Citations

Background Patients with single-ventricle physiology are often palliated with the Fontan operation, which may involve the creation of a fenestration. We aimed to evaluate differences in cardiopulmonary exercise test (CPET) performance between patients with fenestrated and non-fenestrated Fontan circulation. Methods Patients with a Fontan circulation referred to CPET between 2006 and 2024 were included and were categorised based on their fenestration status at the time of CPET. Logistic regression analyses were performed to assess the impact of fenestration on peak oxygen consumption (VO 2 ), and Cox proportional hazard to evaluate the impact of fenestration on cardiovascular outcomes (death, heart transplant and Fontan-related hospitalisation). Results Of the 184 patients, 141 were classified as non-fenestrated and 43 as fenestrated. The minute ventilation-carbon dioxide production (V E /VCO 2 slope) was higher in the fenestrated (36.9±7.9) versus (33.2±6.2; p=0.009) in the non-fenestrated group. There was no significant difference in predicted VO 2 between groups (non-fenestrated 51.9%±14.4 vs 51.3%±15.6; p=0.7). Resting oxygen saturation was higher in the non-fenestrated group (93%±4.7 compared with fenestrated group 90.1%±5; p<0.001). Fontan fenestration was not significantly associated with the composite outcome; older patient age at the time of the CPET, cirrhosis and ventricular ejection fraction <40% were significantly associated with higher risk, while higher resting systolic blood pressure, left ventricular morphology and higher predicted peak VO 2 were protective. Conclusions The increased hypoxia and reduced ventilatory efficiency associated with Fontan fenestration offset any potential benefits, resulting in similar exercise performance between the groups. Fontan fenestration was not significantly associated with cardiovascular outcomes.

Abstract Aims Endogenous endophthalmitis (EE) is a rarely reported complication of infective endocarditis (IE). In an international series, we sought to determine the clinical and microbiological profile, treatment, and outcome of patients presenting with IE-related EE. Methods and results Cases recorded from 2014 to 2023 in nine centres in Europe and the United States were collected. Results were compared to a matched control group. Conclusion Sixty-six patients with EE were reported, mean age of 65.2 ± 14.9 years, 71% (n = 47) male. Blood cultures were positive in 97% (64 cases) of patients, with a predominance of streptococci (46%, n = 30). As compared with the control group (n = 264), the EE group presented with more frequent diabetes (35% vs. 21%, P = 0.02), history of cirrhosis (9% vs. 3%, P = 0.04), glomerulonephritis (15% vs. 0.4%, P &lt; 0.001), embolism before admission (92% vs. 55%, P &lt; 0.001), and Janeway lesions (9% vs. 1%, P = 0.002). Streptococcal infection (46% vs. 26%, P = 0.001) was more frequent and Enterococcal infection (0% vs. 18%, P &lt; 0.001) less frequent in the EE group. The main ocular symptoms were a decrease in visual acuity (96%), red eye (55%), and ocular pain (55%). Treatment of EE consisted of intravitreal antibiotic injection in 55 (83%) patients and vitrectomy in 17 (26%). Improvement of visual acuity was observed in 36 (55%) patients. Conclusion EE is a serious complication of IE with severe residual vision impairment. Patients with IE should be evaluated for ocular complications, since early detection of EE is crucial to prevent delays in management and to preserve visual function.

Background: The relationship between vegetation characteristics in Staphylococcus aureus infective endocarditis (IE) and blood culture time to positivity (TTP) has not been investigated. This study evaluates the correlation between vegetation length and TTP in patients with S. aureus IE. Methods: A retrospective cohort study was conducted that included 164 definite cases S. aureus IE. Vegetation length was determined by transesophageal echocardiography (TEE), and TTP was measured in hours from the initial time of blood culture incubation to positivity. Correlations between vegetation characteristics and TTP were analyzed using Spearman’s rank correlation coefficient. Results: A modest but statistically significant negative correlation was observed between vegetation length and TTP (Spearman ρ = −0.18, p = 0.020), suggesting that larger vegetations were associated with shorter TTP. No significant correlations were found for other vegetation characteristics (e.g., vegetation mobility, location, or number) and TTP. Conclusions: Larger vegetation size in S. aureus IE was associated with shorter TTP. These findings highlight the importance of vegetation size in the pathophysiology of S. aureus IE and its role in bacteremia dynamics.

