Search Results (20)

Background/Objectives: Transcatheter aortic valve replacement (TAVR) has been introduced as an optimal treatment for patients with severe aortic stenosis, offering a minimally invasive alternative to surgical aortic valve replacement. Predicting these outcomes following TAVR is crucial. Artificial intelligence (AI) has emerged as a promising tool for improving post-TAVR outcome prediction. In this systematic review and meta-analysis, we aim to summarize the current evidence on utilizing AI in predicting post-TAVR outcomes. Methods: A comprehensive search was conducted to evaluate the studies focused on TAVR that applied AI methods for risk stratification. We assessed various ML algorithms, including random forests, neural networks, extreme gradient boosting, and support vector machines. Model performance metrics—recall, area under the curve (AUC), and accuracy—were collected with 95% confidence intervals (CIs). A random-effects meta-analysis was conducted to pool effect estimates. Results: We included 43 studies evaluating 366,269 patients (mean age 80 ± 8.25; 52.9% men) following TAVR. Meta-analyses for AI model performances demonstrated the following results: all-cause mortality (AUC = 0.78 (0.74–0.82), accuracy = 0.81 (0.69–0.89), and recall = 0.90 (0.70–0.97); permanent pacemaker implantation or new left bundle branch block (AUC = 0.75 (0.68–0.82), accuracy = 0.73 (0.59–0.84), and recall = 0.87 (0.50–0.98)); valve-related dysfunction (AUC = 0.73 (0.62–0.84), accuracy = 0.79 (0.57–0.91), and recall = 0.54 (0.26–0.80)); and major adverse cardiovascular events (AUC = 0.79 (0.67–0.92)). Subgroup analyses based on the model development approaches indicated that models incorporating baseline clinical data, imaging, and biomarker information enhanced predictive performance. Conclusions: AI-based risk prediction for TAVR complications has demonstrated promising performance. However, it is necessary to evaluate the efficiency of the aforementioned models in external validation datasets. Full article

Transcatheter aortic valve replacement (TAVR) is now established as a safe and effective treatment for severe aortic stenosis across all surgical risk categories. Nevertheless, periprocedural conduction disturbances—including new-onset left bundle branch block (LBBB), right bundle branch block (RBBB), and other intraventricular blocks—remain among the most frequent complications, often resulting in permanent pacemaker (PPM) implantation and impacting left ventricular remodeling. A review was conducted using the PubMed/MEDLINE database. Relevant clinical trials, observational studies, and meta-analyses addressing post-TAVR LBBB were included and analysed with a focus on frequency, risk factors, and association with adverse outcomes. We describe the incidence of post-TAVR conduction disturbances and identify key predictors: pre-existing RBBB, membranous septum length, valve oversizing, implantation depth, infra-annular leaflet extension, compression ratio, and valve type/generation. New-onset LBBB is a frequent complication after TAVR and may negatively affect patient outcomes. Accurate risk stratification and standardised post-procedural monitoring protocols are essential. Further prospective studies are needed to better define management strategies for patients developing LBBB after TAVR. Full article

Cardiac resynchronization therapy (CRT) using biventricular (BiV) pacing is the standard treatment for heart failure (HF) patients with reduced left ventricular ejection fraction (LVEF) and electrical dyssynchrony. However, one in three patients remains a non-responder. Left bundle branch area pacing (LBBAP) could represent a more physiological alternative, but its effectiveness is limited in cases of atypical left bundle branch block (LBBB) or intraventricular conduction delay (IVCD). Left Bundle Branch Pacing Optimized cardiac resynchronization therapy (LOT-CRT) integrates LBBAP with coronary sinus (CS) lead pacing to improve electrical synchrony and clinical outcomes. This review evaluates the feasibility, advantages, disadvantages, and clinical outcomes of LOT-CRT. Additionally, we describe our center’s experience and propose an evidence-based implantation algorithm. A review of published studies investigating LOT-CRT was conducted, comparing its effectiveness with BiV-CRT and LBBAP alone using QRS narrowing, LVEF improvement, left ventricular remodeling, New York Heart Association (NYHA) class changes and NT-proBNP levels. It was found that LOT-CRT outperforms BiV-CRT or LBBAP alone in selected populations, at the cost of higher clinical skills, longer procedural times, and specific device setups. Randomized trials are underway to further define its role in clinical practice. Full article

