Citations

Abstract Aims The increasing adoption of transcatheter tricuspid valve replacement (TTVR) offers a promising therapeutic option for patients with severe tricuspid regurgitation. However, many of these patients have pre-existing cardiac implantable electronic devices (CIEDs), raising concerns about potential lead-related complications. Despite these concerns, limited data exist on the impact of TTVR on CIED integrity and function. This study aimed to evaluate the impact of TTVR on CIED lead function, including pacing thresholds, sensing, and impedance, in patients undergoing TTVR with the EVOQUE valve system. Methods and results A retrospective observational study was conducted at Mayo Clinic Rochester, including 32 consecutive patients who underwent TTVR with pre-existing CIEDs. A total of 32 patients were included, with a mean age of 79.2 ± 8.4 years; 59% were female. A total of 62.5% had a permanent pacemaker, 12.5% had an implantable cardioverter-defibrillator, 15.6% had a cardiac resynchronization therapy pacemaker, and 9.4% had a cardiac resynchronization therapy defibrillator. Following TTVR, 10 (31%) of patients developed lead function changes during a median device follow-up of 210 days (IQR: 43–307 days). The right ventricular lead was primarily affected, with only one case involving an atrial lead. Neither the Ottawa score nor the anatomical lead position reliably predicted lead abnormality (P = 0.86 and P = 0.53, respectively). R-wave sensing changes were the most common lead change observed, affecting 55% of cases. In 67% of these cases, R-wave sensing alterations occurred as an isolated finding, with no significant change in impedance or thresholds, and were managed conservatively without any need for device reprogramming. Four patients (13%) had findings concerning for a lead insulation breach, in which one (3%) required a lead revision. Among five patients with follow-up exceeding 600 days, two patients exhibited a statistically significant gradual decline in impedance without other lead dysfunction, suggesting potential subclinical lead degradation. Conclusion Transcatheter tricuspid valve replacement with the EVOQUE system in the setting of cardiac device leads is associated with lead function changes in 31%. The majority of lead-related changes were managed conservatively, but 13% of patients had findings concerning for an insulation breach. Future studies should focus on refining implantation techniques and defining optimal strategies for managing device-lead interactions in this population.

Abstract Background Experts' interpretations of medical images for lesion diagnosis may not always align with the underlying in vivo tissue pathology and, therefore, cannot be considered the definitive truth regarding malignancy or benignity. While current machine learning (ML) models in medical imaging can replicate expert interpretations, their results may also diverge from the actual ground truth. Purpose This study investigates various factors contributing to these discrepancies and proposes solutions. Methods The central idea of the proposed solution is to integrate prior knowledge into ML models to enhance the characterization of in vivo tissues. The incorporation of prior knowledge into decision‐making is task‐specific, tailored to the data acquired for that task. This central idea was tested on the diagnosis of lesions using low dose computed tomography (LdCT) for early cancer detection, particularly focusing on more challenging, ambiguous or indeterminate lesions (IDLs) as classified by experts. One key piece of prior knowledge involves CT x‐ray energy spectrum, where different energies interact with in vivo tissues within a lesion, producing variable but reproducible image contrasts that encapsulate biological information. Typically, CT imaging devices use only the high‐energy portion of this spectrum for data acquisition; however, this study considers the full spectrum for lesion diagnostics. Another critical aspect of prior knowledge includes the functional or dynamic properties of in vivo tissues, such as elasticity, which can indicate pathological conditions. Instead of relying solely on abstract image features as current ML models do, this study extracts these tissue pathological characteristics from the image contrast variations. Results The method was tested on LdCT images of four sets of IDLs, including pulmonary nodules and colorectal polyps, with pathological reports serving as the ground truth for malignancy or benignity. The method achieved an area under the receiver operating characteristic curve (AUC) of 0.98 ± 0.03, demonstrating a significant improvement over existing state‐of‐the‐art ML models, which typically have AUCs in the 0.70 range. Conclusion Leveraging prior knowledge in machine intelligence can enhance lesion diagnosis, resolve the ambiguity of IDLs interpreted by experts, and improve the effectiveness of LdCT screening for early‐stage cancers.

