Echocardiographic phenotype in severe aortic valve stenosis with and without cardiac amyloidosis: The AMY-TAVI trial

Background: Longitudinal Strain (LS) pattern in cardiac amyloidosis (CA) typically spares the apex of the heart, which is a sensitive and specific finding that can be used to distinguish CA from other causes of left ventricular (LV) hypertrophy. RELAPS >1 suggests with high specificity CA, and shows a bright red in the apical segments of the polar map. Purpose(s): To identify differential echocardiographic characteristics of aortic stenosis (AS) with concomitant TTR-CA (AS-CA) compared to AS alone. Method(s): Patients with severe symptomatic AS undergoing TAVI were prospectively and consecutively included between Jan-19 and Dec-20. Pre-procedure, a complete echocardiogram was performed that included deformation parameters using Speckle-Tracking. Strain derived Indices accepted for CA screening were calculated: RELAPS: Relative apical LS (average apical LS/average basal+mid LS);SAB: (apical-septal/basal-septal LS);EFSR: (LVEF/GLS). After TAVI, a 99Tc-DPD scintigraphy and a proteinogram were performed to screen for CA. Result(s): 324 patients were included. The mean age was 81 yo, 52% women. 39 (12%) patients presented cardiac uptake on scintigraphy: 14 (4.3%) grade 1;13 (4%) grade 2, and 11 (3.4%) grade 3. Strain analysis could be performed in 243 patients due to acoustic window and covid19 pandemic restrictions. Echocardiographic characteristics between AS alone and those with grade 1 (AS-DTD1) and grade 2/3 (AS-CA) are shown in Table 1. Compared with AS alone, patients with AS-CA had significantly lower transvalvular gradients, although similar AVA, and low flow-low gradient (LF-LG) AS was more prevalent. AS-CA exhibited slightly worse cardiac remodeling (LV mass ind: 202 g/m2 vs 176 g/m2, p=0.032), and worse diastolic dysfunction, but without significant differences in thickness, diameters or volumes, with similar relative wall thickness (RWT: 0.53 vs. 0.51 mm, p=0.52). LVEF was similar, however myocardial contraction fraction (MCF= stroke volume/myocardial volume) and MAPSE were worse in AS-CA. GLS, RELAPS, SAB and EFSR were not different, but RELAPS >1 pattern was more prevalent in AS-CA (74% vs 44%, p=0,006) (Figure 1). Mass/strain ratio (RMS) was similar. There were no differences in size and fractional emptying of left atrium, or atrial septum thickness. Right ventricle (RV) size was similar, as well as conventional function parameters (TAPSE and S'). However, RV LS was worse in AS-CA. Pericardial effusion was more prevalent in AS-CA (25% vs 7.4%, p=0.013). In the multivariate analysis, predictors of AS-CA were: Age (OR: 1,2, p=0,02), BG (OR: 0,2, p=0,01), E/A (OR: 4,7, p=0,02), LV Mass index (OR: 1,02, p=0,04) and RELAPS >1 (OR: 0,12, p=0,01). Conclusion(s): Dual pathology of AS-AC is common in older patients referred for TAVI. Although it is more prevalent in patients with AS-CA, RELAPS>1 pattern can be present in almost 50% of patients with severe AS alone, which reduces its value as screening tool for CA in this clinical setting respect to others. (Table Presented).

Echocardiographic phenotype and prognostic value of relative apical sparing of longitudinal strain pattern in severe aortic stenosis with and without cardiac amyloidosis. The AMYTAVI study