Background Echocardiographic evaluation of vegetations is crucial in infective endocarditis ( IE ). Although several studies have noted a link between larger vegetations and an increased risk of embolization, a more comprehensive evaluation of vegetation characteristics in a contemporary cohort has not been conducted. Our study aimed to define the short‐term risk of symptomatic embolization in patients with IE . Methods and Results The Mayo Clinic IE registry was screened to identify patients from 2015 to 2021 who had undergone transesophageal echocardiography. Multivariable subdistribution hazards regression analysis was used to identify factors associated with the cumulative incidence of symptomatic embolism over 30 days accounting for the competing risk of death. Overall, 779 patients with IE were included, of whom 517 (66.4%) were men, median age was 65.0 ( interquartile range, 52.9–74.8) years, and 89.3% were White. In total, 234 patients had a symptomatic embolic event, a 30‐day cumulative incidence of 30.2%. In multivariable analysis, a highly mobile vegetation was the strongest predictor of embolism ( P <0.001). Vegetation length with interaction of IE type was also associated with embolic risk ( P <0.001), with a stronger effect in native valve IE ( P interaction=0.001). Other associated factors included multiple vegetations, younger age, and Staphylococcus aureus . A nomogram that incorporated these factors was constructed to facilitate the prediction of embolic risk. Conclusions Highly mobile, larger vegetations are associated with embolic events. Embolic risk could be assessed by evaluating length as a continuous variable, alongside other echocardiographic findings, using a newly developed scoring tool; external validation is warranted.

Background: Many children born with single ventricle physiology are palliated with Fontan operation, which may include a fenestration creation. This has been demonstrated to improve short-term outcomes after surgery. Reduced exercise capacity has been shown to be a predictor of prognosis in Fontan patients. Aim: We sought to compare cardiopulmonary exercise test (CPET) data between fenestrated and non-fenestrated Fontan patients. Methods: We conducted a retrospective cohort study of 185 patients referred for CPET from 2011 to 2024. Patients with complete CPET data were included. Type of Fontan, comorbidities, and echocardiogram data were ascertained electronically. Patients were divided into 2 different groups according to the fenestration patency. Fisher’s exact test or chi-square was used to compare categorical variables. T-test and Turkey-Kramer were used to compare continuous variables. Adjustment using General Lineal Models procedure were used to identify any confounder that could affect the results. P value <0.05 was considered significant. Results: 142 patients were classified in the non-fenestrated (NF) group, and 43 in the fenestrated group (FF). Baseline characteristics of both groups are shown in Table 1. From the evaluated CPET variables, the minute ventilation-carbon dioxide production (VE/VCO2) was higher in the FF (p=<0.001), and oxygen saturation at peak exercise (SatO2) was lower in this group (p= <0.001) (Figure 1). There was no significant difference between peak oxygen consumption (VO2) between groups. When adjusted by comorbidities only VE/VCO2 nadir, slope and peak SatO2 were statistically significant different between groups (Table 2). Conclusion: Ventilatory variables showed significant differences when fenestration was presented, secondary to V-Q mismatch from increased right to left shunt. Despite the theoretical advantage of increased cardiac output from Fontan fenestration, exercise performance was similar between both groups.

