ISSN 1671-5411 CN 11-5329/R

2021 Vol. 18, No. 9

Intracardiac echocardiography in the diagnosis and closure of patent foramen ovale
Kang-Ning HAN, Xiao-Teng MA, Shi-Wei YANG, Yu-Jie ZHOU
2021, 18(9): 697-701. doi: 10.11909/j.issn.1671-5411.2021.09.009
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In-hospital outcomes of transapical versus surgical aortic valve replacement: from the U.S. national inpatient sample
Ashraf Abugroun, Osama Hallak, Ahmed Taha, Alejandro Sanchez-Nadales, Saria Awadalla, Hussein Daoud, Efehi Igbinomwanhia, Lloyd W Klein
2021, 18(9): 702-710. doi: 10.11909/j.issn.1671-5411.2021.09.005
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 OBJECTIVE  To compare the outcomes of transapical transcatheter aortic valve replacement (TA-TAVR) and surgical aortic valve replacement (SAVR) using a large US population sample.  METHODS  The U.S. National Inpatient Sample was queried for all patients who underwent TA-TAVR or SAVR during the years 2016−2017. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were in-hospital stroke, pericardiocentesis, pacemaker insertion, mechanical ventilation, vascular complications, major bleeding, acute kidney injury, length of stay, and cost of hospitalization. Outcomes were modeled using multi-variable logistic regression for binary outcomes and generalized linear models for continuous outcomes.  RESULTS  A total of 1560 TA-TAVR and 44,280 SAVR patients were included. Patients who underwent TA-TAVR were older and frailer. Compared to SAVR, TA-TAVR correlated with a higher mortality (4.5% vs. 2.7%, effect size (SMD) = 0.1) and higher periprocedural complications. Following multivariable analysis, both TA-TAVR and SAVR had a similar adjusted risk for in-hospital mortality. TA-TAVR correlated with lower odds of bleeding with (adjusted OR (aOR) = 0.26; 95% CI: 0.18−0.38; P < 0.001), and a shorter length of stay (adjusted mean ratio (aMR) = 0.77; 95% CI: 0.69−0.84; P < 0.001), but higher cost (aMR = 1.18; 95% CI: 1.10−1.28; P < 0.001). No significant differences in other study outcomes. In subgroup analysis, TA-TAVR in patients with chronic lung disease had higher odds for mortality (aOR = 3.11; 95%CI: 1.37−7.08; P = 0.007).  CONCLUSION  The risk-adjusted analysis showed that TA-TAVR has no advantage over SAVR except for patients with chronic lung disease where TA-TAVR has higher mortality.
Risk factors for acute kidney injury following coronary artery bypass graft surgery in a Chinese population and development of a prediction model
Yang LI, Xue-Jian HOU, Tao-Shuai LIU, Shi-Jun XU, Zhu-Hui HUANG, Peng-Yun YAN, Xiao-Yu XU, Ran DONG
2021, 18(9): 711-719. doi: 10.11909/j.issn.1671-5411.2021.09.011
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 BACKGROUND Acute kidney injury (AKI) after coronary artery bypass graft (CABG) surgery is associated with significant morbidity and mortality. This retrospective study aimed to establish a risk score for postoperative AKI in a Chinese population.  METHODS A total of 1138 patients undergoing CABG were collected from September 2018 to May 2020 and divided into a derivation and validation cohort. AKI was defined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression analysis was used to determine the independent predictors of AKI, and the predictive ability of the model was determined using a receiver operating characteristic (ROC) curve.  RESULTS The incidence of cardiac surgery–associated acute kidney injury (CSA-AKI) was 24.17%, and 0.53% of AKI patients required dialysis (AKI-D). Among the derivation cohort, multivariable logistic regression showed that age ≥ 70 years, body mass index (BMI) ≥ 25 kg/m2, estimated glomerular filtration rate (eGFR) ≤ 60 mL/min per 1.73 m2, ejection fraction (EF) ≤ 45%, use of statins, red blood cell transfusion, use of adrenaline, intra-aortic balloon pump (IABP) implantation, postoperative low cardiac output syndrome (LCOS) and reoperation for bleeding were independent predictors. The predictive model was scored from 0 to 32 points with three risk categories. The AKI frequencies were as follows: 0−8 points (15.9%), 9−17points (36.5%) and ≥ 18 points (90.4%). The area under of the ROC curve was 0.730 (95% CI: 0.691−0.768) in the derivation cohort. The predictive index had good discrimination in the validation cohort, with an area under the curve of 0.735 (95% CI: 0.655−0.815). The model was well calibrated according to the Hosmer-Lemeshow test (P = 0.372).  CONCLUSION  The performance of the prediction model was valid and accurate in predicting KDIGO-AKI after CABG surgery in Chinese patients, and could improve the early prognosis and clinical interventions.
