Doxorubicin treatments induce significant changes on the cardiac autonomic nervous system in childhood acute lymphoblastic leukemia long-term survivors Abstract Aims Acute lymphoblastic leukemia (ALL) is one of the leading malignancies in children worldwide. The cardiotoxicity of anti-cancer treatments leads to a dysfunction of the cardiac autonomic nervous system. Protection strategies, with dexrazoxane treatments, were used to counter these adverse effects. The aim of this study was to investigate the effects of the treatments on the cardiac autonomic nervous system. Methods and results A total of 203 cALL survivors were included in our analyses and were classified into 3 categories based on the prognostic risk group: standard risk, high risk with and without dexrazoxane. A 24-h Holter monitoring was performed to study the cardiac autonomic nervous system. The frequency domain heart rate variability (HRV) was used to validate the cardiac autonomic nervous system modifications. Other analyses were performed using linear HRV indexes in the time domain and non-linear indexes. A frequency domain HRV parameters analysis revealed significant differences on an overall time-period of 24 h. A repeated measures ANOVA indicated a group-effect for the low frequency (p = 0.029), high frequency (p = 0.03) and LF/HF ratio (p = 0.029). Significant differences in the time domain and in the non-linear power spectral density HRV parameters were also observed. Conclusion Anti-cancer treatments induced significant changes in the cardiac autonomic nervous system. The HRV was sensitive enough to detect cardiac autonomic nervous system alterations depending on the cALL risk category. Protection strategies (i.e., dexrazoxane treatments), which were used to counter the adverse effects of doxorubicin, could prevent changes observed in the cardiac autonomic nervous system.

Atrial high rate episodes in patients with cardiac implantable electronic devices: implications for clinical outcomes Abstract Background Atrial high rate episodes (AHREs) detected by cardiac implantable electronic devices (CIEDs) are associated with an increased risk of stroke. However, the impact of AHRE on improving stroke risk stratification scheme remains uncertain. Objective The purpose of this study was to assess the impact of AHRE on prognosis in relation with cardiovascular events and risk stratification. Methods A total of 856 consecutive patients who had dual-chamber CIEDs implanted were retrospectively analyzed. To detect AHREs, they were monitored for 6 months after CIEDs’ implantation and were followed for a mean of 4.0 years for clinical outcomes such as thromboembolism or death. Results Overall, 125 (14.6%) of patients developed AHREs within the first 6 months (median age 72.0 years, 39.3% female). Patients with AHREs had a high rate of thromboembolism (2.6%/year) and mortality (3.0%/year). On multivariate analysis, AHRE was significantly associated with increased risk of thromboembolism [hazard ratio (HR) 3.40; 95% confidence interval (CI) 1.38–8.37, P = 0.01] and death (HR 3.47; 95% CI 1.51–7.95; P < 0.01). The predictive abilities of the CHADS2 and CHA2DS2-VASc scores were modest, with no significant improvements by adding AHRE to those scores. However, the integrated discrimination improvement and net reclassification improvement showed that the addition of AHRE to the CHADS2 and CHA2DS2-VASc scores statistically improved their predictive ability for the composite outcome. Conclusions AHRE was an independent factor associated with increased risk of clinical outcomes. The addition of AHRE to the clinical risk scores significantly improved discrimination for thromboembolism or death.

Uptake in antithrombotic treatment and its association with stroke incidence in atrial fibrillation: insights from a large German claims database Abstract Background Underuse of oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF) results in thousands of preventable strokes in Germany each year. This study aimed to assess changes in antithrombotic therapy in AF patients after increased use of direct oral anticoagulants (DOACs) in Germany and to evaluate whether the adoption of DOAC therapy was associated with changes in AF-related stroke and bleeding over time. Methods Analyses were carried out on a large claims-based dataset of 4 million health-insured Germans. The study population consisted of 601,261 prevalent AF patients between 2011 and 2016 who were assigned to one of the following four treatment groups: DOAC, VKA, antiplatelets or no antithrombotic treatment. Treatment patterns were descriptively analysed and represented by cohort and CHA2DS2-VASc score. Clinical outcomes before and after the adoption of DOAC therapy were assessed using Poisson regression models. Results Use of OAC increased from 42 to 61% between 2011 and 2016, mainly due to more frequent prescription of DOACs. However, some underuse of OAC therapy remained even in high risk AF patients. In parallel with the increased prescription rate of OAC, there was an overall 24% incidence reduction in stroke between 2011 and 2016 which was mainly driven by reductions in ischemic strokes. Over the same time period the risk for major bleeding remained unchanged. Conclusion Between 2011 and 2016, the use of guideline-conform antithrombotic therapy in Germany has significantly increased. This was associated with a significant decline in strokes without an increased incidence of bleeding complications.

