Interaction between sex and left ventricular reverse remodeling and its association with outcomes after transcatheter aortic valve implantation

Women with severe aortic stenosis (AS) have better long-term prognosis after transcatheter aortic valve implantation (TAVI) compared to men. Whether this is caused by sex-related differences in left ventricular (LV) reverse remodeling after TAVI is unknown. Patients with severe AS who underwent transfemoral TAVI between 2007 and 2018 were selected. LV dimensions, volumes, and ejection fraction (LVEF) were assessed by transthoracic echocardiography before TAVI and at 6 and 12 months follow-up after TAVI. LV reverse remodeling was defined as the percentual LV mass index (LVMi) reduction compared to baseline. The primary outcome was all-cause mortality. A total of 459 patients (80 ± 8 years; 52% male) were included. At 6 and 12 months follow-up, both sexes showed significant reductions in LV volumes and LVMi accompanied by improvement in LVEF, without significant differences between the sexes over time. During a median follow-up of 2.8 [IQR 1.9-4.3] years, 181 (39%) patients died. Women showed better outcomes compared to men (log-rank p = 0.024). In addition, male sex was independently associated with all-cause mortality in multivariable Cox regression (HR 1.423, 95% CI 1.039-1.951, p = 0.028). No association was observed between the interaction of percentual LVMi reduction and sex with outcomes (p = 0.64). Men and women with severe AS had similar improvement in LVEF, and similar reductions in LV volumes and LVMi at 6 and 12 months after TAVI. Women showed better survival after TAVI as compared to men. The superior outcomes noted in women after TAVI are not associated with sex differences in LV reverse remodeling.[GRAPHICS].</p

Vessel and sex differences in pericoronary adipose tissue attenuation obtained with coronary CT in individuals without coronary atherosclerosis

Pericoronary adipose tissue (PCAT) attenuation, derived from coronary computed tomography angiography (CCTA), is associated with coronary artery inflammation. Values for PCAT attenuation in men and women without atherosclerosis on CCTA are lacking. The aim of the current study was to assess the mean PCAT attenuation in individuals without coronary artery atherosclerosis on CCTA. Data on PCAT attenuation in men and women without coronary artery atherosclerosis on CCTA were included in this retrospective analysis. The PCAT attenuation was analyzed from the proximal part of the right coronary artery (RCA), the left anterior descending artery (LAD), and the left circumflex artery (LCx). For patient level analyses the mean PCAT attenuation was defined as the mean of the three coronary arteries. In 109 individuals (mean age 45 +/- 13 years; 44% men), 320 coronary arteries were analyzed. The mean PCAT attenuation of the overall population was - 64.4 +/- 8.0 HU. The mean PCAT attenuation was significantly lower in the LAD compared with the LCx and RCA (- 67.8 +/- 7.8 HU vs - 62.6 +/- 6.8 HU vs - 63.6 +/- 7.9 HU, respectively, p </p

Subclinical leaflet thrombosis after transcatheter aortic valve implantation: no association with left ventricular reverse remodeling at 1-year follow-up

Hypo-attenuated leaflet thickening (HALT) of transcatheter aortic valves is detected on multidetector computed tomography (MDCT) and reflects leaflet thrombosis. Whether HALT affects left ventricular (LV) reverse remodeling, a favorable effect of LV afterload reduction after transcatheter aortic valve implantation (TAVI) is unknown. The aim of this study was to examine the association of HALT after TAVI with LV reverse remodeling. In this multicenter case-control study, patients with HALT on MDCT were identified, and patients without HALT were propensity matched for valve type and size, LV ejection fraction (LVEF), sex, age and time of scan. LV dimensions and function were assessed by transthoracic echocardiography before and 12 months after TAVI. Clinical outcomes (stroke or transient ischemic attack, heart failure hospitalization, new-onset atrial fibrillation, all-cause mortality) were recorded. 106 patients (age 81 +/- 7 years, 55% male) with MDCT performed 37 days [IQR 32-52] after TAVI were analyzed (53 patients with HALT and 53 matched controls). Before TAVI, all echocardiographic parameters were similar between the groups. At 12 months follow-up, patients with and without HALT showed a significant reduction in LV end-diastolic volume, LV end-systolic volume and LV mass index (from 125 +/- 37 to 105 +/- 46 g/m(2), p = 0.001 and from 127 +/- 35 to 101 +/- 27 g/m2, p < 0.001, respectively, p for interaction = 0.48). Moreover, LVEF improved significantly in both groups. In addition, clinical outcomes were not statistically different. Improvement in LVEF and LV reverse remodeling at 12 months after TAVI were not limited by HALT.</p