Prospective evaluation of health status, quality of life and clinical outcomes following implantable defibrillator generator exchange
Faisal M Merchant, John Larson, Leon Darghosian, Paige Smith, Soroosh Kiani, Stacy Westerman, Anand D. Shah, David S. Hirsh, Michael S. Lloyd, Angel R. Leon, Mikhael F. El-Chami
2021, 18(9): 720-727. doi: 10.11909/j.issn.1671-5411.2021.09.007
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 BACKGROUND Little is known about health status and quality of life (QoL) after implantable cardioverter-defibrillator (ICD) generator exchange (GE). METHODS We prospectively followed patients undergoing first-time ICD GE. Serial assessments of health status were performed by administering the 36-Item Short Form Survey (SF-36). RESULTS Mean age was 67.5 ± 14.3 years, left ventricle ejection fraction (LVEF) was 36.5% ± 15.0% and over 40% of the cohort had improved LVEF to > 35% at the time of GE. SF-36 scores were significantly worse in physical/general health domains compared to domains of emotional/social well-being (P < 0.001 for each comparison). Physical health scores were significantly worse among those with medical comorbidities including diabetes, chronic obstructive pulmonary disease and atrial fibrillation. Mean follow-up was 1.6 ± 0.5 years after GE. Overall SF-36 scores remained stable across all domains during follow-up. Survival at 3 years post-GE was estimated at 80%. Five patients died during follow-up and most deaths were adjudicated as non-arrhythmic in origin. Four patients experienced appropriate ICD shocks after GE, three of whom had LVEF which remains impaired LVEF (i.e., < 35%) at the time of GE. CONCLUSION Patients undergoing ICD GE have significantly worse physical health compared to emotional/social well-being, which is associated with the presence of medical comorbidities. In terms of clinical outcomes, the incidence of appropriate shocks after GE among those with improvement in LVEF is very low, and most deaths post-procedure appear to be non-arrhythmic in origin. These data represent an attempt to more fully characterize the spectrum of QoL and clinical outcomes after GE.
Beta-blockers and 1-year clinical outcomes in hospitalized heart failure patients with atrial fibrillation
Fu-Wei XING, Li-Hua ZHANG, Hai-Bo ZHANG, Xue-Ke BAI, Dan-Li HU, Xin ZHENG, Jing LI
2021, 18(9): 728-738. doi: 10.11909/j.issn.1671-5411.2021.09.010
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 OBJECTIVE  To assess the association between beta-blockers and 1-year clinical outcomes in heart failure (HF) patients with atrial fibrillation (AF), and further explore this association that differs by left ventricular ejection fraction (LVEF) level.  METHODS  We enrolled hospitalized HF patients with AF from China Patient-centered Evaluative Assessment of Cardiac Events Prospective Heart Failure Study. COX proportional hazard regression models were employed to calculate hazard ratio of beta-blockers. The primary outcome was all-cause death.  RESULTS  Among 1762 HF patients with AF (756 women [41.4%]), 1041 (56%) received beta-blockers at discharge and 1272 (72.2%) had an LVEF > 40%. During one year follow up, all-cause death occurred in 305 (17.3%), cardiovascular death occurred in 203 patients (11.5%), and rehospitalizations for HF occurred in 622 patients (35.2%). After adjusting for demographic characteristics, social economic status, smoking status, medical history, anthropometric characteristics, and medications used at discharge, the use of beta-blockers at discharge was not associated with all-cause death [hazard ratio (HR): 0.86; 95% Confidence Interval (CI): 0.65−1.12; P = 0.256], cardiovascular death (HR: 0.76, 95% CI: 0.52−1.11; P = 0.160), or the composite outcome of all-cause death and HF rehospitalization (HR: 0.97, 95% CI: 0.82−1.14; P = 0.687) in the entire cohort. There were no significant interactions between use of beta-blockers at discharge and LVEF with respect to all-cause death, cardiovascular death, or composite outcome. In the adjusted models, the use of beta-blockers at discharge was not associated with all-cause death, cardiovascular death, or composite outcome across the different levels of LVEF: reduced (< 40%), mid-range (40%−49%), or preserved LVEF (≥ 50%).  CONCLUSION  Among HF patients with AF, the use of beta-blockers at discharge was not associated with 1-year clinical outcomes, regardless of LVEF.
