Journal: Heart

Sorted by: date / impact
Abstract

Major elective non-cardiac operations in adults with congenital heart disease.

Williamson CG, Ebrahimian S, Ascandar N, Sanaiha Y, ... Biniwale RM, Benharash P
Objective
To assess the impact of congenital heart disease (CHD) on resource utilisation and clinical outcomes in patients undergoing major elective non-cardiac operations.
Background
Due to advances in congenital cardiac management in recent years, more patients with CHD are living into adulthood and are requiring non-cardiac operations.
Methods
The 2010-2018 Nationwide Readmissions Database was used to identify all adults undergoing major elective operations (pneumonectomy, hepatectomy, hip replacement, pancreatectomy, abdominal aortic aneurysm repair, colectomy, gastrectomy and oesophagectomy). Multivariable regression models were used to categorise key clinical outcomes.
Results
Of an estimated 4 941 203 adults meeting inclusion criteria, 5234 (0.11%) had a previous diagnosis of CHD. Over the study period, the incidence of CHD increased from 0.06% to 0.17%, p<0.001. CHD patients were on average younger (63.3±14.8 vs 64.4±12.5 years, p=0.004), had a higher Elixhauser Comorbidity Index (3.3±2.2 vs 2.3±1.8, p<0.001) and received operations at high volume centres more frequently (66.6% vs 62.0%, p=0.003). Following risk adjustment, these patients had increased risk of in-hospital mortality (adjusted risk ratio (ARR): 1.76, 95% CI 1.25 to 2.47), experienced longer hospitalisation durations (+1.6 days, 95% CI 1.3 to 2.0) and cost more (+$8370, 95% CI $6686 to $10 055). Furthermore, they were more at risk for in-hospital complications (ARR: 1.24 95% CI 1.17 to 1.31) and endured higher adjusted risk of readmission at 30 days (ARR: 1.32 95% CI 1.13 to 1.54).
Conclusions
Adults with CHD are more frequently comprising the major elective operative cohort for non-cardiac cases. Due to the inferior clinical and financial outcomes suffered by this population, perioperative risk stratification may benefit from the inclusion of CHD as a factor that portends unfavourable outcomes.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 29 Sep 2022; epub ahead of print
Williamson CG, Ebrahimian S, Ascandar N, Sanaiha Y, ... Biniwale RM, Benharash P
Heart: 29 Sep 2022; epub ahead of print | PMID: 36175113
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Role of the electrocardiogram in the risk stratification of pulmonary hypertension.

Hendriks PM, Kauling RM, Geenen LW, Eindhoven JA, ... Boomars KA, van den Bosch AE
Introduction
The prognosis of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) remains dismal. Better risk prediction is needed. This study investigated the prognostic value of ECG characteristics.
Methods
In this single-centre prospective study, consecutive treatment-naïve patients with PAH or CTEPH were included at time of diagnosis. From the 12-lead ECG, obtained at baseline, the following parameters were collected: heart rate (HR), rhythm, QRS axis, conduction times, P-top amplitudes in II, R-top and S-wave amplitudes in V1 and V5 and repolarisation disorders. Associations between the ECG and transplant-free survival was assessed by Kaplan-Meier curves and Cox-proportional hazard regressions.
Results
In total, 140 patients were included (median age: 60.7 years, 63.6% female). The ECG was abnormal in 86.2%: sinus rhythm was not present in 9.3%, right QRS axis was observed in 47.8%, mean QRS duration was 101±17 ms. Only 42.5% of the patients had normal repolarisation, 34.5% had right ventricular strain and 14.4% non-specific repolarisation disorders. Over a median follow-up time of 3.49 (IQR: 1.37-6.42) years, 45 patients (32.5%) died or underwent lung transplantation. Transplant-free survival was worse in patients presenting with an abnormal ECG (64.0% vs 86.0%; p=0.037). The following ECG characteristics were associated with all-cause mortality or lung transplantation: heart rate (HR 1.02, 95% CI: 1.00 to 1.05), QRS duration >120 ms (HR 2.61, 95% CI: 1.01 to 6.71) and S-wave amplitude in V5 (HR 1.10, 95% CI: 1.04 to 1.17).
Conclusion
Only 13.8% of patients with PAH and CTEPH presented with a normal ECG, which is associated with favourable outcome. The ECG provides additional prognostic value to current clinical parameters and should be considered in risk prediction.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 28 Sep 2022; epub ahead of print
Hendriks PM, Kauling RM, Geenen LW, Eindhoven JA, ... Boomars KA, van den Bosch AE
Heart: 28 Sep 2022; epub ahead of print | PMID: 36171071
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Cardiogenetics: the role of genetic testing for inherited arrhythmia syndromes and sudden death.

Specterman MJ, Behr ER
There have been remarkable advances in our knowledge of the underlying heritability of cardiac arrhythmias. Long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, progressive cardiac conduction disease and the short QT syndrome comprise the inherited arrhythmia syndromes (IASs). Pathogenic variants in cardiac ion channel and calcium handling protein genes lead to these conditions, usually in the absence of overt structural cardiac disease. Diagnosis is contingent on the ECG phenotype but genetic testing may help to confirm the diagnosis and provide information on the mechanism of arrhythmogenesis that may guide treatment and provide prognostic information in relation to the risk of sudden arrhythmic death. Clinical genetic testing uses \'panels\' of genes that are the likely culprits for the IASs being investigated. An International Consortium (Clinical Genome Resource) has curated gene panels based on genetic and experimental evidence of causation of inherited conditions and that have a role in clinical genetic testing. A \'single gene\' or monogenic basis for IASs exists but in future, missing heritability and incomplete penetrance will be uncovered by association of common variants through genome-wide association studies. Novel rare variants will also be detected through whole-genome sequencing. The formulation of polygenic risk scores will likely help to predict phenotypic expression and response to treatments/risk stratification and move genetic testing very much to the fore of the diagnostic process.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Sep 2022; epub ahead of print
Specterman MJ, Behr ER
Heart: 27 Sep 2022; epub ahead of print | PMID: 36167638
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Temporal association between invasive procedures and infective endocarditis.