Background: Cardiac amyloidosis is a rapidly progressing and severe condition leading to heart failure and reduced quality of life. Amyloid deposits impair both chronotropic and pumping functions of the heart. The Cardiopulmonary Exercise Test (CPET) is a vital tool in assessing the severity and progression of this disease. Aims: This study aims to investigate the differences in chronotropic function associated with the stages of heart failure in patients with cardiac amyloidosis and outcomes. Methods: A retrospective cohort study was conducted involving 194 patients diagnosed with cardiac amyloidosis who underwent at least one CPET from February 2010 to February 2024. Medical records were reviewed for data on the type of amyloidosis, comorbidities, and CPET results. The cohort was divided into two groups according to the Weber Classification: Weber Class A/B and Weber Class C/D. Patients who had CPET studies post-heart transplant were excluded. Statistical analyses, including Fisher’s exact test and chi-square test, were used. Cox regression model analysis, proportional hazards model for time to event. Adjustment for beta-blocker use was made to assess chronotropic incompetence. A p-value <0.05 was considered significant. Results: Among the 194 patients, 94 were classified as Weber A/B and 100 as Weber C/D. The average age at the time of the stress test was similar between the groups: 62.9 ± 11.7 years for Weber A/B and 62.3 ± 10.7 years for Weber C/D (p=0.087) Table 1 . Chronotropic function, evaluated through CPET, showed significant differences. Heart rate reserve was significantly lower in the Weber C-D group compared to the A-B group (p<0.001). The chronotropic index was also significantly lower in the Weber C-D group Figure 2. Chronotropic incompetence was observed in 43.9% of the Weber A and increased progressively, being significantly more prevalent in the Weber D group (100%) (p<0.001). Additionally, Chronotropic incompetence was strongly associated with the composite outcome of (hospitalization for heart failure and death) HR 1.932 (1.126 -3.313) p =0.0167 (Table 2). Conclusion: CPET assessment of chronotropic function correlates with VO2 parameter evaluated in Weber classification. Patients with higher Weber stages of heart failure in amyloidosis exhibited a higher prevalence of chronotropic incompetence, indicating it could serve as a marker of cardiac function.

Abstract Background Cardiopulmonary exercise testing (CPET) has emerged as an important tool for risk stratification and prognosis assessment in patients with cardiac diseases. The Weber and Ventilatory Functional Classification have been correlated with outcomes in patients with Heart Failure (HF). Weber classification is based on VO2: Weber class A, peak VO2 &gt;20 mL/kg per minute; class B, peak VO2 16–20 mL/kg per minute; class C, peak VO2 10–16 mL/kg per minute; and class D, peak VO2 ≤10 mL/kg per minute and Ventilatory classification on VE/VCO2 slope I-IV (Figure A). Although VO2 and VE/VCO2 variables have found altered in the amyloidosis population, the applicability of this classification in a cohort of amyloidosis patients and its correlation with all-cause mortality have not been explored. Purpose To evaluate if the Weber and Ventilatory Classification of HF predicts mortality amyloidosis patients. Methods 194 with diagnosis of amyloidosis who underwent CPET from February 2010 to February 2024 were included in this retrospective cohort study. Patients with at least one CPET complete data were included in the analysis. Data on the type of amyloidosis, comorbidities, and echocardiogram were retrieved from medical records. Cohort was divided into two groups according to the Weber Classification: Weber Class A/B and Weber Class C/D. Individuals with CPET studies after heart transplant were excluded from the analysis. Statistical analyses including Fisher’s exact test, chi-square, Tukey-Kramer (TK), Cox regression model analysis, proportional hazards model for time to event, and Kaplan–Meier curves were performed. A p-value &lt;0.05 was considered significant. Results Out of the 194 patients, 94 were classified as Weber A-B and 100 as Weber B-C. The age at stress test was similar between the groups: Weber A/B 62.9 ± 11.7 years and Weber C/D 62.3 ± 10.7 years (p=0.087). Ejection Fraction was similar between groups, 32% and 28.9% in A-B and C-D respectively (p =0.207). Higher levels of NT-proBNP were found in the Weber C/D group. The prevalence of comorbidities was balanced among the groups except chronic kidney disease, which was higher in Weber Class C/D (40%) vs (20.2%) in Weber Class A/B (Table 1). Cox analysis revealed a strong association between higher Weber class and the outcome HR 2.36 (1.18 – 4.71) p=0.014. For Higher Ventilatory Class (Group III-IV) similar results were found HR 2.95 (1.60 – 5.45) p=0.005(Table 2). Mortality was significantly higher during the follow-up in the Weber C/D group (25%) vs (10%) in the Weber A-B group p=0.007(Figure D). Conclusion Weber and ventilatory Classification based on CPET, besides predicting outcomes in patients with cardiac disease, are strong predictors of mortality in patients with amyloidosis. These findings suggest that this patient group benefits from earlier stratification to assess prognosis and the potential requirement for transplant independently from other factors.