Digital literacy as a potential barrier to implementation of cardiology tele-visits after COVID-19 pandemic: the INFO-COVID survey
Giuseppe Boriani, Anna Maisano, Niccolò Bonini, Alessandro Albini, Jacopo Francesco Imberti, Andrea Venturelli, Matteo Menozzi, Valentina Ziveri, Vernizia Morgante, Giovanni Camaioni, Matteo Passiatore, Gerardo De Mitri, Giulia Nanni, Denise Girolami, Riccardo Fontanesi, Valerio Siena, Daria Sgreccia, Vincenzo Livio Malavasi, Anna Chiara Valenti, Marco Vitolo
2021, 18(9): 739-747. doi: 10.11909/j.issn.1671-5411.2021.09.003
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 BACKGROUND  During the COVID-19 pandemic, the implementation of telemedicine has represented a new potential option for outpatient care. The aim of our study was to evaluate digital literacy among cardiology outpatients.  METHODS  From March to June 2020, a survey on telehealth among cardiology outpatients was performed. Digital literacy was investigated through six main domains: age; sex; educational level; internet access; availability of internet sources; knowledge and use of teleconference software programs.  RESULTS  The study included 1067 patients, median age 70 years, 41.3% females. The majority of the patients (58.0%) had a secondary school degree, but among patients aged ≥ 75 years old the most represented educational level was primary school or none. Overall, for internet access, there was a splitting between “never” (42.1%) and “every day” (41.0%), while only 2.7% answered “at least 1/month” and 14.2% “at least 1/week”. In the total population, the most used devices for internet access were smartphones (59.0%), and WhatsApp represented the most used app (57.3%). Internet users were younger compared to non-internet users (63 vs. 78 years old, respectively) and with a higher educational level. Age and educational level were associated with non-use of internet (age-per 10-year increase odds ratio (OR) = 3.07, 95% CI: 2.54−3.71, secondary school OR = 0.18, 95% CI: 0.12−0.26, university OR = 0.05, 95% CI: 0.02−0.10).  CONCLUSIONS  Telemedicine represents an appealing option to implement medical practice, and for its development it is important to address the gaps in patients’ digital skills, with age and educational level being key factors in this setting.
Cardiac hybrid imaging: novel tracers for novel targets
Andrea Ponsiglione, Raffaele Ascione, Carmela Nappi, Massimo Imbriaco, Michele Klain, Renato Cuocolo, Alberto Cuocolo, Mario Petretta
2021, 18(9): 748-758. doi: 10.11909/j.issn.1671-5411.2021.09.006
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Non-invasive cardiac imaging has explored enormous advances in the last few decades. In particular, hybrid imaging represents the fusion of information from multiple imaging modalities, allowing to provide a more comprehensive dataset compared to traditional imaging techniques in patients with cardiovascular diseases. The complementary anatomical, functional and molecular information provided by hybrid systems are able to simplify the evaluation procedure of various pathologies in a routine clinical setting. The diagnostic capability of hybrid imaging modalities can be further enhanced by introducing novel and specific imaging biomarkers. The aim of this review is to cover the most recent advancements in radiotracers development for SPECT/CT, PET/CT, and PET/MRI for cardiovascular diseases.