Electrical and mechanical dyssynchrony (MD) underlies left ventricular (LV) contractile dysfunction in patients with heart failure (HF) and left bundle branch block (LBBB). In some cases, cardiac resynchronization therapy (CRT) almost completely reverses LV contractile dysfunction. The LBBB electrocardiographic Strauss criteria and MD assessment were proposed to improve CRT response. However, using these techniques separately does not improve LV contraction in 20–40% of patients after CRT device implantation. We aimed to evaluate whether the combined use of electrocardiography (ECG), speckle-tracking echocardiography (STE) and cardiac scintigraphy could improve the prognosis of CRT super-response in patients with HF and Strauss LBBB criteria during a 6-month follow-up period. The study prospectively included patients with HF, classified as New York Heart Association (NYHA) functional class (FC) II–III in sinus rhythm with Strauss LBBB criteria and reduced left ventricular ejection fraction (LVEF). Before and 6 months after CRT device implantation, ECG, STE and cardiac scintigraphy were performed. The study’s primary endpoint was the NYHA class improvement ≥ 1 and left ventricle end systolic volume decrease > 30% or LVEF improvement > 15% after 6 months of CRT. Based on collected data, we developed a prognostic model regarding the CRT super-response. Out of 54 (100.0%) patients, 39 (72.2%) had a CRT super-response. Patients with CRT super-response were likelier to have a greater S wave amplitude in V₂ lead (p = 0.004), higher rates of global longitudinal strain (GLS) (p = 0.001) and interventricular delay (IVD) (p = 0.005). Only three indicators (S wave amplitude in V₂ lead, GLS and IVD) were independently associated with CRT super-response in univariable and multivariable logistic regression. We created a prognostic model based on the logistic equation and calculated a cut-off value (>0.73). The resulting ROC curve revealed a discriminative ability with an AUC of 0.957 (sensitivity 87.2%; specificity 100.0%). The electrical and mechanical dyssynchrony assessment using ECG, STE and cardiac scintigraphy is useful in the prediction of CRT super-response in patients with HF and Strauss LBBB criteria during a 6-month follow-up period. Our prognostic model can identify patients who are super-responders to CRT. Full article

Background/Objectives: This study assessed the long-term prognostic implications of newly developed left bundle branch block (LBBB) in patients with ST-elevation myocardial infarction (STEMI) and a single coronary lesion, following primary percutaneous coronary intervention (PCI). Methods: Among 3526 patients admitted with acute myocardial infarction between January 2011 and December 2013, 42 were identified with STEMI, a single coronary lesion, and newly diagnosed LBBB. A control group of 42 randomly selected STEMI patients without LBBB was also included. All participants were prospectively evaluated with a median follow-up duration of 9.4 years. Demographic, clinical, and laboratory data were analyzed to assess the impact of LBBB on long-term outcomes. Results: The baseline characteristics were similar between the groups. The STEMI with new LBBB group had significantly higher rates of new myocardial infarction, revascularization, and mortality, highlighting the severe prognostic implications and elevated risk for adverse outcomes compared to STEMI without LBBB. The multivariate Cox regression analysis demonstrated that the presence of LBBB (HR: 2.15, 95% CI: 1.28–3.62, p = 0.003), lower LVEF (HR: 1.45, 95% CI: 1.22–1.72, p < 0.001), and longer pain-to-admission time (HR: 1.32, 95% CI: 1.09–1.61, p = 0.008) were significant independent predictors of adverse outcomes. Conclusions: Newly acquired LBBB in STEMI patients is associated with poorer long-term outcomes. Early identification and management of factors such as reduced LVEF and timely hospital admission, specifically in patients with new-onset LBBB, can improve prognosis. Full article