Non-cardiac comorbidities and mortality in patients with heart failure with reduced vs. preserved ejection fraction: a study using the Swedish Heart Failure Registry Abstract Background Heart failure (HF) and non-cardiac comorbidities often coexist and are known to have an adverse effect on outcome. However, the prevalence and prognostic impact of non-cardiac comorbidities in patients with HF with reduced ejection fraction (HFrEF) vs. those with preserved (HFpEF) remain inadequately studied. Methods and results We used data from the Swedish Heart Failure Registry from 2000 to 2012. HFrEF was defined as EF < 50% and HFpEF as EF ≥ 50%. Of 31 344 patients available for analysis, 79.3% (n = 24 856) had HFrEF and 20.7% (n = 6 488) HFpEF. The outcome was all-cause mortality. We examined the association between ten non-cardiac comorbidities and mortality and its interaction with EF using adjusted hazard ratio (HR). Stroke, anemia, gout and cancer had a similar impact on mortality in both phenotypes, whereas diabetes (HR 1.57, 95% confidence interval [CI] [1.50–1.65] vs. HR 1.39 95% CI [1.27–1.51], p = 0.0002), renal failure (HR 1.65, 95% CI [1.57–1.73] vs. HR 1.44, 95% CI [1.32–1.57], p = 0.003) and liver disease (HR 2.13, 95% CI [1.83–2.47] vs. HR 1.42, 95% CI [1.09–1.85] p = 0.02) had a higher impact in the HFrEF patients. Moreover, pulmonary disease (HR 1.46, 95% CI [1.40–1.53] vs. HR 1.66 95% CI [1.54–1.80], p = 0.007) was more prominent in the HFpEF patients. Sleep apnea was not associated with worse prognosis in either group. No significant variation was found in the impact over the 12-year study period. Conclusions Non-cardiac comorbidities contribute significantly but differently to mortality, both in HFrEF and HFpEF. No significant variation was found in the impact over the 12-year study period. These results emphasize the importance of including the management of comorbidities as a part of a standardized heart failure care in both HF phenotypes.

Cardiac surgery 2018 reviewed Abstract For the year 2018, more than 22,000 published references can be found in PubMed when entering the search term “cardiac surgery”. As in the last 4 years, this review focusses on conventional cardiac surgery publications which provide important and interesting information especially relevant for non-surgical colleagues. Interventional techniques have been considered if they were published in the context of classic surgical techniques. We have again reviewed the fields of coronary revascularization and valve surgery and briefly touched on aortic surgery and surgery for terminal heart failure. For revascularization of complex coronary artery disease, bypass grafting was reconfirmed as gold standard and computer-tomographic angiography established equipoise for decision-making with classic angiography. For aortic valve treatment, some new longer-term outcomes from TAVI vs. SAVR trials confirmed equipoise of both treatments for high and medium risk. New information was provided for INR-management of mechanical aortic valves as well as long-term experiences for alternatives to mechanical valves (i.e., Ross and the relatively new Ozaki procedure). In the mitral and tricuspid field, prevalence data illustrate a significant amount of under-treatment for mitral and tricuspid valve regurgitation and evidence for life prolonging-effects of surgery. Finally, elongation of the ascending aorta was identified as new risk factor for aortic dissection and 2 years outcome of the newest generation of left ventricular assist devices demonstrate impressive improvements in outcome. While this article attempts to summarize the most pertinent publications, it does not expect to be complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader “solid ground” for up-to-date decision-making in cardiac surgery and a stimulus for in-depth reading.

Left atrial anterior line ablation using ablation index and inter-lesion distance measurement Abstract Background Ablation index (AI) is a novel ablation quality marker that incorporates contact force (CF), time and power in a weighted formula to provide accurate information about lesion formation during catheter ablation. This index has been evaluated for pulmonary vein isolation (PVI) but has not been systematically used for other left atrial (LA) procedures so far. The aim of this study is to evaluate the feasibility and efficacy of this index for LA anterior line (AL) ablation (LAALA). Methods 30 consecutive patients with persistent atrial fibrillation or LA macro-reentrant tachycardia and large low-voltage area at the left atrial anterior wall were evaluated and divided into 2 groups: group 1 (15 pts) LAALA guided by CF; group 2 (15 pts) LAALA guided by AI target (500) and inter-lesion distance ≤ 6 mm. Results In group 2, shorter ablation time (12.5 ± 3.8 vs 17 ± 7 min, p = 0.049), overall RF application time (7.9 ± 1.4 vs 10.8 ± 3.2 min. p = 0.01) and less radiofrequency (RF) applications (14.5 ± 2.3 vs 20.5 ± 6.1 p = 0.01) were necessary to achieve AL bi-directional block. Acute reconnection of the AL was documented in three patients (20%) of group 1 and in no patient of group 2 (20% vs 0% p = 0.22). At site of reconnection, an inter-lesion distance > 6 mm was always found. There was no difference in terms of CF and power between group 2 and group 1. AI was statistically different between group 2 and group 1 (AI = 511 ± 77 vs 451 ± 111; p = 0.004). Conclusion AI-guided LAALA in this study was feasible and featured by shorter ablation time, shorter overall RF application time and a reduced number of RF applications to achieve AL bidirectional block.

