared the utilization of RIFLE and AKIN criteria for the diagnosis, classification, and prediction of mortality. The AKIN criteria allowed the identification of more patients as having AKI (9.6 vs. 3.9 %, p

Patients hospitalized for an acute myocardial infarction (AMI) are at risk for early readmission. Readmission rates in the community reportedly reach approximately 20%, and 30-day readmission rates have become a quality-of-care marker. Telemedicine is one strategy for improving clinical outcomes by offering real-time biometrics tracking and rapid intervention. We retrospectively assessed the 30-day readmission rate of post-AMI members of a telemedicine system.All "SHL"-Telemedicine subscribers who sustained an AMI and those who became subscribers within 10 days from discharge post-AMI between 2009 and 2012 were assessed. Their files were reviewed for demographics, coronary risk factors, reasons for readmission, and discharge diagnoses.In total, 897 suitable patients (mean age, 62±14 years; 81% males) were included. They had made 3,318 calls to the monitor center for consultation. A mobile intensive care unit was dispatched for 158 patients, 64 were transported to the hospital, and 52 (5.8%) were readmitted (10 patients were readmitted twice). Thirty-five readmissions were for noncardiac reasons. Twelve patients had acute coronary syndrome (11 were revascularized). Readmission rates were higher in patients with repeat AMIs (11.9% versus 5.3% among those with no AMI history) and in females (9.6% versus 4.9% among males). Unlike published figures for the general population, there were no significant differences between readmitted and non-readmitted patients regarding diabetes, hypertension, or congestive heart failure.Telemedicine technology shows considerable promise for reducing 30-day readmission rates of post-AMI patients.