Right vs. left ventricular longitudinal strain for mortality prediction after transcatheter aortic valve implantation

INTRODUCTION This study aims at exploring biventricular remodelling and its implications for outcome in a representative patient cohort with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS Pre-interventional echocardiographic examinations of 100 patients with severe AS undergoing TAVI were assessed by speckle tracking echocardiography of both ventricles. Association with mortality was determined for right ventricular global longitudinal strain (RVGLS), RV free wall strain (RVFWS) and left ventricular global longitudinal strain (LVGLS). During a median follow-up of 1,367 [959-2,123] days, 33 patients (33%) died. RVGLS was lower in non-survivors [-13.9% (-16.4 to -12.9)] than survivors [-17.1% (-20.2 to -15.2); P = 0.001]. In contrast, LVGLS as well as the conventional parameters LV ejection fraction (LVEF) and RV fractional area change (RVFAC) did not differ (P = ns). Kaplan-Meier analyses indicated a reduced survival probability when RVGLS was below the -14.6% cutpoint (P < 0.001). Lower RVGLS was associated with higher mortality [HR 1.13 (95% CI 1.04-1.23); P = 0.003] independent of LVGLS, LVEF, RVFAC, and EuroSCORE II. Addition of RVGLS clearly improved the fitness of bivariable and multivariable models including LVGLS, LVEF, RVFAC, and EuroSCORE II with potential incremental value for mortality prediction. In contrast, LVGLS, LVEF, and RVFAC were not associated with mortality. DISCUSSION In patients with severe AS undergoing TAVI, RVGLS but not LVGLS was reduced in non-survivors compared to survivors, differentiated non-survivors from survivors, was independently associated with mortality, and exhibited potential incremental value for outcome prediction. RVGLS appears to be more suitable than LVGLS for risk stratification in AS and timely valve replacement

Predicting mortality after transcatheter aortic valve replacement using preprocedural CT

Transcatheter aortic valve replacement (TAVR) is a widely used intervention for patients with severe aortic stenosis. Identifying high-risk patients is crucial due to potential postprocedural complications. Currently, this involves manual clinical assessment and time-consuming radiological assessment of preprocedural computed tomography (CT) images by an expert radiologist. In this study, we introduce a probabilistic model that predicts post-TAVR mortality automatically using unprocessed, preprocedural CT and 25 baseline patient characteristics. The model utilizes CT volumes by automatically localizing and extracting a region of interest around the aortic root and ascending aorta. It then extracts task-specific features with a 3D deep neural network and integrates them with patient characteristics to perform outcome prediction. As missing measurements or even missing CT images are common in TAVR planning, the proposed model is designed with a probabilistic structure to allow for marginalization over such missing information. Our model demonstrates an AUROC of 0.725 for predicting all-cause mortality during postprocedure follow-up on a cohort of 1449 TAVR patients. This performance is on par with what can be achieved with lengthy radiological assessments performed by experts. Thus, these findings underscore the potential of the proposed model in automatically analyzing CT volumes and integrating them with patient characteristics for predicting mortality after TAVR

3D Atrial Strain for Predicting Recurrence of Atrial Fibrillation after Pulmonary Vein Isolation

AIMS: Association of two-(2D) and three-dimensional (3D) left atrial strain (LAS) and low-voltage area (LVA) with recurrence of atrial fibrillation (AF) after pulmonary vein isolation (PVI) was assessed. METHODS AND RESULTS: 3D LAS, 2D LAS, and LVA were obtained in 93 consecutive patients undergoing PVI and recurrence of AF was analyzed prospectively. AF recurred in 12 patients (13%). The 3D left atrial reservoir strain (LARS) and pump strain (LAPS) were lower in patients with recurrent AF than without (p = 0.008 and p = 0.009, respectively). In univariable Cox regression, 3D LARS or LAPS were associated with recurrent AF (LARS: HR = 0.89 (0.81-0.99), p = 0.025; LAPS: HR = 1.40 (1.02-1.92), p = 0.040), while other values were not. Association of 3D LARS or LAPS with recurrent AF was independent of age, body mass index, arterial hypertension, left ventricular ejection fraction, and end-diastolic volume index and left atrial volume index in multivariable models. Kaplan-Meier curves revealed that patients with 3D LAPS -5.9% had a significant risk of recurrent AF. CONCLUSIONS: 3D LARS and LAPS were associated with recurrent AF after PVI. Association of 3D LAS was independent of relevant clinical and echocardiographic parameters and improved their predictive value. Hence, they may be applied for outcome prediction in patients undergoing PVI

A Novel Heterozygous Desmoplakin Variant Causes Cardiocutaneous Syndrome with Arrhythmogenic Cardiomyopathy and Palmoplantar Keratosis

Cardiocutaneous syndrome (CCS) is often caused by genetic variants in desmoplakin (DSP) in the presence of thick calluses on the hands and soles of the feet (palmoplantar keratoderma) in combination with arrhythmogenic cardiomyopathy. In this case report, we describe a 58-year-old man presenting with a history of cardiomyopathy with recurrent sustained ventricular tachycardia and palmoplantar keratosis. The cardiological evaluation showed biventricular cardiomyopathy, and repeated genetic testing identified a novel DSP variant. Repeated genetic testingis clinically meaningful in patients with a high probability of a specific inherited cardiac disease, such as CCS, particularly if molecular screening has been performed in the pre-NGS era with an incomplete NGS panel or outdated technology as presented in this case report