Background: The management of patients with aortic valve pathologies can sometimes fall into a “gray zone”, where the optimal treatment approach is not straightforward. The comparative benefits of sutureless aortic valve replacement (SUAVR) using the Perceval bioprosthesis versus transcatheter aortic valve implantation (TAVI) for the “gray zone” of aortic valve replacement procedures remain a topic of debate. To further explore this issue, we conducted a study with pairwise, single-arm, and Kaplan–Meier-based meta-analyses to compare the outcomes of SUAVR with the Perceval bioprosthesis versus TAVI, as well as to evaluate the efficacy, safety, and durability of SUAVR with the Perceval bioprosthesis over mid-term and long-term follow-up periods. Methods: The PubMed, PubMed Central, OVID Medline, Cochrane Library, Embase, and Web of Science databases were systematically searched. All study types were included, except study protocols and animal studies, without time restrictions. The final search was carried out in May 2024. Results: No statistically significant differences were observed in permanent pacemaker implantation (PPI) rates between the two groups. SUAVR showed a lower incidence of new-onset myocardial infarction but was associated with higher rates of new-onset atrial fibrillation and major bleeding. TAVI had higher rates of left bundle branch block and major vascular complications. Conclusions: Our findings show that SUAVR has a lower incidence of complications and a favorable mid-term overall survival compared to TAVI. SUAVR has more advantages compared to TAVI and can be considered a valuable and promising option for the “grey zone” of aortic valve pathologies. Full article

Background/Objectives: Coronary artery disease, a leading global cause of death, highlights the essential need for early detection and management of modifiable cardiovascular risk factors to prevent further coronary events. Methods: This study, conducted at a major tertiary academic PCI-capable hospital in Romania from 1 January 2011 to 31 December 2013, prospectively analyzed 387 myocardial infarction with ST-segment elevation (STEMI) patients to assess the long-term management of modifiable risk factors. This study particularly focused on patients with new-onset left bundle branch block (LBBB) and compared them with a matched control group without LBBB. Results: During median follow-up periods of 9.6 years for LBBB patients and 9.2 years for those without LBBB, it was found that smoking, obesity, and dyslipidemia were prevalent in 73.80%, 71.42%, and 71.42% of the LBBB group, respectively, at baseline. Significant reductions in smoking were observed in both groups, with the LBBB group’s smoking rates decreasing significantly to 61.90% (p = 0.034). Patients with LBBB more frequently achieved low-density lipoprotein cholesterol (LDLc) target levels during the follow-up period (from 71.42% to 59.52%; p = 0.026) compared to the control group (from 66.67% to 71.42%; p = 0.046). Prescription rates for dual antiplatelet therapy (DAPT), angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs), beta-blockers, and statins were initially high but then decreased by the follow-up. Statin use was reduced from 97.62% to 69.04% (p = 0.036) in the LBBB group and from 100% to 61.90% (p = 0.028) in the non-LBBB group. This study also highlighted moderate correlations between obesity (r = 0.627, p = 0.040) and subsequent coronary reperfusion in the LBBB group, while dyslipidemia and smoking showed very strong positive correlations across both groups (dyslipidemia: r = 0.903, p = 0.019 for LBBB; r = 0.503, p = 0.048 for non-LBBB; smoking: r = 0.888, p = 0.035 for LBBB; r = 0.517, p = 0.010 for non-LBBB). Conclusions: These findings underscore the crucial need for targeted management of modifiable risk factors, particularly focusing on dyslipidemia and smoking cessation, to improve subsequent coronary reperfusion outcomes post-STEMI, especially in patients with complicating factors like LBBB. Full article