Coronary computed tomography angiography-based endothelial wall shear stress in normal coronary arteries

Endothelial wall shear stress (ESS) is a biomechanical force which plays a role in the formation and evolution of atherosclerotic lesions. The purpose of this study is to evaluate coronary computed tomography angiography (CCTA)-based ESS in coronary arteries without atherosclerosis, and to assess factors affecting ESS values. CCTA images from patients with suspected coronary artery disease were analyzed to identify coronary arteries without atherosclerosis. Minimal and maximal ESS values were calculated for 3-mm segments. Factors potentially affecting ESS values were examined, including sex, lumen diameter and distance from the ostium. Segments were categorized according to lumen diameter tertiles into small (= 3.2 mm) segments. A total of 349 normal vessels from 168 patients (mean age 59 +/- 9 years, 39% men) were included. ESS was highest in the left anterior descending artery compared to the left circumflex artery and right coronary artery (minimal ESS 2.3 Pa vs. 1.9 Pa vs. 1.6 Pa, p < 0.001 and maximal ESS 3.7 Pa vs. 3.0 Pa vs. 2.5 Pa, p < 0.001). Men had lower ESS values than women, also after adjusting for lumen diameter (p < 0.001). ESS values were highest in small segments compared to intermediate or large segments (minimal ESS 3.8 Pa vs. 1.7 Pa vs. 1.2 Pa, p < 0.001 and maximal ESS 6.0 Pa vs. 2.6 Pa vs. 2.0 Pa, p < 0.001). A weak to strong correlation was found between ESS and distance from the ostium (rho = 0.22-0.62, p < 0.001). CCTA-based ESS values increase rapidly and become widely scattered with decreasing lumen diameter. This needs to be taken into account when assessing the added value of ESS beyond lumen diameter in highly stenotic lesions

Coronary volume to left ventricular mass ratio in patients with diabetes mellitus

BackgroundDiabetes mellitus is a major risk factor for coronary artery disease (CAD) and may provoke structural and functional changes in coronary vasculature. The coronary volume to left ventricular mass (V/M) ratio is a new anatomical parameter capable of revealing a potential physiological imbalance between coronary vasculature and myocardial mass. The aim of this study was to examine the V/M derived from coronary computed tomography angiography (CCTA) in patients with diabetes.MethodsPatients with clinically suspected CAD enrolled in the ADVANCE (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care) registry and known diabetic status were included. Coronary artery volume and left ventricular myocardial mass were analyzed from CCTA and the V/M ratio was calculated and compared between patients with and without diabetes.ResultsOf the 3053 patients (age 66 ​± ​10 years; 66% male) with known diabetic status, diabetes was present in 21.9%. Coronary volume was lower in patients with diabetes compared to those without diabetes (2850 ​± ​940 ​mm3 vs. 3040 ​± ​970 ​mm3, p ​ConclusionThe V/M ratio was significantly lower in patients with diabetes compared to non-diabetics, even after correcting for obstructive coronary stenosis. The clinical value of the reduced V/M ratio in diabetic patients needs further investigation.</p

The Quantity of Epicardial Adipose Tissue in Patients Having Ablation for Atrial Fibrillation With and Without Heart Failure

