S. Ramkumar

Association of the Active and Passive Components of Left Atrial Deformation with Left Ventricular Function

Background: Left atrial (LA) strain imaging enables the quantitative assessment of LA function. The clinical relevance of these measurements is dependent on the provision of information incremental to the left ventricular (LV) evaluation. The aim of this study was to test the hypothesis that LA pump function but not reservoir function is independent of measurement of LV mechanics. Methods: Echocardiography was undertaken in a community‐based study of 576 participants ≥65 years of age with one or more risk factors (e.g., hypertension, diabetes mellitus, obesity). Strain analysis was conducted using a dedicated software package, using R‐R gating. LV function was classified as normal in the presence of global longitudinal strain (GLS) (≤−18%) or global circumferential strain (GCS) (≤−22%). The associations between GLS or GCS and LA reservoir, conduit, and pump strain were assessed using univariate and multivariate linear regression. Results: Patients (mean age 71 ± 5 years, 54% women) with reduced GLS had higher blood pressure and rates of diabetes and obesity (P < .05). LA reservoir strain and conduit strain were lower in the group with impaired GLS (38.2 ± 7.3% vs 39.9 ± 6.4% [P = .004] and 18.7 ± 5.7% vs 20.5 ± 5.1% [P < .001], respectively), but there was no difference in LA pump strain (19.5 ± 5.5% vs 19.3 ± 4.6%, P = .72). GLS was independently associated with LA reservoir and conduit strain (P < .05) but not independently associated with LA pump strain (P = .91). Reduced GCS was associated with a larger body mass index, male sex, and diabetes (P < .05). There were no differences in LA reservoir, conduit, and pump strain in patients with normal and abnormal GCS (P > .05). Conclusions: The application of LA strain is specific to the component measured. LA pump strain is independent of LV mechanics. HighlightsLeft atrial strain analysis provides quantitative assessment of left atrial function.There is currently a lack of guidelines on image acquisition, electrocardiographic gating, and analysis methods.It is unclear if left atrial strain provides incremental information to left ventricular strain.This study compares the relationship between the three components of left atrial strain with left ventricular function to assess if left atrial function is primarily determined by left ventricular function.

Safety and efficacy of valve repositioning during transcatheter aortic valve replacement with the Lotus Valve System.

OBJECTIVE To determine the safety and efficacy of valve repositioning following transcatheter aortic valve replacement (TAVR) with the Lotus Valve System (Boston Scientific, Marlborough, MA, USA). INTRODUCTION TAVR is a well-established treatment for severe aortic stenosis. The Lotus Valve System is fully repositionable and retrievable. Valve repositioning has the potential to minimize TAVR-related complications caused by valve malposition; however, the effect on adverse event rates such as stroke is unknown. METHODS Consecutive patients with severe aortic stenosis treated with the Lotus Valve System (n=125) were prospectively recruited. Patients who did not require valve repositioning (Group A) were compared to patients who required one or more valve repositions (Group B). The primary end-point was 30-day occurrence of major adverse cardiovascular and cerebrovascular events (MACCE). Secondary end-points included each component of the primary end-point, new pacemaker insertion, and procedural or 30-day major adverse events, defined according to VARC-2 definitions. RESULTS Valve repositioning was utilized in 60.8% (76/125) of patients including 17.1% (13/76) who required full valve resheathing. The most frequent indications for valve repositioning were altering the depth and angulation of initial implantation (69.7%), reducing paravalvular regurgitation (13.2%), and attempt to correct new or worsened heart block (7.9%). Baseline characteristics were similar in both groups. The primary end-point occurred in 12.2% and 6.6% of Group A and B, respectively (p=0.10). Thirty-day new pacemaker implantation was 34.1% and 18.8% in Group A and B, respectively (p=0.06). The secondary end-point measures were not significantly different between the groups. CONCLUSION Repositioning facilitated correct anatomical positioning of all devices leading to optimal prosthesis hemodynamics and a trend to lower pacemaker rate without increased risk of MACCE.

Guideline-Based intervention to reduce telemetry rates in a large tertiary centre

Inappropriate cardiac telemetry use is associated with reduced patient flow and increased healthcare costs.

Retrospective Cohort Study Examining Reduced Intensity and Duration of Anticoagulant and Antiplatelet Therapy Following Left Atrial Appendage Occlusion with the WATCHMAN Device.