Thornhill MH, Crum A, Campbell R, Stone T, ... Baddour L, Nicoll J
Objective
Antibiotic prophylaxis has been recommended for patients at increased risk of infective endocarditis (IE) undergoing specific invasive procedures (IPs) despite a lack of data supporting its use. Therefore, antibiotic prophylaxis recommendations ceased in the mid-2000s for all but those at high IE risk undergoing invasive dental procedures. We aimed to quantify any association between IPs and IE.
Methods
All 14 731 IE hospital admissions in England between April 2010 and March 2016 were identified from national admissions data, and medical records were searched for IP performed during the 15-month period before IE admission. We compared the incidence of IP during the 3 months immediately before IE admission (case period) with the incidence during the preceding 12 months (control period) to determine whether the odds of developing IE were increased in the 3 months after certain IP.
Results
The odds of IE were increased following permanent pacemaker and defibrillator implantation (OR 1.54, 95% CI 1.27 to 1.85, p<0.001), extractions/surgical tooth removal (OR 2.14, 95% CI 1.22 to 3.76, p=0.047), upper (OR 1.58, 95% CI 1.34 to 1.85, p<0.001) and lower gastrointestinal endoscopy (OR 1.66, 95% CI 1.35 to 2.04, p<0.001) and bone marrow biopsy (OR 1.76, 95% CI 1.16 to 2.69, p=0.039). Using an alternative analysis, bronchoscopy (OR 1.33, 95% CI 1.06 to 1.68, p=0.049) and blood transfusions/red cell/plasma exchange (OR 1.2, 95% CI 1.07 to 1.35, p=0.012) were also associated with IE.
Conclusions
This study identifies a significant association between specific IPs (permanent pacemaker and defibrillator implantation, dental extraction, gastrointestinal endoscopy and bronchoscopy) and subsequent IE that warrants re-evaluation of current antibiotic prophylaxis recommendations to prevent IE in high IE risk individuals.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Heart: 22 Sep 2022; epub ahead of print
Thornhill MH, Crum A, Campbell R, Stone T, ... Baddour L, Nicoll J
Heart: 22 Sep 2022; epub ahead of print | PMID: 36137742
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Role and relevance of risk stratification models in the modern-day management of non-ST elevation acute coronary syndromes.

Balasubramanian RN, Mills GB, Wilkinson C, Mehran R, Kunadian V
We summarise the international guidelines surrounding risk stratification as well as discuss new emerging data for future development of a new risk model in the management of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS accounts for the bulk of acute coronary syndrome presentations in the UK, but management strategies in this group of patients have remained a subject of debate for decades. Patients with NSTE-ACS represent a heterogeneous population with a wide variation in short-term and long-term clinical outcomes, which makes a uniform, standardised treatment approach ineffective and inappropriate. Studies in the modern era have provided some guidance in treating this subset of patients: the provision of early, more potent therapies has been shown to improve outcomes in patients at a particularly elevated risk of adverse outcomes. International guidelines recommend adopting an individualised treatment approach through the use of validated risk prediction models to identify such patients at high risk of adverse outcomes. The present available evidence, however, is based on dated demographics, different diagnostic thresholds and outdated therapies. In particular, the evidence has limited applicability to female patients and older people with frailty. Moreover, the current risk models do not capture key prognostic variables, leading to an inaccurate estimation of patients\' baseline risk and subsequent mistreatment. Therefore, the current risk models are no longer fit for purpose and there is a need for risk prediction scores that account for different population demographics, higher sensitivity troponin assays and contemporary treatment options.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 14 Sep 2022; epub ahead of print
Balasubramanian RN, Mills GB, Wilkinson C, Mehran R, Kunadian V
Heart: 14 Sep 2022; epub ahead of print | PMID: 36104217
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Joint British Society consensus recommendations for magnetic resonance imaging for patients with cardiac implantable electronic devices.

Bhuva A, Charles-Edwards G, Ashmore J, Lipton A, ... Roditi G, Manisty C
Magnetic Resonance Imaging (MRI) is increasingly a fundamental component of the diagnostic pathway across a range of conditions. Historically, the presence of a cardiac implantable electronic device (CIED) has been a contraindication for MRI, however, development of MR Conditional devices that can be scanned under strict protocols has facilitated the provision of MRI for patients. Additionally, there is growing safety data to support MR scanning in patients with CIEDs that do not have MR safety labelling or with MR Conditional CIEDs where certain conditions are not met, where the clinical justification is robust. This means that almost all patients with cardiac devices should now have the same access to MRI scanning in the National Health Service as the general population. Provision of MRI to patients with CIED, however, remains limited in the UK, with only half of units accepting scan requests even for patients with MR Conditional CIEDs. Service delivery requires specialist equipment and robust protocols to ensure patient safety and facilitate workflows, meanwhile demanding collaboration between healthcare professionals across many disciplines. This document provides consensus recommendations from across the relevant stakeholder professional bodies and patient groups to encourage provision of safe MRI for patients with CIEDs.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 14 Sep 2022; epub ahead of print
Bhuva A, Charles-Edwards G, Ashmore J, Lipton A, ... Roditi G, Manisty C
Heart: 14 Sep 2022; epub ahead of print | PMID: 36104218
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Sex-based differences in atrial fibrillation ablation adverse events.

Mszar R, Friedman DJ, Ong E, Du C, ... Curtis JP, Freeman JV
Objective
Older, relatively small studies identified female sex as a risk factor for adverse events after catheter ablation for atrial fibrillation (AF). We aimed to assess contemporary sex-based differences in baseline and procedural characteristics, adverse events, and quality of life among adults undergoing catheter ablation for AF.
Methods
In this observational cohort study, we evaluated those enrolled in the National Cardiovascular Data Registry AFib Ablation Registry between January 2016 and September 2020. Using logistic regression, we analysed the association between patient sex and in-hospital adverse events.
Results
Among 58 960 adults (34.6% women) from 150 centres undergoing AF ablation by 706 physicians, women were older (68 vs 64 years, p<0.001), had more comorbidities, and had lower AF-related quality of life at the time of ablation (mean Atrial Fibrillation Effect on QualiTy-of-life Questionnaire) score: 51.8 vs 62.2, p<0.001). Women had a higher risk of hospitalisation >1 day (adjusted OR (aOR) 1.41 (95% CI 1.33 to 1.49)), major adverse event (aOR 1.60 (95% CI 1.33 to 1.92)) and any adverse event (aOR 1.57 (95% CI 1.41 to 1.75)). Women had a higher risk of bradycardia requiring pacemaker, phrenic nerve damage, pericardial effusion, bleeding and vascular injury, but had no differences in death or acute pulmonary vein isolation.
Conclusions
Among almost 60 000 patients in the largest prospective registry of AF ablation procedures, female sex was independently associated with a higher risk of hospitalisation >1 day, adverse events, and reduced quality of life, although there were no differences in death or acute pulmonary vein isolation.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 14 Sep 2022; epub ahead of print
Mszar R, Friedman DJ, Ong E, Du C, ... Curtis JP, Freeman JV
Heart: 14 Sep 2022; epub ahead of print | PMID: 36104219
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Relationship between orthostatic blood pressure changes and intensive blood pressure management in patients with hypertension.