Aims: TOMM40 single nucleotide polymorphism (SNP) rs2075650 consists of allelic variation c.275-31A > G and it has been linked to Alzheimer disease, apolipoprotein and cholesterol levels and other risk factors. However, data on its role in cardiovascular disorders are lacking. The first aim of the study is to evaluate mortality according to TOMM40 genotype in a cohort of selected patients affected by advanced atherosclerosis. Second aim was to investigate the relationship between Xg and AA alleles and the presence of conduction disorders and implantation of defibrillator (ICD) or pacemaker (PM) in our cohort. Materials and Methods: We enrolled 276 patients (mean age 70.16 ± 7.96 years) affected by hemodynamic significant carotid stenosis and/or ischemia of the lower limbs of II or III stadium Fontaine. We divided the population into two groups according to the genotype (Xg and AA carriers). We evaluated several electrocardiographic and echocardiographic parameters, including heart rate, rhythm, presence of right and left bundle branch block (LBBB and RBBB), PR interval, QRS duration and morphology, QTc interval, and left ventricular ejection fraction (LVEF). We clinically followed these patients for 82.53 ± 30.02 months and we evaluated the incidence of cardiovascular events, number of deaths and PM/ICD implantations. Results: We did not find a difference in total mortality between Xg and AA carriers (16.3 % vs. 19.4%; p = 0.62). However, we found a higher mortality for fatal cardiovascular events in Xg carriers (8.2% vs. 4.4%; HR = 4.53, 95% CI 1.179–17.367; p = 0.04) with respect to AA carriers. We noted a higher percentage of LBBB in Xg carriers (10.2% vs. 3.1%, p = 0.027), which was statistically significant. Presence of right bundle branch block (RBBB) was also higher in Xg (10.2% vs. 4.4%, p = 0.10), but without reaching statistically significant difference compared to AA patients. We did not observe significant differences in heart rate, presence of sinus rhythm, number of device implantations, PR and QTc intervals, QRS duration and LVEF between the two groups. At the time of enrolment, we observed a tendency for device implant in Xg carriers at a younger age compared to AA carriers (58.50 ± 0.71 y vs. 72.14 ± 11.11 y, p = 0.10). During the follow-up, we noted no statistical difference for new device implantations in Xg respect to AA carriers (8.2% vs. 3.5%; HR = 2.384, 95% CI 0.718–7.922; p = 0.156). The tendency to implant Xg at a younger age compared to AA patients was confirmed during follow-up, but without reaching a significant difference(69.50 ± 2.89 y vs. 75.63 ± 8.35 y, p = 0.074). Finally, we pointed out that Xg carriers underwent device implantation 7.27 ± 4.43 years before AA (65.83 ± 6.11 years vs. 73.10 ± 10.39 years) and that difference reached a statistically significant difference (p = 0.049) when we considered all patients, from enrollment to follow-up. Conclusions: In our study we observed that TOMM40 Xg patients affected by advanced atherosclerosis have a higher incidence of developing fatal cardiovascular events, higher incidence of LBBB and an earlier age of PM or ICD implantations, as compared to AA carriers. Further studies will be needed to evaluate the genomic contribution of TOMM40 SNPs to cardiovascular deaths and cardiac conduction diseases. Full article

Transcatheter aortic valve implantation (TAVI) is an established alternative to surgery in patients with symptomatic severe aortic stenosis and has expanded its indications to even low-surgical-risk patients. Conduction abnormalities (CA) and permanent pacemaker (PPM) implantations remain a relatively common finding post TAVI due to the close proximity of the conduction system to the aortic root. New onset left bundle branch block (LBBB) and high-grade atrioventricular block are the most commonly reported CA post TAVI. The overall rate of PPM implantation post TAVI varies and is related to pre- and intra-procedural factors. Therefore, when screening patients for TAVI, Heart Teams should take under consideration the various anatomical, pathophysiological and procedural conditions that predispose to CA and PPM requirement after the procedure. This is particularly important as TAVI is being offered to younger patients with longer life-expectancy. Herein, we highlight the incidence, predictors, impact and management of CA in patients undergoing TAVI. Full article

The cardiac variant of Fabry disease (FD) has high rates of missed diagnosis and misdiagnosis due to the lack of systemic symptoms. Here, we report a case of a 68-year-old female with delayed-onset FD presenting as concentric left ventricular hypertrophy (LVH) with right bundle branch block, atrial fibrillation, and diastolic dysfunction, which was first presented with coronary artery spasm. Early cardiac-specific signs are crucial for diagnosing this disease due to the lack of extracardiac indications and the late onset of symptoms. This case raises a new red flag that patients with unexplained LVH and its atypical electrocardiographic (ECG) manifestations accompanied by diastolic dysfunction should be considered for FD. We also recommend further refinement of examinations associated with Fabry disease, which will contribute to the early diagnosis and treatment of the disease. Full article