Impact of single-visit American versus European office blood pressure measurement procedure on individual blood pressure classification: a cross-sectional study Abstract Objectives Recently, ACC/AHA and ESC/ESH guidelines defined different office blood pressure measurement (OBPM) procedures and ranges. We aimed to describe the effect of the different methods to calculate OBPM on BP classification. Methods and results Four standardised OBPM were performed in 802 patients within a single visit. BP values were calculated (EUR-/US-BPM) and categorised (EUR-/US-Ranges) according to ACC/AHA and ESC/ESH guidelines. Comparing the BPM procedures, the mean absolute difference of systolic and diastolic BP was 4 (SD ± 5) and 3 (SD ± 3) and a difference ≥ 5 mmHg was found in 35% and 16%, respectively. There was an increase of grade 1/2 arterial hypertension of 87% and 120% comparing BP values categorised according to US-Ranges with EUR-Ranges after applying EUR- or US-BPM to all (p < 0.0001), of 25% and 6% comparing BP values calculated according to US-BPM with EUR-BPM applying EUR- or US-Ranges to all (p = 0.006 and p = 0.17), and of 134% comparing US-Ranges/US-BPM with EUR-Ranges/EUR-BPM (p < 0.0001), respectively. Overall, 16% were reclassified to higher categories when applying US-BPM, and 42–45% of patients classified as “high normal” applying EUR-BPM procedures were reclassified when applying US-BPM procedure, 76–77% of them to “hypertensive” categories. Conclusion Besides the effect of the redefinition of BP categories by ACC/AHA, the calculation method of US-BPM compared to EUR-BPM leads to a further relevant increase of patients classified as “hypertensive”. In addition to the definition of uniform outcome-oriented target BP values, there is an urgent need for a universal definition of an OBPM procedure as prerequisite for proper BP classification and patient management.

Relation of lowering door-to-balloon time and mortality in ST segment elevation myocardial infarction patients undergoing percutaneous coronary intervention Abstract Background Current guidelines for the treatment of ST-segment elevation myocardial infarction (STEMI) recommend a door-to-balloon time (DBT) of ≤ 90 min for patients undergoing primary percutaneous coronary intervention (PCI). We aimed to investigate the possible impact of further reduction in DBT intervals beyond the 90 min cutoff on short and long-term outcomes among STEMI patients undergoing primary PCI. Methods We retrospectively studied 889 STEMI patients (median age 61 years, 83% men) who underwent successful primary PCI and had a DBT of ≤ 90 min. Patients were stratified according to DBT into 2 groups: < 60 min and 60–90 min. Patients records were assessed for the occurrence of in-hospital complications, 30-day and 1-year mortality. Results Patients having DBT < 60 min (n = 608, 68%) were more likely to present earlier, in daytime and weekdays, and had better post-procedural left ventricular ejection fraction and lower 30-day mortality (3% vs. 6%, p = 0.03). Mortality over 1-year was significantly lower among patients having DBT < 60 compared to DBT of 60–90 min (4.6% vs. 9.6%, p = 0.004). In a binary logistic regression model DBT < 60 min was associated with 51% risk reduction for 1-year mortality (OR 0.49, 95% CI 0.25–0.93, p = 0.03). Conclusions Among STEMI patients undergoing primary PCI within 90 min of admission DBT < 60 min was independently associated with better 1-year mortality.

Role of percutaneous edge-to-edge repair in secondary mitral regurgitation after MITRA-FR and COAPT

Haemodynamic prosthetic valve performance in patients with early leaflet thrombosis after transcatheter aortic valve implantation Abstract Aims We sought to evaluate haemodynamic prosthetic valve performance in patients with early leaflet thrombosis (LT) after transcatheter aortic valve implantation (TAVI). Method and Results In this retrospective observational study, 59 patients with LT underwent clinical and echocardiographic follow-up. During a median follow-up of 383 days 41 patients received antiplatelet therapy (APT-group) and 18 patients oral anticoagulation due to atrial fibrillation (AC-group). The mean pressure gradient (MPG) at baseline did not differ between groups (P = 0.875). During follow-up, MPG increased from 11.0 (9.0; 14.5) to 13.0 mmHg (10.0; 18.0)_ in the APT-group (P = 0.010) but remained unchanged in the AC-group (P = 0.297) resulting in a significantly higher MPG in patients on antiplatelet therapy (P = 0.024). Similarly, change of MPG per year was significantly higher in the APT-group [1.4 (− 0.9; 7.0) vs. − 0.6 (− 2.5; 1.1), P = 0.014]. Seven (17.1%) patients in the APT-group and two(11.1%) patients in the AC-group developed MPGs of at least 20 mmHg (P = 0.558). Three patients (7.3%) in the APT- and none in the AC-group developed symptoms of obstructive thrombosis (P = 0.239). In our adjusted analysis, only lack of anticoagulation was significantly associated with change in gradients during follow-up (P = 0.012). Conclusions In patients with LT, antiplatelet-, but not anticoagulant therapy, was associated with significant increases in MPG, which may lead to symptomatic obstructive valve thrombosis.