Pei J, Zhang H, Li Y, Yan J, ... Zheng XL, Hu X
Introduction
The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that closely controlling blood pressure (BP) could decrease cardiovascular outcome risk without increasing the orthostatic hypotension rate. We aimed to evaluate the association between baseline orthostatic BP change and major adverse cardiovascular event (MACE) occurrence.
Methods
We conducted a post hoc analysis using SPRINT data including 9329 patients with hypertension. The SPRINT trial was a two-arm, multicentre, randomised clinical trial designed to test whether an intensive treatment aimed at reducing systolic BP (SBP) to <120 mm Hg would reduce cardiovascular disease risk. Orthostatic BP change was defined as baseline standing systolic BP (SBP)-baseline mean seated SBP, or diastolic BP (DBP)-baseline mean seated DBP.
Results
We found a U-shaped relationship between orthostatic BP changes and MACE occurrence. All lowest risk points were around 0 mm Hg. On the left side of the inflection point, MACE risk decreased with orthostatic BP change decrease (HR=0.99, 95% CI (0.98 to 1.00), p=0.04, SBP change) (HR=0.97, 95% CI (0.95 to 0.99), p<0.01, DBP change); on the right side, MACE risk increased with orthostatic BP change increase (HR=1.02, 95% CI (1.01 to 1.06), p<0.01, SBP change) (HR=1.01, 95% CI (1.00 to 1.03), p=0.16, DBP change). There was no significant interaction effect between orthostatic SBP (p for interaction=0.37) or DBP changes (p for interaction=0.33) and intensive BP management.
Conclusions
Orthostatic DBP increase and SBP decrease were associated with an increased MACE risk. The benefits of intensive BP management were also consistent across different orthostatic BP change ranges.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 25 Aug 2022; epub ahead of print
Pei J, Zhang H, Li Y, Yan J, ... Zheng XL, Hu X
Heart: 25 Aug 2022; epub ahead of print | PMID: 36007937
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Shared decision making in cardiology: a systematic review and meta-analysis.

Mitropoulou P, Grüner-Hegge N, Reinhold J, Papadopoulou C
Objectives
To evaluate the effectiveness of interventions to improve shared decision making (SDM) in cardiology with particular focus on patient-centred outcomes such as decisional conflict.
Methods
We searched Embase (OVID), the Cochrane library, PubMed and Web of Science electronic databases from inception to January 2021 for randomised controlled trials that investigated the effects of interventions to increase SDM in cardiology. The primary outcomes were decisional conflict, decisional anxiety, decisional satisfaction or decisional regret; a secondary outcome was knowledge gained by the patients.
Results
Eighteen studies which reported on at least one outcome measure were identified, including a total of 4419 patients. Interventions to increase SDM had a significant effect on reducing decisional conflict (standardised mean difference (SMD) -0.211, 95% CI -0.316 to -0.107) and increasing patient knowledge (SMD 0.476, 95% CI 0.351 to 0.600) compared with standard care.
Conclusions
Interventions to increase SDM are effective in reducing decisional conflict and increasing patient knowledge in the field of cardiology. Such interventions are helpful in supporting patient-centred healthcare and should be implemented in wider cardiology practice.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 25 Aug 2022; epub ahead of print
Mitropoulou P, Grüner-Hegge N, Reinhold J, Papadopoulou C
Heart: 25 Aug 2022; epub ahead of print | PMID: 36007938
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Anatomy of the conduction tissues 100 years on: what have we learned?

Sánchez-Quintana D, Anderson RH, Tretter JT, Cabrera JA, Sternick EB, Farré J
Knowledge of the anatomy of the \'conduction tissues\' of the heart is a 20th century phenomenon. Although controversies still continue on the topic, most could have been avoided had greater attention been paid to the original descriptions. All cardiomyocytes, of course, have the capacity to conduct the cardiac impulse. The tissues specifically described as \'conducting\' first generate the cardiac impulse, and then deliver it in such a fashion that the ventricles contract in orderly fashion. The tissues cannot readily be distinguished by gross inspection. Robust definitions for their recognition had been provided by the end of the first decade of the 20th century. These definitions retain their currency. The sinus node lies as a cigar-shaped structure subepicardially within the terminal groove. There is evidence that it is associated with a paranodal area that may have functional significance. Suggestions of dual nodes, however, are without histological confirmation. The atrioventricular node is located within the triangle of Koch, with significant inferior extensions occupying the atrial vestibules and with septal connections. The conduction axis penetrates the insulating plane of the atrioventricular junctions to continue as the ventricular pathways. Remnants of a ring of cardiomyocytes observed during development are also to be found within the atrial vestibules, particularly a prominent retroaortic remnant, although that their role has still to be determined. Application of the initial criteria for nodes and tracts shows that there are no special \'conducting tissues\' in the pulmonary venous sleeves that might underscore the abnormal rhythm of atrial fibrillation.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 25 Aug 2022; 108:1430-1437
Sánchez-Quintana D, Anderson RH, Tretter JT, Cabrera JA, Sternick EB, Farré J
Heart: 25 Aug 2022; 108:1430-1437 | PMID: 34969873
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Absolute coronary flow and microvascular resistance reserve in patients with severe aortic stenosis.

Paolisso P, Gallinoro E, Vanderheyden M, Esposito G, ... de Bruyne B, Barbato E
Background
Development of left ventricle (LV) hypertrophy in aortic stenosis (AS) is accompanied by adaptive coronary flow regulation. We aimed to assess absolute coronary flow, microvascular resistance, coronary flow reverse (CFR) and microvascular resistance reserve (MRR) in patients with and without AS.
Methods
Absolute coronary flow and microvascular resistance were measured by continuous thermodilution in 29 patients with AS and 29 controls, without AS, matched for age, gender, diabetes and functional severity of epicardial coronary lesions. Myocardial work, total myocardial mass and left anterior descending artery (LAD)-specific mass were quantified by echocardiography and cardiac-CT.
Results
Patients with AS presented a significantly positive LV remodelling with lower global longitudinal strain and global work efficacy compared with controls. Total LV myocardial mass and LAD-specific myocardial mass were significantly higher in patients with AS (p=0.001). Compared with matched controls, absolute resting flow in the LAD was significantly higher in the AS cohort (p=0.009), resulting into lower CFR and MRR in the AS cohort compared with controls (p<0.005 for both). No differences were found in hyperaemic flow and resting and hyperaemic resistances. Hyperaemic myocardial perfusion (calculated as the ratio between the absolute coronary flow subtended to the LAD, expressed in mL/min/g), but not resting, was significantly lower in the AS group (p=0.035).
Conclusions
In patients with severe AS and non-obstructive coronary artery disease, with the progression of LV hypertrophy, the compensatory mechanism of increased resting flow maintains adequate perfusion at rest, but not during hyperaemia. As a consequence, both CFR and MRR are significantly impaired.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 17 Aug 2022; epub ahead of print
Paolisso P, Gallinoro E, Vanderheyden M, Esposito G, ... de Bruyne B, Barbato E
Heart: 17 Aug 2022; epub ahead of print | PMID: 35977812
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Rationale and design of a randomised trial of intravenous iron in patients with heart failure.