The distribution of epicardial adipose tissue (EAT) across the spectrum of heart failure (HF) has yet to be fully elucidated. The present study investigated the distribution of EAT in an HF spectrum and its association with clinical and echocardiographic parameters. A total of 326 patients who underwent contrast-enhanced computed tomography before transcatheter atrial fibrillation ablation with and without HF symptoms, and a wide range of left ventricular (LV) ejection fractions (LVEF) were included. EAT mass was quantified on contrast-enhanced computed tomography using dedicated software. A total of 36 patients had HF with reduced LVEF (HFrEF) (11.0%), 46 had HF with mid-range LVEF (HFmrEF) (14.1%), 53 had HFpEF (16.3%), and 191 did not have HF symptoms (58.6%) and were considered controls. Patients with HFpEF had the largest EAT mass, significantly higher than the control group (128 ± 36 g vs 95 ± 35 g, p </p

Prognostic Implications of Change in Left Ventricular Ejection Fraction After Transcatheter Aortic Valve Implantation

Reduced left ventricular (LV) systolic function is associated with worse prognosis in patients with severe aortic stenosis (AS) treated with transcatheter aortic valve implantation (TAVI). We aimed to examine the changes in left ventricular ejection fraction (LVEF) after TAVI among patients with varying baseline LVEF. Moreover, variables associated with lack of LVEF improvement were identified and the association with long-term outcomes was investigated. A total of 560 patients (age 80 ± 7 years, 53% men) with severe AS who underwent transfemoral TAVI between 2007 and 2019 were selected. LVEF was assessed from transthoracic echocardiography at baseline (before TAVI) and at 6 and 12 months after TAVI. Patients were stratified according to baseline LVEF: (1) LVEF ≥50%, (2) LVEF 40% to 49%, and (3) LVEF <40%. The clinical end point was ≥5% LVEF improvement. The primary outcome was all-cause mortality. Patients with baseline LVEF<40% showed greater increase in LVEF than those with baseline LVEF 40% to 49% and LVEF ≥50% (from 33% ± 6% to 43% ± 10%, p <0.001; from 45% ± 3% to 52% ± 8%, p <0.001; and from 58% ± 5% to 59% ± 7%, p = 0.012, respectively, p for interaction <0.001). Coronary artery disease (odds ratio [OR] 1.80 [95% confidence interval (CI) 1.06 to 3.06], p = 0.031), myocardial infarction (OR 2.07 [95% CI 1.19 to 3.61], p = 0.010), and permanent pacemaker (OR: 1.93 [95% CI 1.25 to 3.00], p = 0.003) were independently associated with the lack of ≥5% LVEF improvement. During a median follow-up of 3.8 (interquartile range 2.6 to 5.2) years, 176 patients died (31%). Patients with ≥5% LVEF improvement had similar outcomes compared with those with <5% LVEF improvement (log-rank p = 0.89). In conclusion, patients with severe AS and baseline LVEF <40% had the greatest improvement in LVEF at 1-year follow-up after TAVI. Coronary artery disease, myocardial infarction, and permanent pacemaker were associated with lack of LVEF improvement. However, LVEF improvement at 12 months was not associated with long-term outcomes.</p

Managing Patients With Moderate Aortic Stenosis

Current guidelines recommend that clinical surveillance for patients with moderate aortic stenosis (AS) and aortic valve replacement (AVR) may be considered if there is an indication for coronary revascularization. Recent observational studies, however, have shown that moderate AS is associated with an increased risk of cardiovascular events and mortality. Whether the increased risk of adverse events is caused by associated comorbidities, or to the underlying moderate AS itself, is incompletely understood. Similarly, which patients with moderate AS need close follow-up or could potentially benefit from early AVR is also unknown. In this review, the authors provide a comprehensive overview of the current published reports on moderate AS. They first provide an algorithm that helps to diagnose moderate AS correctly, especially when discordant grading is observed. Although the traditional focus of AS assessment has been on the valve, it is increasingly acknowledged that AS is not only a disease of the aortic valve but also of the ventricle. The authors therefore discuss how multimodality imaging can help to evaluate the left ventricular remodeling response and improve risk stratification in patients with moderate AS. Finally, they summarize current evidence on the management of moderate AS and highlight ongoing trials on AVR in moderate AS