Abstract Background Cardiopulmonary exercise testing (CPET) is a widely used tool for risk stratification and prognosis in patients with chronic heart failure. In amyloid patients, cardiac amyloid deposits are associated with poor prognosis, increased risk for arrhythmias, sudden death, and subsequent exercise limitation due to restrictive cardiomyopathy. The type of amyloidosis and its affectation of the heart are different, and little is known about the CPET parameters according to the type of cardiac amyloidosis. Purpose In this study, we aim to compare CPET data in different types of amyloidosis to determine if CPET variables evaluated could have a significant difference that could impact the follow-up or prognosis of the patients based on the type of amyloidosis. Methods We conducted a retrospective cohort study of 194 patients with a diagnosis of cardiac amyloidosis referred for CPET from February 2010 to February 2024. Patients with at least one CPET data were included in our analysis. The type of amyloidosis, comorbidities, and echocardiogram data were retrieved from medical records. Patients were divided into 3 different groups according to the type of amyloidosis: AL Amyloidosis(AL), Variant TTR Amyloidosis (vTRR), and Wild Type TTR Amyloidosis (wtTTR). Individuals with CPET studies after heart transplant were excluded from the analysis. Fisher’s exact test or chi-square was used to compare categorical variables. ANOVA and Tukey-Kramer (TK) were used to compare continuous variables. Adjustment using General Linear Models (GLM) procedure was used to identify any confounder that could affect the results. A p-value &lt;0.05 was considered significant. Results Out of the 194 patients, 66 had AL Amyloidosis, 40 had vTTR Amyloidosis, and 88 had wtTTR Amyloidosis. Most of the patients were male, and the male predominance was higher in the wtTRR group. There were 41 (62.1%) males in the AL group, 35 (87.5%) in the vTRR group, and 83 (94.3%) in the wtTTR group (p&lt;0.0001). Comorbidities were balanced among the groups. Additional demographic and comorbidities data are shown in Table 1. From the evaluated CPET variables, VE/VCO2 nadir and slope were significantly higher in the wtTTR group when compared to the other groups, as well as Peak VE and Peak TV(Figure A). However, after adjusting for sex, BMI, and age, VE/VCO2 nadir was still significantly higher in the wtTRR group (p=0.003) compared to the other groups, as well as Peak VE, which was higher again in vTTR patients (p=0.001), and Peak TV (Table 2). Conclusion Ventilation variables evaluated in CPET showed alterations in the wtTTR group. These findings suggest that wtTRR amyloid patients could have a severe problem in ventilation that could be of significant relevance in future prognosis.

Introduction: Multiple Valvular Heart Disease (VHD), defined as at least moderate stenotic or regurgitant lesions in ≥2 valves, mixed VHD as combination of lesions in the same valve and mitral annular calcification (MAC) are common conditions. Association between multiple-mixed VHD (MMVHD), MAC and MACE in patients exposed to Radiation Therapy (RT) and/or chemotherapy (CT) who underwent Transcatheter Aortic Valve Replacement (TAVR) has not been studied. Aim: Assess the presence of MMVHD and MAC in cancer patients with prior RT and/or CT and their correlation with MACE (cardiovascular death, myocardial infarction, revascularization, stroke and hospitalization for heart failure) after TAVR. Methods: 544 patients were included and divided into 3 groups: 187 with prior chest RT and CT (RT/CT), 155 CT only, and 202 without CT/RT as controls (Table 1). Data was obtained from the pre-procedure echocardiogram and quantified in a 1-6 scale (none, mild, mild/moderate, moderate, moderate/severe and severe). Fisher’s exact test or chi-square were used to compare categorical. Multiple VHD-MACE correlation was evaluated through multivariable Cox analysis using a proportional hazards model. Results: The prevalence of Multiple VHD was 37.4% in RT/CT, 23.2% in CT, and 13.9% in controls p<0.001(Figure 1). The RT/CT group had a significantly higher prevalence of severe MAC. Multiple VHD predicted MACE at 18 months after TAVR in RT/CT (HR 3.42, CI 1.93-6.08, p<0.001) and in CT (HR 2.55, CI 1.39-4.66, p=0.002) (Table 2). In RT/CT, severe MAC also predicted MACE (HR 3.68, CI 2.13-6.37, p<0.001), while it was not a predictor in the other groups. Stenotic or regurgitant VHD was more prevalent in the RT/CT group (Figure 2). Conclusions: Multiple VHD was found higher in RT/CT and predicted MACE at 18 months post-TAVR, including CT only patients. Severe MAC was also a strong predictor of the outcome in RT/CT patients. Pre-TAVR evaluation of MMVHD lesions is crucial for optimal patient management.