Kalra PR, Cleland JG, Petrie MC, Ahmed FZ, ... Thomson EA, Ford I
Objectives
For patients with a reduced left ventricular ejection fraction (LVEF) heart failure with reduced ejection fraction (HFrEF) and iron deficiency, administration of intravenous iron improves symptoms, exercise capacity and may in the following 12 months, reduce hospitalisations for heart failure. The Effectiveness of Intravenous iron treatment versus standard care in patients with heart failure and iron deficiency (IRONMAN) trial evaluated whether the benefits of intravenous iron persist in the longer term and impact on morbidity and mortality.
Methods
IRONMAN is a prospective, randomised, open-label, blinded endpoint (PROBE) event-driven trial. Patients aged ≥18 years with HFrEF (LVEF ≤45%) and evidence of iron deficiency (ferritin <100 µg/L and/or TSAT <20%) were enrolled if they had either a current or recent hospitalisation for heart failure or elevated plasma concentrations of a natriuretic peptide. Participants were randomised to receive, or not to receive, intravenous ferric derisomaltose in addition to guideline-recommended therapy for HFrEF. Every 4 months, intravenous iron was administered if either ferritin was <100 µg/L or, provided ferritin was ≤400 µg/L, TSAT was <25%. The primary endpoint is a composite of total hospitalisations for heart failure and cardiovascular death. Hospitalisation and deaths due to infection are safety endpoints.
Results
Trial recruitment was completed across 70 UK hospital sites in October 2021. Participants were followed until the end of March 2022. We plan to report the results by November 2022.
Conclusions
IRONMAN will determine whether repeated doses of intravenous ferric derisomaltose are beneficial and safe for the long-term treatment of a broad range of patients with HFrEF and iron deficiency.
Trial registration number
NCT02642562.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Heart: 10 Aug 2022; epub ahead of print
Kalra PR, Cleland JG, Petrie MC, Ahmed FZ, ... Thomson EA, Ford I
Heart: 10 Aug 2022; epub ahead of print | PMID: 35948408
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

State of the art: multimodality imaging in dilated cardiomyopathy.

Halliday BP
Dilated cardiomyopathy represents a common phenotype expressed in individuals with a family of overlapping myocardial diseases due to acquired and/or genetic susceptibility. Disease trajectory, response to therapy and outcomes vary widely; therefore, further refinement of the diagnosis can help guide therapy and inform prognosis. Multimodality imaging plays a key role in this process, as well as excluding alternative causes which may mimic a primary myocardial disease. The following article discusses the role of different imaging modalities as well as what the future may look like in the context of recent research innovations.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 10 Aug 2022; epub ahead of print
Halliday BP
Heart: 10 Aug 2022; epub ahead of print | PMID: 35948409
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Using historical cardiac troponins to identify patients at a high risk of myocardial infarction.

Roos A, Edgren G
Objective
Many patients who present with chest pain have previous measurements of high-sensitivity cardiac troponin T (hs-cTnT). The clinical usefulness of incorporating these measurements in identifying patients who are at a high risk of myocardial infarction (MI) is unknown. We investigated if the relative change between a historical hs-cTnT and the admission hs-cTnT could improve early identification of patients with a high risk of MI.
Methods
We included all patients presenting with chest pain to seven different emergency departments (EDs) in Sweden from December 2009 to December 2016, who had at least one hs-cTnT measurement at the presentation and at least one available prior measurement. We used logistic regression to investigate the diagnostic performance of using various combinations of current and historical hs-cTnT measurements in diagnosing MI within 30 days.
Results
A total of 27 809 visits were included, among whom 2686 (9.7%) had an MI within 30 days. A cut-off value for historical hs-cTnT-adjusted admission hs-cTnT with similar specificity (91.2%) as an admission hs-cTnT of ≥52 ng/L identified 4% more MIs (43% vs 39%) and had a higher positive predictive value, 42.6% (95% CI, 41.0% to 44.3%) vs 38.9% (95% CI 37.4% to 40.4%), as well as a higher positive likelihood ratio, 6.95 (95% CI 6.69 to 7.22) vs 5.95 (95% CI 5.73 to 6.18). Among patients with an admission hs-cTnT of <52 ng/L who were classified as high-risk patients when incorporating past hs-cTnT measurements, 28% suffered an MI.
Conclusions
Historical hs-cTnT levels can be used with admission hs-cTnT to improve early risk stratification of MI in the ED.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 10 Aug 2022; epub ahead of print
Roos A, Edgren G
Heart: 10 Aug 2022; epub ahead of print | PMID: 35948410
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Effects of salt substitutes on clinical outcomes: a systematic review and meta-analysis.

Yin X, Rodgers A, Perkovic A, Huang L, ... Tian M, Neal B
Objectives
The Salt Substitute and Stroke Study (SSaSS) recently reported blood pressure-mediated benefits of a potassium-enriched salt substitute on cardiovascular outcomes and death. This study assessed the effects of salt substitutes on a breadth of outcomes to quantify the consistency of the findings and understand the likely generalisability of the SSaSS results.
Methods
We searched PubMed, Embase and the Cochrane Library up to 31 August 2021. Parallel group, step-wedge or cluster randomised controlled trials reporting the effect of salt substitute on blood pressure or clinical outcomes were included. Meta-analyses and metaregressions were used to define the consistency of findings across trials, geographies and patient groups.
Results
There were 21 trials and 31 949 participants included, with 19 reporting effects on blood pressure and 5 reporting effects on clinical outcomes. Overall reduction of systolic blood pressure (SBP) was -4.61 mm Hg (95% CI -6.07 to -3.14) and of diastolic blood pressure (DBP) was -1.61 mm Hg (95% CI -2.42 to -0.79). Reductions in blood pressure appeared to be consistent across geographical regions and population subgroups defined by age, sex, history of hypertension, body mass index, baseline blood pressure, baseline 24-hour urinary sodium and baseline 24-hour urinary potassium (all p homogeneity >0.05). Metaregression showed that each 10% lower proportion of sodium choloride in the salt substitute was associated with a -1.53 mm Hg (95% CI -3.02 to -0.03, p=0.045) greater reduction in SBP and a -0.95 mm Hg (95% CI -1.78 to -0.12, p=0.025) greater reduction in DBP. There were clear protective effects of salt substitute on total mortality (risk ratio (RR) 0.89, 95% CI 0.85 to 0.94), cardiovascular mortality (RR 0.87, 95% CI 0. 81 to 0.94) and cardiovascular events (RR 0.89, 95% CI 0.85 to 0.94).
Conclusions
The beneficial effects of salt substitutes on blood pressure across geographies and populations were consistent. Blood pressure-mediated protective effects on clinical outcomes are likely to be generalisable across population subgroups and to countries worldwide.
Trial registration number
CRD42020161077.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 09 Aug 2022; epub ahead of print
Yin X, Rodgers A, Perkovic A, Huang L, ... Tian M, Neal B
Heart: 09 Aug 2022; epub ahead of print | PMID: 35945000
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Long working hours, sedentary work, noise, night shifts and risk of ischaemic heart disease.