Advances in telemedicine for the management of the elderly cardiac patient
Nadim El Jamal, Bernard Abi-Saleh, Hussain Isma’eel
2021, 18(9): 759-767. doi: 10.11909/j.issn.1671-5411.2021.09.004
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Telemedicine is the use of information and communication technology to deliver healthcare at a distance. It has been resorted to during the COVID-19 pandemic to lessen the need for in-person patient care decreasing the risk of transmission, and it can be of benefit afterward in the management of cardiac disease. The elderly population has unique challenges concerning the use of telehealth technologies. We thus review the advances in telemedicine technologies in treating elderly cardiac patients including in our discussion only studies with a mean age of participants above 60. Remote monitoring of blood pressure, weight, and symptoms, along with home ECG recording has been found to be superior to usual in-clinic follow up. Combining remote monitoring with video conferencing with physicians, patient education websites, and applications is also of benefit. Remote monitoring of Implantable Cardioverter Defibrillators (ICD) and Cardiac Resynchronization Therapy Defibrillators (CRT-D) is also beneficial but can be at the cost of an increase in both appropriate and inappropriate interventions. Implantable sensing devices compatible with remote monitoring have been developed and have been shown to improve care and cost-effectiveness. New smartphone software can detect arrhythmias using home ECG recordings and can detect atrial fibrillation using smartphone cameras. Remote monitoring of implanted pacemakers has shown non-inferiority to in clinic follow up. On the other hand, small-scale questionnaire-based studies demonstrated the willingness of the elderly cardiac patients to use such technologies, and their satisfaction with their use and ease of use. Large-scale studies should further investigate useability in samples more representative of the general elderly population with more diverse socioeconomic and educational backgrounds. Accordingly, it seems that studying integrating multiple technologies into telehealth programs is of great value. Further efforts should also be put in validating the technologies for specific diseases along with the legal and reimbursement aspects of the use of telehealth.
Cellular signaling pathways of T cells in giant cell arteritis
Hai-Yan LI, Jun-Nan XU, Zong-Wen SHUAI
2021, 18(9): 768-778. doi: 10.11909/j.issn.1671-5411.2021.09.008
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Giant cell arteritis (GCA) is a commonly occurring large vacuities characterized by angiopathy of medium and large-sized vessels. GCA granulomatous formation plays an important role in the pathogenesis of GCA. Analysis of T cell lineages and signaling pathways in GCA have revealed the essential role of T cells in the pathology of GCA. T cells are the dominant population present in GCA lesions. CD4+ T cell subtypes that are present include Th1, Th2, Th9, Th17, follicular helper T (Tfh) cells, and regulatory T (Treg) cells. CD8 T cells can primarily differentiate into cytotoxic CD8+ T lymphocytes and Treg cells. The instrumental part of GCA is the interplay between dendritic cells, macrophages and endothelial cells, which can result in the vascular injury and the characteristics granulomatous infiltrates formation. During the inflammatory loop of GCA, several signaling pathways have been reported to play an essential role in recruiting, activating and differentiating T cells, including T-cell receptor (TCR) signaling, vascular endothelial growth factor (VEGF)-Jagged-Notch signaling and the Janus kinase and signal transducer and activator of transcription (STAT) pathway (JAK-STAT) pathway. In this review, we have focused on the role of T cells and their potential signaling mechanism (s) that are involved in the pathogenesis of GCA. A better understanding of the role of T cells mediated complicated orchestration during the homeostasis and the changes could possibly favor developments of novel treatment strategies against immunological disorders associated with GCA.
Orthostatic hypertension and adverse clinical outcomes in adults and older people
Sarah Damanti, Paolo D Rossi, Matteo Cesari
2021, 18(9): 779-782. doi: 10.11909/j.issn.1671-5411.2021.09.001
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