Introduction: Conduction disorders following aortic valve replacement therapy (AVR), either surgical or percutaneous, are related to a higher risk of complete atrioventricular block and permanent pacemaker implantation (PPI). Aim: The objective of this study was to assess risk factors regarding the incidence of new postoperative and persistent new left bundle branch block (LBBB) 1 year after the implantation of a sutureless/rapid-deployment (SURD) aortic valve prosthesis. Material and Methods: The current study included 200 consecutive patients treated with isolated or concomitant AVR between May 2014 and May 2017 at the Department of Cardiac Surgery in Pasawa with SURD aortic valve EDWARDS INTUITY Elite^TM implantation. The patients were divided according to the presence of new postoperative LBBB (67 patients, 33.5%) and persistent new LBBB 1 year after AVR (35 patients, 17.5%). A comparative analysis was performed between patients with and without new LBBB after AVR and those with and without persistent LBBB 1 year after AVR. Univariate and multivariate regression analyses were conducted to extract the risk factors of LBBB occurrence. Results: Among the risk factors for the lack of new LBBB development after AVR, Euroscore II (p < 0.001) was found, while for the occurrence of persistent new LBBB 1 year after AVR, atrial fibrillation (p = 0.001), length of hospital stay (p = 0.001) and body mass index (p = 0.004) were noted. Conclusions: Patients with new or persistent new LBBB 1 year after AVR had lower mean Euroscore II and BMI values. Their stay at the hospital was also shorter. Full article

(1) Background: Conduction disturbance requiring a new permanent pacemaker (PPM) after transcatheter aortic valve implantation (TAVI) has traditionally been a common complication. New implantation techniques with self-expanding platforms have reportedly reduced the incidence of PPM. We sought to investigate the predictors of PPM at 30 days after TAVI using Evolut R/PRO/PRO+; (2) Methods: Consecutive patients who underwent TAVI with the Evolut platform between October 2019 and August 2022 at University Hospital Galway, Ireland, were included. Patients who had a prior PPM (n = 10), valve-in-valve procedures (n = 8) or received >1 valve during the index procedure (n = 3) were excluded. Baseline clinical, electrocardiographic (ECG), echocardiographic and multislice computed tomography (MSCT) parameters were analyzed. Pre-TAVI MSCT analysis included membranous septum (MS) length, a semi-quantitative calcification analysis of the aortic valve leaflets, left ventricular outflow tract, and mitral annulus. Furthermore, the implantation depth (ID) was measured from the final aortography. Multivariate binary logistic analysis and receiver operating characteristic (ROC) curve analysis were used to identify independent predictors and the optimal MS and ID cutoff values to predict new PPM requirements, respectively; (3) Results: A total of 129 TAVI patients were included (age = 81.3 ± 5.3 years; 36% female; median EuroSCORE II 3.2 [2.0, 5.4]). Fifteen patients (11.6%) required PPM after 30 days. The patients requiring new PPM at 30 days were more likely to have a lower European System for Cardiac Operative Risk Evaluation II, increased prevalence of right bundle branch block (RBBB) at baseline ECG, have a higher mitral annular calcification severity and have a shorter MS on preprocedural MSCT analysis, and have a ID, as shown on the final aortogram. From the multivariate analysis, pre-TAVI RBBB, MS length, and ID were shown to be predictors of new PPM. An MS length of <2.85 mm (AUC = 0.85, 95%CI: (0.77, 0.93)) and ID of >3.99 mm (area under the curve (AUC) = 0.79, (95% confidence interval (CI): (0.68, 0.90)) were found to be the optimal cut-offs for predicting new PPM requirements; (4) Conclusions: Membranous septum length and implantation depth were found to be independent predictors of new PPM post-TAVI with the Evolut platform. Patient-specific implantation depth could be used to mitigate the requirement for new PPM. Full article