Eng A, Dension HJ, Corbin M, Barnes L, ... Laird I, Douwes J
Objective
Ischaemic heart disease (IHD) is a leading cause of death in Western countries. The aim of this study was to examine the associations between occupational exposure to loud noise, long working hours, shift work, and sedentary work and IHD.
Methods
This data linkage study included all New Zealanders employed and aged 20-64 years at the time of the 2013 census, followed up for incident IHD between 2013 and 2018 based on hospitalisation, prescription and death records. Occupation and number of working hours were obtained from the census, and exposure to sedentary work, loud noise and night shift work was assessed using New Zealand job exposure matrices. HRs were calculated for males and females using Cox regression adjusted for age, socioeconomic status, smoking and ethnicity.
Results
From the 8 11 470 males and 7 83 207 females employed at the time of the census, 15 012 male (1.9%) and 5595 female IHD cases (0.7%) were identified. For males, there was a modestly higher risk of IHD for the highest category (>90 dBA) of noise exposure (HR 1.19; 95% CI 1.07 to 1.33), while for females exposure prevalence was too low to calculate an HR. Night shift work was associated with IHD for males (HR 1.10; 95% CI 1.05 to 1.14) and females (HR 1.25; 95% CI 1.17 to 1.34). The population attributable fractions for night shift work were 1.8% and 4.6%, respectively. No clear associations with working long hours and sedentary work were observed.
Conclusions
This study suggests that occupational exposures to high levels of noise and night shift work might be associated with IHD risk.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 08 Aug 2022; epub ahead of print
Eng A, Dension HJ, Corbin M, Barnes L, ... Laird I, Douwes J
Heart: 08 Aug 2022; epub ahead of print | PMID: 35940858
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Transcatheter versus surgical closure of atrial septal defect in adult patients with tricuspid regurgitation.

Kim M, Lee PH, Kim DH, Jung SH, ... Song JK, Song JM
Objectives
Transcatheter closure using a device has been established as an effective atrial septal defect (ASD) treatment, but its value in treating patients with concomitant functional tricuspid regurgitation (TR) is relatively unknown. We sought to evaluate outcomes of patients with ASD and significant TR after transcatheter ASD closure or surgical treatment.
Methods
A total of 252 consecutive adult patients (53.8±13.8 years, 180 females) who had a significant functional TR before ASD closure were retrospectively analysed. The primary end point was a composite of all-cause death, stroke and heart failure. The secondary end point was significant residual TR early and at 1 year after ASD closure.
Results
Transcatheter ASD closure alone and surgical ASD closure along with tricuspid annuloplasty (TAP) were performed in 68 and 184 patients, respectively. Significant TR remained in 32% (81/252) early after ASD closure and in 29% (52/182) after 1 year. The severity of TR was significantly decreased after transcatheter ASD closure (p<0.001). In multivariable analysis, TAP (OR 0.07; p<0.001) and ASD diameter (OR 0.90; p=0.040) were independent predictors of the significant residual TR early after treatment, while only TAP (OR 0.08; p<0.001) was a significant predictor at 1 year after treatment. After propensity score matching in patients with moderate or severe TR, there were no significant differences between the transcatheter ASD closure group and surgical ASD closure plus TAP group in terms of the event rates at 5 years (10.3% vs 5.5%, p=0.963).
Conclusions
While TAP was effective for the treatment of significant TR, transcatheter ASD closure also significantly reduced TR as well. Transcatheter ASD closure may be considered an alternative treatment option in patients with moderate or severe TR.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 29 Jul 2022; epub ahead of print
Kim M, Lee PH, Kim DH, Jung SH, ... Song JK, Song JM
Heart: 29 Jul 2022; epub ahead of print | PMID: 35906027
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Outcome and right ventricle remodelling after valve replacement for pulmonic stenosis.

Laflamme E, Wald RM, Roche SL, Silversides CK, ... Oechslin E, Alonso-Gonzalez R
Background
Complications and need for reinterventions are frequent in patients with pulmonary valve stenosis (PVS). Pulmonary regurgitation is common, but no data are available on outcome after pulmonary valve replacement (PVR).
Methods
We performed a retrospective analysis of 215 patients with PVS who underwent surgical valvotomy or balloon valvuloplasty. Incidence and predictors of reinterventions and complications were identified. Right ventricle (RV) remodelling after PVR was also assessed.
Results
After a median follow-up of 38.6 (30.9-49.4) years, 93% of the patients were asymptomatic. Thirty-nine patients (18%) had at least one PVR. Associated right ventricular outflow tract (RVOT) intervention and the presence of an associated defect were independent predictors of reintervention (OR: 4.1 (95% CI 1.5 to 10.8) and OR: 3.6 (95% CI 1.9 to 6.9), respectively). Cardiovascular death occurred in 2 patients, and 29 patients (14%) had supraventricular arrhythmia. Older age at the time of first intervention and the presence of an associated defect were independent predictors of complications (OR: 1.0 (95% CI 1.0 to 1.1) and OR: 2.1 (95% CI 1.1 to 4.2), respectively). In 16 patients, cardiac magnetic resonance before and after PVR was available. The optimal cut-off values for RV volume normalisation were 193 mL/m2 for RV end-diastolic volume indexed(sensitivity 80%, specificity 64%) and 100 mL/m2 for RV end-systolic volume indexed(sensitivity 80%, specificity 56%).
Conclusions
Previous RVOT intervention, presence of an associated defect and older age at the time of first repair were predictors of outcome. More data are needed to guide timing of PVR, and extrapolation of tetralogy of Fallot guidelines to this population is unlikely to be appropriate.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Jul 2022; 108:1290-1295
Laflamme E, Wald RM, Roche SL, Silversides CK, ... Oechslin E, Alonso-Gonzalez R
Heart: 27 Jul 2022; 108:1290-1295 | PMID: 34815333
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Long-term outcomes in distinct phenogroups of patients with primary mitral regurgitation undergoing valve surgery.

Kwak S, Lee SA, Lim J, Yang S, ... Kim DH, Lee SP
Objectives
Patients with mitral regurgitation (MR) may be heterogeneous with different risk profiles. We aimed to identify distinct phenogroups of patients with severe primary MR and investigate their long-term prognosis after mitral valve (MV) surgery.
Methods
The retrospective cohort of patients with severe primary MR undergoing MV surgery (derivation, n=1629; validation, n=692) was analysed. Latent class analysis was used to classify patients into subgroups using 15 variables. The primary outcome was all-cause mortality after MV surgery.
Results
During follow-up (median 6.0 years), 149 patients (9.1%) died in the derivation cohort. In the univariable Cox analysis, age, female, atrial fibrillation, left ventricular (LV) end-systolic dimension/volumes, LV ejection fraction, left atrial dimension and tricuspid regurgitation peak velocity were significant predictors of mortality following MV surgery. Five distinct phenogroups were identified, three younger groups (group 1-3) and two older groups (group 4-5): group 1, least comorbidities; group 2, men with LV enlargement; group 3, predominantly women with rheumatic MR; group 4, low-risk older patients; and group 5, high-risk older patients. Cumulative survival was the lowest in group 5, followed by groups 3 and 4 (5-year survival for groups 1-5: 98.5%, 96.0%, 91.7%, 95.6% and 83.4%; p<0.001). Phenogroups had similar predictive performance compared with the Mitral Regurgitation International Database score in patients with degenerative MR (3-year C-index, 0.763 vs 0.750, p=0.602). These findings were reproduced in the validation cohort.
Conclusion
Five phenogroups of patients with severe primary MR with different risk profiles and outcomes were identified. This phenogrouping strategy may improve risk stratification when optimising the timing and type of interventions for severe MR.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 26 Jul 2022; epub ahead of print
Kwak S, Lee SA, Lim J, Yang S, ... Kim DH, Lee SP
Heart: 26 Jul 2022; epub ahead of print | PMID: 35882521
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Prevalence and determinants of atrial fibrillation progression in paroxysmal atrial fibrillation.