Abstract Background Moderate-severe mitral annulus calcification (MAC) and left ventricular (LV) diastolic dysfunction are both linked to increased risks of heart failure and mortality. Assessing LV diastolic function (LVDF) in moderate-severe-MAC by echocardiography is frequently challenging and unreliable. We recently validated an AI-ECG model for LVDF. We aimed to determine if this tool can predict long-term mortality in patients with moderate-severe-MAC and whether it can help establish MAC-specific echocardiographic LVDF parameter cutoffs. Methods This retrospective study included all patients from the AI-ECG LVDF study test cohort who underwent comprehensive transthoracic echocardiography confirming moderate-severe-MAC and ECG within fourteen days of each other at Mayo Clinic between 09/2001 and 06/2022. AI-ECG LVDF was determined based on the index ECG. Patients were categorized based on AI-ECG into groups representing normal/grade-1 LVDF, grade-2 LVDF, or grade-3 LVDG (DF-1, DF-2, and DF-3, respectively). Results Of 2,506 patients with moderate-severe-MAC [mean age 77, 64.1% females], 709 (28.3%), 1,510 (60.3%), and 287 (11.5%) were classified as DF-1, DF-2, and DF-3, respectively. Worse LVDF grade was associated with older age, male sex, lower LV ejection fraction, and higher rates of noncardiovascular and cardiovascular comorbidities. Over a median follow-up of 2.8 years, 1,059 (42.3%) patients died. In multivariable survival analysis, DF-2 [adjusted hazard ratio (aHR) 1.43, 95% confidence interval (95%CI) 1.21-1.68] and DF-3 (aHR 1.54, 95%CI 1.22-1.93) were independently associated with a higher risk of death (figure). Findings were also consistent after adjusting to mitral inflow gradients. When comparing LVDF echocardiographic parameters in controls without MAC matched by age, sex, left ventricular ejection fraction, and AI-ECG DF grade, significant differences were observed. Patients with moderate to severe MAC generally exhibited lower e' velocities, higher TR velocities, elevated E/e' ratios, and increased LAVi. Interestingly, the E/A ratio between MAC patients and their matched controls across AI-ECG LVDF grades remained consistent. Conclusion AI-ECG LVDF predicts mortality risk in patients with moderate-severe-MAC, regardless of mitral inflow gradients. Utilizing AI-ECG LVDF might aid in the risk stratification of patients with significant MAC.

Background: Acute Kidney Injury (AKI) is a multifactorial complication following repair of Stanford Type A aortic dissection (TAAD) with an alarmingly high incidence, varying from 20 to 77%. Postoperative AKI following life-threatening disease tends to be much more complex. However, the exact role of postprocedural AKI in the prognosis of patients undergoing TAAD repair has not been elucidated. Aims: This meta-analysis aimed to evaluate the prognostic significance of postprocedural AKI in patients undergoing TAAD repair. Methods: A literature search was conducted using PubMed, EMBASE, and SCOPUS databases. The primary endpoint was 30-day mortality with several secondary endpoints. Risk ratios (RR) with 95% confidence intervals (CIs) were pooled using Review Manager software. Statistical significance was set at p <0.05. Random-effects meta-analyses were performed for all outcomes. Results: Our analysis included 21 studies comprising 10396 patients. Patients with AKI exhibited a significantly higher risk of 30-day mortality (RR=3.98; 95% CI: 3.04-5.22; p<0.00001; I 2 =57%), stroke (RR= 2.05; 95% CI: 1.68-2.50; p<0.00001; I 2 =32%), dialysis requirement (RR= 32.9; 95% CI: 10.39-104.24; p<0.00001; I 2 =90%) (Figure 1), cardiovascular complications (RR= 2.85; 95% CI: 1.65-4.92; p<0.0002; I 2 =85%), sepsis (RR= 4.92; 95% CI: 2.62-9.24; p<0.00001; I 2 =64%), and re-exploration for bleeding (RR=2.46; 95%CI: 1.79-3.39; p<0.00001; I 2 =58%) compared to those without AKI (Figure 2). Conclusion: Patients with AKI demonstrated a significantly increased risk of mortality, stroke, need for dialysis, sepsis, postoperative cardiovascular complications, and re-exploration for bleeding. Further prospective studies are required to better understand the prevention strategies and long-term effects on prognosis of AKI post-repair for TAAD.