BACKGROUND Anticoagulant and antiplatelet therapy are recommended following WATCHMAN implantation (45 days and 6 months) to reduce the risk of embolic events. These patients are often also at high risk of recurrent bleeding complications. We aimed to assess the safety of reduced duration of treatment with anticoagulant and antiplatelet therapy in the early post implant period. METHODS This was a retrospective cohort study assessing the duration of antiplatelet and anticoagulant therapy in 47 consecutive patients following WATCHMAN implant. The primary outcome was rate of major bleeding, stroke and systemic embolic complications. The secondary endpoints were rate of device thrombus and peri-device leak >4mm as assessed by transoesophogeal echocardiography. RESULTS Forty-seven patients were followed up for a mean of 2.4+/-1.7 years (111.4 total patient-years). The rate of stroke was 1.8/100 patient-years (two events) and the rate of major bleeding complication was 8.9/100 patient-years. Three patients had peri-device leak >4mm and no patients had device thrombus visualised. 70.2% of patients had discontinued anticoagulation at 45 days, 89.4% had discontinued dual antiplatelet therapy at 90 days. Seven patients were not on any form of anticoagulant or antiplatelet at five months. Comparison of probability of survival free from stroke by time of cessation of anticoagulant and antiplatelet therapy demonstrated no significant differences (p-value for log rank test 0.238 and 0.820). CONCLUSION Following WATCHMAN implant shortened periods of anticoagulants and antiplatelets may be considered, particularly in the context of high bleeding risk.

Atrial fibrillation detection using single lead portable electrocardiographic monitoring: a systematic review and meta-analysis

Objectives Recent technology advances have allowed for heart rhythm monitoring using single-lead ECG monitoring devices, which can be used for early diagnosis of atrial fibrillation (AF). We sought to investigate the AF detection rate using portable ECG devices compared with Holter monitoring. Setting, participants and outcome measures We searched the Medline, Embase and Scopus databases (conducted on 8 May 2017) using search terms related to AF screening and included studies with adults aged >18 years using portable ECG devices or Holter monitoring for AF detection. We excluded studies using implantable loop recorders and pacemakers. Using a random-effects model we calculated the overall AF detection rate. Meta-regression analysis was performed to explore potential sources for heterogeneity. Quality of reporting was assessed using the tool developed by Downs and Black. Results Portable ECG monitoring was used in 18 studies (n=117 436) and Holter monitoring was used in 36 studies (n=8498). The AF detection rate using portable ECG monitoring was 1.7% (95% CI 1.4 to 2.1), with significant heterogeneity between studies (p<0.001). There was a moderate linear relationship between total monitoring time and AF detection rate (r=0.65, p=0.003), and meta-regression identified total monitoring time (p=0.005) and body mass index (p=0.01) as potential contributors to heterogeneity. The detection rate (4.8%, 95% CI 3.6% to 6.0%) in eight studies (n=10 199), which performed multiple ECG recordings was comparable to that with 24 hours Holter (4.6%, 95% CI 3.5% to 5.7%). Intermittent recordings for 19 min total produced similar AF detection to 24 hours Holter monitoring. Conclusion Portable ECG devices may offer an efficient screening option for AF compared with 24 hours Holter monitoring. PROSPERO registration number CRD42017061021.

TCT-509 Utilisation of 320-Slice Multidetector CT in Assessing the Aortic Root Geometry in Bicuspid Aortic Valves and its Implications for Transcatheter Aortic Valve Replacement

METHODS Between 2012and201593 patients with stable coronary artery disease scheduled for PCI of bifurcation were randomized 1:1 to planning of the procedure based on coronary CTA and angiography (CTAgroup) or angiography alone (CA group). Primary efficacy endpoint was immediate angiographic result measured as a) minimal lumen diameters in main branch (MB) and side branch (SB); b) SB compromise defined as >50% angiographic stenosis; c) SB occlusion defined as TIMI flow grade <2. Secondary efficacy endpoints were: a) procedural characteristics and b) postprocedural FFR in side branch (SB) in a subgroup of patients. Safety outcomes were: a) periprocedural myocardial infarction, b) contrast use and c) radiation dose. Follow-up was obtained by telephone interview 6 months after last patient inclusion.

Feasibility and clinical outcomes in nonagenarians undergoing transcatheter aortic valve replacement with the LOTUS™ valve

Surgical aortic valve replacement (AVR) is associated with very high peri-operative risk in the nonagenarian population.[1] Patients with severe aortic stenosis treated conservatively have high rates of mortality with poor quality of life and loss of independence.[1] Transcatheter aortic valve replacement (TAVR) has been validated in the high risk elderly population as a viable alternative to surgery with comparable outcomes.[2],[3] Results from long term follow up of these patients suggest a clear benefit when compared to medical therapy with regards to mortality and morbidity.[3] However the outcomes and safety of TAVR in the nonagenarian cohort is not well understood. Recent cohort studies have suggested that nonagenarians post TAVR have comparable outcomes to younger patients.[4]–[6] Traditional surgical risk scores have been poor at predicting risk post TAVR and there is increasing use of other markers of risk such as frailty indices.[7]

Feasibility of exercise stress echocardiography for cardiac risk assessment in chronic kidney disease patients prior to renal transplantation

Pharmacologic stress testing is utilized in preference to exercise stress echocardiography (ESE) for cardiac risk evaluation in potential renal transplant recipients due to the perceived lower feasibility of ESE for achieving adequate workload and target heart rate (THR) in this population.