Nguyen BO, Weberndorfer V, Crijns HJ, Geelhoed B, ... Van Gelder I, Rienstra M
Objective
Atrial fibrillation (AF) often progresses from paroxysmal AF (PAF) to more permanent forms. To improve personalised medicine, we aim to develop a new AF progression risk prediction model in patients with PAF.
Methods
In this interim-analysis of the Reappraisal of AF: Interaction Between HyperCoagulability, Electrical Remodelling, and Vascular Destabilisation in the Progression of AF study, patients with PAF undergoing extensive phenotyping at baseline and continuous rhythm monitoring during follow-up of ≥1 year were analysed. AF progression was defined as (1) progression to persistent or permanent AF or (2) progression of PAF with >3% burden increase. Multivariable analysis was done to identify predictors of AF progression.
Results
Mean age was 65 (58-71) years, 179 (43%) were female. Follow-up was 2.2 (1.6-2.8) years, 51 of 417 patients (5.5%/year) showed AF progression. Multivariable analysis identified, PR interval, impaired left atrial function, mitral valve regurgitation and waist circumference to be associated with AF progression. Adding blood biomarkers improved the model (C-statistic from 0.709 to 0.830) and showed male sex, lower levels of factor XIIa:C1-esterase inhibitor and tissue factor pathway inhibitor, and higher levels of N-terminal pro-brain natriuretic peptide, proprotein convertase subtilisin/kexin type 9 and peptidoglycan recognition protein 1 were associated with AF progression.
Conclusion
In patients with PAF, AF progression occurred in 5.5%/year. Predictors for progression included markers for atrial remodelling, sex, mitral valve regurgitation, waist circumference and biomarkers associated with coagulation, inflammation, cardiomyocyte stretch and atherosclerosis. These prediction models may help to determine risk of AF progression and treatment targets, but validation is needed.
Trial registration number
NCT02726698.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Heart: 20 Jul 2022; epub ahead of print
Nguyen BO, Weberndorfer V, Crijns HJ, Geelhoed B, ... Van Gelder I, Rienstra M
Heart: 20 Jul 2022; epub ahead of print | PMID: 35858774
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Salt restriction and risk of adverse outcomes in heart failure with preserved ejection fraction.

Li J, Zhen Z, Huang P, Dong YG, Liu C, Liang W
Background
The optimal salt restriction in patients with heart failure (HF), especially patients with heart failure with preserved ejection fraction (HFpEF), remains controversial.
Objective
To investigate the associations of cooking salt restriction with risks of clinical outcomes in patients with HFpEF.
Methods
Cox proportional hazards model and subdistribution hazards model were used in this secondary analysis in 1713 participants with HFpEF from the Americas in the TOPCAT trial. Cooking salt score was the sum of self-reported salt added during homemade food preparation. The primary endpoint was a composite of cardiovascular death, HF hospitalisation and aborted cardiac arrest, and secondary outcomes were all-cause death, cardiovascular death and HF hospitalisation.
Results
Compared with patients with cooking salt score 0, patients with cooking salt score >0 had significantly lower risks of the primary endpoint (HR=0.760, 95% CI 0.638 to 0.906, p=0.002) and HF hospitalisation (HR=0.737, 95% CI 0.603 to 0.900, p=0.003), but not all-cause (HR=0.838, 95% CI 0.684 to 1.027, p=0.088) or cardiovascular death (HR=0.782, 95% CI 0.598 to 1.020, p=0.071). Sensitivity analyses using propensity score matching baseline characteristics and in patients who prepared meals mostly at home yielded similar results. Subgroup analysis suggested that the association between overstrict salt restriction and poor outcomes was more predominant in patients aged ≤70 years and of non-white race.
Conclusion
Overstrict cooking salt intake restriction was associated with worse prognosis in patients with HFpEF, and the association seemed to be more predominant in younger and non-white patients. Clinicians should be prudent when giving salt restriction advice to patients with HFpEF.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 18 Jul 2022; epub ahead of print
Li J, Zhen Z, Huang P, Dong YG, Liu C, Liang W
Heart: 18 Jul 2022; epub ahead of print | PMID: 35851318
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Predictors of mortality after atrial correction of transposition of the great arteries.

Antonová P, Rohn V, Chaloupecky V, Simkova I, ... Havova M, Janousek J
Objectives
To determine the long-term and transplantation-free survival of all patients after atrial correction of transposition of the great arteries (TGA) in the Czech and Slovak republics, including its preoperative and perioperative determinants.
Methods
Retrospective analysis of all 454 consecutive patients after atrial correction of TGA was performed. Of these, 126 (27.8%) were female, median age at operation was 7.4 months (Q1 5.3; Q3 13.3) and 164 (36.1%) underwent the Mustard procedure. The relationships between age, weight, the complexity of TGA, operative technique, additional surgical procedures, immediate postoperative presence of tricuspid regurgitation and revision procedures during follow-up to major composite outcome, as such defined as long-term and transplantation-free survival, were tested.
Results
Early 30-day mortality did not differ between the Mustard (9.76%) and Senning (8.97%) cohorts (p=0.866). The long-term and transplantation-free survival, which differed between the Mustard and Senning cohorts in favour of the Senning procedure (HR 0.43; 95% CI 0.21 to 0.87), was shorter in complex TGA (HR 2.4; 95% CI 1.59 to 3.78) and in complex surgical interventions (HR 3.51; 95% CI 2.31 to 5.56). The immediate presence of at least moderate tricuspid regurgitation after correction was associated with a shorter long-term and transplantation-free survival in the univariate but not in the multivariable model.
Conclusions
The lower long-term survival of patients after an atrial switch operation of TGA in the Czech and Slovak republics is associated with greater complexity of TGA, complex surgical interventions and application of the the Mustard operative procedure.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 18 Jul 2022; epub ahead of print
Antonová P, Rohn V, Chaloupecky V, Simkova I, ... Havova M, Janousek J
Heart: 18 Jul 2022; epub ahead of print | PMID: 35851319
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Diagnostic accuracy of splinter haemorrhages in patients referred for suspected infective endocarditis.