Left atrial pump strain predicts long-term survival after transcatheter aortic valve implantation

BACKGROUND This study aims at investigating left atrial (LA) deformation by left atrial reservoir (LARS) and pump strain (LAPS) and its implications for long-term survival in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). METHODS Speckle tracking echocardiography was performed in 198 patients with severe AS undergoing TAVI. Association of strain parameters with cardiovascular mortality was determined. RESULTS Over a follow-up time of 5 years, 49 patients (24.7%) died. LAPS was more impaired in non-survivors than survivors (P = 0.010), whereas no difference was found for LARS (P = 0.114), LA ejection fraction (P = 0.241), and LA volume index (P = 0.292). Kaplan-Meier analyses yielded a reduced survival probability according to the optimal threshold for LAPS (P = 0.002). A more impaired LAPS was associated with increased mortality risk (HR 1.12 [95% CI 1.02-1.22]; P = 0.014) independent of LVEF, LAVI, age, and sex. Addition of LAPS improved multivariable echocardiographic (LVEF, LAVI) and clinical (age, sex) models with potential incremental value for mortality prediction (P = 0.013 and P = 0.031, respectively). In contrast, LARS and LAVI were not associated with mortality. CONCLUSIONS In patients undergoing aortic valve replacement for severe AS, LAPS was impaired in patients dying during long-term follow-up after TAVI, differentiated survivors from non-survivors, was independently associated with long-term mortality, and yielded potential incremental value for survival prediction after TAVI. LAPS seems useful for risk stratification in severe AS and timely valve replacement

Left ventricular global work index and prediction of cardiovascular mortality after transcatheter aortic valve implantation

INTRODUCTION Echocardiography is used for assessment of patients after transcatheter aortic valve implantation (TAVI). Global work index (GWI) integrates LV deformation throughout the cardiac cycle and LV afterload and may be advantageous for long-term follow-up. METHODS We analysed 144 patients with severe aortic stenosis who underwent TAVI and echocardiography within two weeks afterwards. GE EchoPAC v2.6 was applied for determining LV ejection fraction, global longitudinal strain (GLS), stroke work (SW), cardiac power output (CPO), and GWI. The endpoint was cardiovascular mortality. RESULTS During median follow-up of 625 [IQR: 511-770] days, 20 (14%) patients died. Clinical baseline characteristics were comparable between non-survivors and survivors. GWI (p = 0.003) and LVEF (p = 0.039) were lower in non-survivors, while GLS, SW, and CPO were not different. In Kaplan-Meier analysis patients with GWI ≤1234 mmHg% exhibited a lower survival probability (P = 0.006). In univariable Cox regression, a significant mortality association was identified for GWI (P = 0.004), weaker for LVEF (P = 0.014), but not for the other parameters. In multivariable Cox regression, GWI independently improved an LV systolic function model including LVEF and GLS. Similarly, GWI but not LVEF independently improved outcome association of different clinical models. CONCLUSIONS GWI was lower in non-survivors than survivors, differentiated non-survivors from survivors, was associated with mortality independent of clinical or LV parameters, and improved the fitness of clinical or LV prediction models. In contrast, GLS, SW, and CPO did not show any of these properties. GWI provides added value for follow-up after TAVI possibly by integrating LV deformation throughout the cardiac cycle

Right vs. left ventricular longitudinal strain for mortality prediction after transcatheter aortic valve implantation

IntroductionThis study aims at exploring biventricular remodelling and its implications for outcome in a representative patient cohort with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI).Methods and resultsPre-interventional echocardiographic examinations of 100 patients with severe AS undergoing TAVI were assessed by speckle tracking echocardiography of both ventricles. Association with mortality was determined for right ventricular global longitudinal strain (RVGLS), RV free wall strain (RVFWS) and left ventricular global longitudinal strain (LVGLS). During a median follow-up of 1,367 [959–2,123] days, 33 patients (33%) died. RVGLS was lower in non-survivors [−13.9% (−16.4 to −12.9)] than survivors [−17.1% (−20.2 to −15.2); P = 0.001]. In contrast, LVGLS as well as the conventional parameters LV ejection fraction (LVEF) and RV fractional area change (RVFAC) did not differ (P = ns). Kaplan–Meier analyses indicated a reduced survival probability when RVGLS was below the −14.6% cutpoint (P &lt; 0.001). Lower RVGLS was associated with higher mortality [HR 1.13 (95% CI 1.04–1.23); P = 0.003] independent of LVGLS, LVEF, RVFAC, and EuroSCORE II. Addition of RVGLS clearly improved the fitness of bivariable and multivariable models including LVGLS, LVEF, RVFAC, and EuroSCORE II with potential incremental value for mortality prediction. In contrast, LVGLS, LVEF, and RVFAC were not associated with mortality.DiscussionIn patients with severe AS undergoing TAVI, RVGLS but not LVGLS was reduced in non-survivors compared to survivors, differentiated non-survivors from survivors, was independently associated with mortality, and exhibited potential incremental value for outcome prediction. RVGLS appears to be more suitable than LVGLS for risk stratification in AS and timely valve replacement

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10&nbsp;years; 78.2% included were male with a median age of 37&nbsp;years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020