Abstract Background Thromboembolic stroke risk remains a clinical challenge in cardiac amyloidosis (CA) patients with atrial fibrillation because of the increased prevalence of left atrial appendage thrombi irrespective of CHA2DS2-VASc score and a higher prevalence of factors that increase the risk of bleeding with anticoagulation. Left atrial appendage closure (LAAC) is an effective option in patients with atrial fibrillation and high bleeding risk; however, data describing a LAAC strategy for stroke prevention in patients with CA is limited. Among non-CA patients, procedural success and serious complication rates are around 98% and 3% respectively. Purpose In this multicenter retrospective study, we aimed to investigate whether left atrial appendage closure (LAAC) could reduce the risk of bleeding complications and ischemic cerebrovascular events in patients with CA. Methods In an international multi-center retrospective study, patients with CA that underwent LAAC were included. The diagnosis of CA was established on the basis of histologic confirmation or advanced multimodality cardiac imaging as per current consensus statements. Results A total of 28 patients (93% male; 87% ATTR-CA; 13% AL-CA; mean age 80 years) met inclusion criteria. At baseline, mean CHA2DS2-VASc and HAS-BLED scores were 4 and 3 respectively, mean left ventricular ejection fraction was 50%, and mean indexed left atrial volume was 58 mL/m2. 21% of patients had a prior history of ischemic stroke, 14% prior history of hemorrhagic stroke, 7% prior transient ischemic attack, and 54% had a prior history of major or minor bleeding. Procedural success was achieved in 26 patients (93%) with procedural complications occurring in 2 patients (vascular access site bleeding and cardiac tamponade). Regarding in-hospital and follow-up complications, 0% ischemic stroke, 0% hemorrhagic stroke, and major or minor bleeding in 4% of patients. During follow up, device thrombosis occurred in only 1 patient. Conclusion LAAC is a feasible and effective alternative to anticoagulation in patients with CA and excessive bleeding risk, with procedural success and complication rates similar to reported studies of non-CA patients.

Abstract Background Heart failure (HF) and atrial fibrillation (AF) are intertwined, sharing common risk factors and influencing each other in a reciprocal manner. While left ventricular diastolic dysfunction (LVDD) stands as a hallmark of HF's hemodynamic profile, its direct correlation with heightened AF risk remains uncertain. Our recent validation of an artificial intelligence-enabled electrocardiogram (AI-ECG) algorithm for LVDD detection has opened new avenues. Yet, whether AI-ECG-detected LVDD correlates with long-term AF risk remains unexplored. Methods We performed a retrospective study among all patients with a comprehensive LVDD assessment from the test population of the AI-ECG LVDD study between September 2001 and June 2022. Patients with prior documented AF according to health records or previous ECG were excluded. Patients were classified by AI-ECG as normal diastolic function (DF), grade 1 (G1), grade 2 (G2), or grade 3 (G3) LVDD. We assessed the risk of AF across AI-ECG LVDD grade, with normal DF as reference, with competing risk models. Results Of 97,023 patients free of AF at baseline, 63,533 (65.4%), 10,776 (11.1%), 18,940 (19.5%), and 3,774 (3.9%) were classified as normal DF, G1-LVDD, G2-LVDD, and G3-LVDD, respectively. Worse AI-ECG LVDD was associated with older age, lower left ventricular ejection fraction (LVEF), and higher rates of HF, diabetes, hypertension, chronic pulmonary disease, renal failure, and cardiovascular disease (p-of-trend&lt;0.001 for all). Over a median follow-up of 4.8 years (interquartile range 1.8-9.2 years), new-onset AF occurred in 6,795 (7.0%) patients. In multivariable survival analysis, adjusted to multiple risk factors including LVEF and clinical HF, G2 and G3 LVDD, representing patients with high filling pressures, were independently associated with a higher AF-risk [G2-LVDD: adjusted hazard ratio (aHR) 1.64 (95% confidence interval (95%CI) 1.52-1.73), G3-LVDD: aHR 2.24 (95%CI 2.02-2.48)]. Conclusion The AI-ECG LVDD algorithm independently predicts long-term AF risk, regardless of LVEF and clinical HF status, highlighting its potential for identifying high-risk populations and guiding proactive monitoring and management.