Schwiebert R, Baig W, Wu J, Sandoe JAT
Objective
Splinter haemorrhages are an examination finding that has classically been associated with infective endocarditis (IE), but are not included in current diagnostic algorithms. Splinter haemorrhages have not been evaluated as a diagnostic tool using modern definitions of IE. We determined their sensitivity and specificity in patients with suspected IE and investigated their inclusion in the Duke criteria.
Methods
This is a retrospective diagnostic accuracy study using data from 1119 patients with suspected IE referred to the IE service. Patients were categorised according to the Duke criteria, the current diagnostic gold standard, into Duke \'rejected\', \'possible\' or \'definite\' groups. Definite cases (n=451) served as the true positives and rejected cases (n=486) as the true negatives against which splinter haemorrhages were compared. Duke possible cases (n=182) were used the assess the clinical impact of adding splinter haemorrhages to the Duke criteria.
Results
In clinically suspected cases of IE and using the Duke criteria as the gold standard comparator, splinter haemorrhages had a sensitivity of 26% (95% CI 22 to 31) (119 out of 451) and a specificity of 83% (95% CI 79 to 86) (403 out of 486). Inclusion of splinter haemorrhages as a minor vascular phenomenon in the Duke criteria would result in a reclassification of 12% of cases from Duke rejected to possible and 13% from Duke possible to definite.
Conclusion
Splinter haemorrhages are an insensitive tool in the diagnosis of IE, but their high specificity indicates they do have clinical value in patients with suspected infection. Their inclusion in the Duke criteria as a minor vascular criterion reduces diagnostic uncertainty for some Duke possible cases, while increasing it for a similar proportion of Duke rejected cases.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 16 Jul 2022; epub ahead of print
Schwiebert R, Baig W, Wu J, Sandoe JAT
Heart: 16 Jul 2022; epub ahead of print | PMID: 35842232
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

New-onset persistent left bundle branch block following sutureless aortic valve replacement.

Vilalta V, Cediel G, Mohammadi S, López H, ... Bayes-Genis A, Rodés-Cabau J
Objective
To evaluate the incidence, predictive factors and prognostic value of new-onset persistent left bundle branch block (NOP-LBBB) in patients undergoing sutureless surgical aortic valve replacement (SU-SAVR).
Methods
A total of 329 consecutive patients without baseline conduction disturbances or previous permanent pacemaker implantation (PPI) who underwent SU-SAVR with the Perceval valve (LivaNova Group, Saluggia, Italy) in two centres from 2013 to 2019 were included. Patients were on continuous ECG monitoring during hospitalisation and 12-lead ECG was performed after the procedure and at hospital discharge. NOP-LBBB was defined as a new postprocedural LBBB that persisted at hospital discharge. Baseline, procedural and follow-up clinical and echocardiography data were collected in a dedicated database.
Results
New-onset LBBB was observed in 115 (34.9%) patients, and in 76 (23.1%) persisted at hospital discharge. There were no differences in baseline and procedural characteristics between patients with (n=76) and without (n=253) NOP-LBBB. After a median follow-up of 3.3 years (2.3-4.4 years), patients with NOP-LBBB had a higher incidence of PPI (14.5% vs 6.3%, p=0.016), but exhibited similar rates of all-cause mortality (19.4% vs 19.2%, p=0.428), cardiac mortality (8.1% vs 9.4%, p=0.805) and heart failure readmission (21.0% vs 23.2%, p=0.648), compared with the no/transient LBBB group. NOP-LBBB was associated with a decrease in left ventricular ejection fraction (LVEF) at 1-year follow-up (delta: -5.7 vs +0.2, p<0.001).
Conclusions
NOP-LBBB occurred in approximately a quarter of patients without prior conduction disturbances who underwent SU-SAVR and was associated with a threefold increased risk of PPI along with a negative impact on LVEF at follow-up.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 16 Jul 2022; epub ahead of print
Vilalta V, Cediel G, Mohammadi S, López H, ... Bayes-Genis A, Rodés-Cabau J
Heart: 16 Jul 2022; epub ahead of print | PMID: 35842233
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Eligibility for early rhythm control in patients with atrial fibrillation in the UK Biobank.

Kany S, Cardoso VR, Bravo L, Williams JA, ... Gkoutos GV, Kirchhof P
Objective
The Early Treatment of Atrial Fibrillation for Stroke Prevention (EAST-AFNET4) trial showed a clinical benefit of early rhythm-control therapy in patients with recently diagnosed atrial fibrillation (AF). The generalisability of the results in the general population is not known.
Methods
Participants in the population-based UK Biobank were assessed for eligibility based on the EAST-AFNET4 inclusion/exclusion criteria. Treatment of all eligible participants was classified as early rhythm-control (antiarrhythmic drug therapy or AF ablation) or usual care. To assess treatment effects, primary care data and Hospital Episode Statistics were merged with UK Biobank data.Efficacy and safety outcomes were compared between groups in the entire cohort and in a propensity-matched data set.
Results
AF was present in 35 526/502 493 (7.1%) participants, including 8340 (988 with AF <1 year) with AF at enrolment and 27 186 with incident AF during follow-up. Most participants (22 003/27 186; 80.9%) with incident AF were eligible for early rhythm-control.Eligible participants were older (70 years vs 63 years) and more likely to be female (42% vs 21%) compared with ineligible patients. Of 9004 participants with full primary care data, 874 (9.02%) received early rhythm-control. Safety outcomes were not different between patients receiving early rhythm-control and controls. The primary outcome of EAST-AFNET 4, a composite of cardiovascular death, stroke/transient ischaemic attack and hospitalisation for heart failure or acute coronary syndrome occurred less often in participants receiving early rhythm-control compared with controls in the entire cohort (HR 0.82, 95% CI 0.71 to 0.94, p=0.005). In the propensity-score matched analysis, early rhythm-control did not significantly decrease of the primary outcome compared with usual care (HR 0.87, 95% CI 0.72 to 1.04, p=0.124).
Conclusion
Around 80% of participants diagnosed with AF in the UK population are eligible for early rhythm-control. Early rhythm-control therapy was safe in routine care.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Heart: 14 Jul 2022; epub ahead of print
Kany S, Cardoso VR, Bravo L, Williams JA, ... Gkoutos GV, Kirchhof P
Heart: 14 Jul 2022; epub ahead of print | PMID: 35835543
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Left atrial appendage preservation versus closure during surgical ablation of atrial fibrillation.

Kim HJ, Chang DH, Kim SO, Kim JK, ... Lee JW, Kim JB
Objective
There is limited evidence regarding the effectiveness of left atrial appendage (LAA) closure during surgical ablation of atrial fibrillation (AF) in yielding superior clinical outcomes. This study aimed to evaluate the association of LAA closure versus preservation with the risk of adverse clinical outcomes among patients undergoing surgical ablation during cardiac surgery.
Methods
We evaluated 1640 patients (aged 58.8±11.5 years, 898 women) undergoing surgical ablation during cardiac surgery (including mitral valve (MV), n=1378; non-MV, n=262) between 2001 and 2018. Of these, 804 had LAA preserved, and the remaining 836 underwent LAA closure. Comparative risks of stroke and mortality between the two groups were evaluated after adjustments with inverse-probability-of-treatment weighting (IPTW). Longitudinal echocardiographic data (n=9674, 5.9/patient) on transmitral A-wave and E/A-wave ratio were analysed by random coefficient models.
Results
Adjustment with IPTW yielded patient cohorts well-balanced for baseline profiles. During a median follow-up of 43.5 months (IQR 19.0-87.3 months), stroke and death occurred in 87 and 249 patients, respectively. The adjusted risk of stroke (HR 0.85; 95% CI 0.52-1.39) and mortality (HR 0.80; 95% CI 0.61 to 1.05) did not differ significantly between the two groups. Echocardiographic data demonstrated higher transmitral A-wave velocity (group-year interaction, p=0.066) and lower E/A-wave ratio (group-year interaction, p=0.045) in the preservation group than in the closure group.
Conclusions
LAA preservation during surgical AF ablation was not associated with an increased risk of stroke or mortality. Postoperative LA transport functions were more favourable with LAA preservation than with LAA closure.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 13 Jul 2022; epub ahead of print
Kim HJ, Chang DH, Kim SO, Kim JK, ... Lee JW, Kim JB
Heart: 13 Jul 2022; epub ahead of print | PMID: 35831016
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Aortic cusp abnormalities in patient with trileaflet aortic valve and root aneurysm.