This retrospective cohort study investigated the incidence and risk factors of major adverse cardiovascular events (MACE) after 1 year of first-documented myocardial infarctions (MIs) in a multi-ethnic Asian population. Secondary MACE were observed in 231 (14.3%) individuals, including 92 (5.7%) cardiovascular-related deaths. Both histories of hypertension and diabetes were associated with secondary MACE after adjustment for age, sex, and ethnicity (HR 1.60 [95%CI 1.22–2.12] and 1.46 [95%CI 1.09–1.97], respectively). With further adjustments for traditional risk factors, individuals with conduction disturbances demonstrated higher risks of MACE: new left-bundle branch block (HR 2.86 [95%CI 1.15–6.55]), right-bundle branch block (HR 2.09 [95%CI 1.02–4.29]), and second-degree heart block (HR 2.45 [95%CI 0.59–10.16]). These associations were broadly similar across different age, sex, and ethnicity groups, although somewhat greater for history of hypertension and BMI among women versus men, for HbA1c control in individuals aged >50 years, and for LVEF ≤ 40% in those with Indian versus Chinese or Bumiputera ethnicities. Several traditional and cardiac risk factors are associated with a higher risk of secondary major adverse cardiovascular events. In addition to hypertension and diabetes, the identification of conduction disturbances in individuals with first-onset MI may be useful for the risk stratification of high-risk individuals. Full article

Objective: The goal of this manuscript is to compare clinical and echocardiographic outcomes of patients undergoing aortic valve replacement (AVR) with Perceval sutureless bioprosthesis (SU-AVR) and sutured bioprosthesis (SB). Methods: Following the PRISMA statement, data were extracted from studies published after August 2022 and found in PubMed/MEDLINE, EMBASE, CENTRAL/CCTR, ClinicalTrials.gov, SciELO, LILACS, and Google Scholar. The primary outcome of interest was post-procedural permanent pacemaker implantation, and the secondary outcomes were new left bundle branch block (LBBB), moderate/severe paravalvular leak (PVL), valve dislocation (pop-out), need for a second transcatheter heart valve, 30-day mortality, stroke, and echocardiographic outcomes. Results: Twenty-one studies were included in the analysis. When SU-AVR was compared to other SB, mortality ranged from 0 to 6.4% for Perceval and 0 to 5.9% for SB. Incidence of PVL (Perceval 1–19.4% vs. SB 0–1%), PPI (Perceval 2–10.7% vs. SB 1.8–8.5%), and MI (Perceval 0–7.8% vs. SB 0–4.3%) were comparable. In addition, the stroke rate was lower in the SU-AVR group when compared to SB (Perceval 0–3.7% vs. SB 1.8–7.3%). In patients with a bicuspid aortic valve, the mortality rate was 0–4% and PVL incidence was 0–2.3%. Long-term survival ranged between 96.7 and 98.6%. Valve cost analysis was lower for the Perceval valve and higher for sutured bioprosthesis. Conclusions: Compared to SB valves, Perceval bioprosthesis has proved to be a reliable prosthesis for surgical aortic valve replacement due to its non-inferior hemodynamics, implantation speed, reduced cardiopulmonary bypass time, reduced aortic cross-clamp time, and shorter length of stay. Full article

Background: We have previously reported that the incidence of postoperative conduction disorders, especially left bundle branch block (LBBB), after implantation of a rapid deployment Intuity™ Elite aortic valve prosthesis (Edwards Lifesciences, Irvine, CA, USA), was significantly increased compared with conventional aortic valve replacement. We were now interested in how these disorders behaved at intermediate follow-up. Methods: All 87 patients who had undergone surgical aortic valve replacement (SAVR) using the rapid deployment Intuity™ Elite prosthesis and were shown to have conduction disorders at the time of hospital discharge were followed up after surgery. These patients’ ECGs were recorded at least 1 year after surgery, and the persistence of the new postoperative conduction disorders was assessed. Results: At hospital discharge, 48.1% of the patients had developed new postoperative conduction disorders, with LBBB being the predominant conduction disturbance (36.5%). At medium-term follow-up (526 days, standard deviation (SD) = 169.6, standard error (SE) = 19.3 days, respectively), 44% of the new LBBB and 50% of the new right bundle branch block (RBBB) had disappeared. There was no new atrio-ventricular block III (AVB III) that occurred. One new pacemaker (PM) was implanted during follow-up because of AVB II Mobitz type II. Conclusions: At medium-term follow-up after the implantation of a rapid deployment Intuity™ Elite aortic valve prosthesis, the number of new postoperative conduction disorders, especially LBBB, has considerably decreased but remains high. The incidence of postoperative AV block III remained stable. Full article