Abstract Purpose To assess incidence and risk factors for anthracycline-induced left ventricular dysfunction, and associated mortality in order to inform patients and providers of the risk, as well as for clinical trial endeavours. Background Anthracyclines (ACs) are very effective cancer therapeutics, but their use is confronted by the risk of cardiotoxicity. Estimates of AC-induced cardiotoxicity based on systematic analyses are limited and have not recently been defined. We present here a systematic review and meta-analysis of the incidence of anthracycline induced subclinical (AC-LVD) and clinical LV dysfunction (AC-CHF) and AC-CHF related mortality in non-liposomal AC recipients over the last 3 decades. Methods We searched Ovid MEDLINE(R), Embase, Cochrane Database and other major databases from their inception until June 22, 2023 for studies examining the rate of AC induced cardiomyopathy in patients receiving ACs and anthraquinones for haematologic, breast (BC) and sarcomatous malignancies. Covidence was used to aid with the management of our systematic review. Screening of abstracts and data extraction was independently performed by 2 reviewers. Results 6,365 abstracts were reviewed, of which 74 were included in the final analysis. 72 studies (n=41,138) reported data on AC-LVD, and 47 studies (n=27,012) reported data on AC-CHF. The average age was 53 years and 50% of the patients were female. Data on cardiac function at baseline was available in only 70% of the studies. Overall, AC-LVD occurred in 8.2% (95% CI 6.8%-10.2% I2 97%) (Fig 1). AC-CHF was noted in 2.2% (95% CI 1.6% to 2.9%, I2 91%) (Fig 2A), mortality related to decompensated AC-CHF was 0.5% (95% CI 0.3%-0.9%, I2 88%) (Fig 2B) while total mortality rate among AC recipients was 24.9% (95% CI 14.8-38.7%, I2 99%). Incidence of AC-LVD was higher in doxorubicin recipients (vs other ACs 10.5% vs 5-5.6%), studies from North America & Asia (vs other regions; 9.3-9.6% vs 6.7%), and prospective studies (vs retrospective studies; 8.7% vs 7.5%). AC-LVD was more common in BC patients (vs other cancers; 8.7% vs 3.5-7.2%) while AC-CHF was more common in lymphoma patients (8.5% vs 1.6-4.1%). AC-LVD was 4.6 times (95% CI 1.2-17.1, p=0.02) more likely in patients with a mean age &gt;70 (vs &lt;70). 21 definitions for AC-LVD were used across the studies. The most common definition (15 studies; n=7904) was "any decline in LVEF from baseline" resulting in a 5.8% rate of AC-LVD. Conclusions AC-LVD and AC-CHF has been reported in up to 10% and 3% of AC recipients, respectively. AC-CHF related mortality occurs in &lt;1% of anthracycline recipients and has a 2-3% share in overall mortality among these patients. The type of malignancy and anthracycline can influence the rate of AC-LVD, AC-CHF and AC-CHF related mortality. Global region, age of the patient population and study design also seem to influence incidence rates. There is noteworthy heterogeneity in definitions for cardiotoxicity across studies.

Abstract Background Non-bacterial thrombotic endocarditis (NBTE) is a non-infectious condition characterized by thrombotic and/or inflammatory depositions involving the cardiac valves. It is a challenging diagnosis of exclusion. Purpose This study aimed to better characterize patients with pathologically proven NBTE and assess its clinical, echocardiographic characteristics and prognostic implications. Methods We retrospectively identified patients with pathology-proven NBTE at a single center. Patients with positive preoperative blood cultures, a history of active or treated infective endocarditis, or identification of valvular organisms by special stains were excluded from the study. Patients with pathology reports of valve perforation or chordal rupture were also excluded because of the high likelihood of an infectious etiology for these lesions. Results A total of 53 patients with NBTE (median age 57 years; 61% females) were identified. In this cohort, 22% had a history of malignancy, 30% had connective tissue disease, 32% had coronary artery disease, and 11% prior history of NBTE. Neurological events accounted for 18 (34%) of the presenting symptoms (TIA n=17, CVA n=9), while new valvular dysfunction in 7 (13%) and fever in 8 (15%) of patients. Five patients (9%) had NBTE involving more than one valve. NBTE involved the mitral valve in 64%, aortic valve in 38% prosthetic/mechanical valve in 11%, and tricuspid valve in 5%. NBTE was identified at the time of autopsy in 34% of patients. NBTE recurred in 3 patients during follow-up. Excluding patients diagnosed at the time of autopsy, 9% of patients died within 1 year of NBTE diagnosis. Conclusion NBTE was diagnosed pathologically in the presence of hyper-inflammatory states due to critical illness or immunological diseases. It was predominantly on the left side of the heart and was associated with embolic phenomena, either clinically or on imaging. Patients diagnosed with antemortem with NBTE have a high mortality in the first year (9%).