Ehrlich T, Hagendorff A, Abeln K, Froede L, Giebels C, Schaefers HJ
Background
The frequency of concomitant cusp pathology in aortic root aneurysm with or without aortic regurgitation is not well known, and the sensitivity and specificity of two-dimensional trans-oesophageal echocardiography (2D TEE) in its detection has not yet been specified.
Objectives
We analysed the type and frequency of concomitant cusp alterations in root aneurysm referred for surgery. Sensitivity and specificity of 2D TEE in detecting these alterations were determined.
Methods
In 582 patients (age 56.8±15.4 years, 453 male) with trileaflet aortic valves undergoing root replacement for regurgitation (n=347) or aneurysm (n=235), details of valve morphology were analysed. In a subcohort (n=281), intraoperative TEEs were analysed retrospectively and correlated with the intraoperative findings.
Results
Any cusp pathology was present in 90.9% (prolapse: n=473; retraction: n=30; calcification: n=14; fenestration: n=12), morphologically normal cusps were seen in only 52 patients (8.93%). Valve-sparing surgery was performed in 525 (90.2%) instances, composite replacement in 57 (9.8%). Preoperative TEE correctly identified any postroot repair prolapse in 70.6% and any retraction in 85%. The sensitivity of TEE in detecting any prolapse was 68.6% (specificity of 79.5%). The sensitivity was highest for the right cusp and intermediate for the non-coronary.
Conclusions
Cusp prolapse is frequent in root aneurysm and trileaflet aortic valves. Prolapse is underdiagnosed by 2D TEE in many cases because pre-existent stretching of cusp tissue is masked by the geometric effects of root dilatation.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 08 Jul 2022; epub ahead of print
Ehrlich T, Hagendorff A, Abeln K, Froede L, Giebels C, Schaefers HJ
Heart: 08 Jul 2022; epub ahead of print | PMID: 35803710
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Transfer of congenital heart patients from paediatric to adult services in England.

Espuny Pujol F, Franklin RC, Crowe S, Brown KL, ... Pagel C, English KM
Objective
This study assessed the transfer of patients from paediatric cardiac to adult congenital heart disease (ACHD) services in England and the factors impacting on this process.
Methods
This retrospective cohort study used a population-based linked data set (LAUNCHES QI data set: \'Linking Audit and National datasets in Congenital Heart Services for Quality Improvement\') including all patients born between 1987 and 2000, recorded as having a congenital heart disease (CHD) procedure in childhood. Hospital Episode Statistics data identified transfer from paediatric to ACHD services between the ages of 16 and 22 years.
Results
Overall, 63.8% of a cohort of 10 298 patients transferred by their 22nd birthday. The estimated probability of transfer by age 22 was 96.5% (95% CI 95.3 to 97.7), 86.7% (95% CI 85.6 to 87.9) and 41.0% (95% CI 39.4 to 42.6) for severe, moderate and mild CHD, respectively. 166 patients (1.6%) died between 16 and 22 years; 42 of these (0.4%) died after age 16 but prior to transfer. Multivariable ORs in the moderate and severe CHD groups up to age 20 showed significantly lower likelihood of transfer among female patients (0.87, 95% CI 0.78 to 0.97), those with missing ethnicity data (0.31, 95% CI 0.18 to 0.52), those from deprived areas (0.84, 95% CI 0.72 to 0.98) and those with moderate (compared with severe) CHD (0.30, 95% CI 0.26 to 0.35). The odds of transfer were lower for the horizontal compared with the vertical care model (0.44, 95% CI 0.27 to 0.72). Patients who did not transfer had a lower probability of a further National Congenital Heart Disease Audit procedure between ages 20 and 30 compared with those who did transfer: 12.3% (95% CI 5.1 to 19.6) vs 32.5% (95% CI 28.7 to 36.3).
Conclusions
Majority of patients with moderate or severe CHD in England transfer to adult services. Patients who do not transfer undergo fewer elective CHD procedures over the following decade.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 06 Jul 2022; epub ahead of print
Espuny Pujol F, Franklin RC, Crowe S, Brown KL, ... Pagel C, English KM
Heart: 06 Jul 2022; epub ahead of print | PMID: 35794015
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Comparisons between biopsy-proven versus clinically diagnosed cardiac sarcoidosis.

Kitai T, Nabeta T, Naruse Y, Taniguchi T, ... Matsue Y, Izumi C
Objectives
Diagnosis of cardiac sarcoidosis (CS) without histological evidence remains controversial. This study aimed to compare characteristics and outcomes of histologically proven versus clinically diagnosed cases of CS, which were adjudicated using Heart Rhythm Society or Japanese Circulation Society criteria.
Methods
A total of 512 patients with CS (age: 62±11 years, female: 64.3%) enrolled in the multicentre registry were studied. Histologically confirmed patients were classified as \'biopsy-proven CS\', while those with the presence of strongly suggestive clinical findings of CS without histological evidence were classified as \'clinical CS\'. Primary outcome was a composite of all-cause death, heart failure hospitalisation and ventricular arrhythmia event.
Results
In total, 314 patients (61.3%) were classified as biopsy-proven CS, while 198 (38.7%) were classified as clinical CS. Patients classified under clinical CS were associated with higher prevalence of left ventricular dysfunction, septal thinning, and positive findings in fluorodeoxyglucose-positron emission tomography or Gallium scintigraphy than those under biopsy-proven CS. During median follow-up of 43.7 (23.3-77.3) months, risk of primary outcome was comparable between the groups (adjusted HR: 1.24, 95% CI: 0.88 to 1.75, p=0.22). Similarly, the risks of primary outcome were comparable between patients with clinical isolated CS who did not have other organ/tissue involvement, and biopsy-proven isolated CS (adjusted HR: 1.23, 95% CI: 0.56 to 2.70, p=0.61).
Conclusions
A substantial number of patients were diagnosed with clinical CS without confirmatory biopsy. Considering the worse clinical outcomes irrespective of the histological evidence, the diagnosis of clinical CS is justifiable if imaging findings suggestive of CS are observed.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 05 Jul 2022; epub ahead of print
Kitai T, Nabeta T, Naruse Y, Taniguchi T, ... Matsue Y, Izumi C
Heart: 05 Jul 2022; epub ahead of print | PMID: 35790370
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:

This program is still in alpha version.