Introduction: It is estimated that 15% of patients with AS have concomitant cardiac amyloidosis (CA). Left ventricular (LV) longitudinal strain (LS) pattern with relative apical sparing (RELAPS>1), shown as bright red in the apical segments on the polar map, has been strongly associated with CA. Its presence and its significance in AS is yet to be determined. Purpose(s): To determine the prevalence of the RELAPS>1 pattern in patients with severe AS with and without concomitant CA, and to analyze the echocardiographic phenotype associated with this strain pattern and its prognostic value. Method(s): Patients with severe symptomatic AS undergoing TAVI were prospectively and consecutively included between Jan-19 and Dec-20. Pre-procedure, a complete echocardiogram was performed that included deformation parameters using Speckle-Tracking. Strain derived Indices accepted for CA screening were calculated: RELAPS: Relative apical LS (average apical LS/average basal+mid LS);SAB: (apical-septal/basal-septal LS);EFSR: (LVEF/GLS). After TAVI, a 99Tc-PYP scintigraphy and a proteinogram were performed to screen for CA. Result(s): 324 patients were included. The mean age was 81 yo, 52% women. Strain analysis could be performed in 243 patients due to acoustic window and covid19 pandemic restrictions. Among those, 111 (46%) presented relative apical sparing (RELAPS>1). There were no differences in clinical characteristics between patients with RELAPS <1 and >1: Similar age, sex, cardiovascular risk factors and funcional class, renal function or NT-proBNP. Among patients with RELAPS>1 there was more frecuently CA with uptake grade 2 and 3 on scintigraphy (15% vs. 4.5%, P=0.006) (Figure 1). RELAPS>1 group showed greater LV hypertrophic remodeling: Thicker myocardial wall with smaller ventricular cavity, especially concentric hypertrophy;LVEF and GLS was similar, however, MAPSE and myocardial contraction fraction (MCF) were worse in RELAPS >1 group, and EFSR was significantly higher (4.2 vs 3.9, p=0.002). RELAPS >1 group had smaller aortic valve area (AVA: 0.6 vs 0.7 cm2, p=0.045), but similar transvalvular gradients due to lower stroke volume. It had larger atria and less left atrial (LA) fractional emptying, as well as higher prevalence of atrial fibrillation (AF: 41% vs 27%, p=0.03). Right ventricle (RV) size were similar, however, RV function was worse in RELAPS >1 group (TAPSE: 19 vs 21 mm, p=0.003;free Wall LS: -24 vs -27%, p=0.008). There was no difference in all-cause mortality at 1 year of follow-up between groups (6.4% vs. 6.3%, p=1). Figure 2 represents the morphological characteristics according to the LS phenotype. Conclusion(s): In severe AS, RELAPS >1 is present in almost half of the patients. It is associated with worse cardiac remodeling, as well as higher prevalence of AF. However, it wasn't associated with higher mortality at 1 year. 1 in 7 patients with AS and RELAPS >1 have concomitant ATTR CA grade 2/3.

COVID-19 infection impact on cardiovascular and thrombotic events during acute phase and medium-term of the disease

Background: Coronavirus disease (COVID-19) was labelled a global pandemic in April 2020 by the World Health Organisation. By December of the same year the disease caused by SARS-COV-2, known as COVID-19 (Coronavirus disease 2019), had spread over 200 countries, infecting more than 70 million people, causing more that 1.5 million of deaths. Recent studies suggest SARS-CoV-2 infection may be related to cardiovascular and thrombotic events although the strength of association remains unclear. Aims: Evaluate the emergence of cardiovascular and thrombotic events (such as major acute cardiovascular events, ictus and other thrombosis) in the acute moment and in medium-term follow-up in COVID-19 patients. Methods: Single-Center, retrospective, observational study of cohorts based on all the inhabitants of the health area. Survival analysis of main outcomes (mortality, heart failure [HF], and major acute cardiovascular events-MACE -[a composite of cardiovascular mortality, myocardial infarction and stroke]) were adjusted by multivariate logistic regression. Results: Of the total population studied, 447,979 inhabitants, 1,030 (0.23%) were diagnosed with COVID-19 infection, of which 14,8% were smokers, 31,2% had high blood pressure (HTA), 12,8% had diabetes, 29,2% had dyslipidaemia, 2,7% had peripheral artery disease, 4,7% had ischemic heart disease, 3,3% had had a previous transient ischemic attack, 10% were in anti-aggregation treatment and 5,8% were in anticoagulation treatment at the time of diagnosis. Concerning the analytics middle values, the group treated with ACEI/ARAB had higher troponins and ferritin than the group without ACEI/ARAB treatment, whereas higher reactive C protein and D-dimer were found in this last group. The main results showed that COVID-19 infection had no effect regarding to cardiovascular and thrombotic disease on mortality (OR: 1.64, 95% CI 0.98 2.76, p=0.062), heart failure (OR: 0.98, 95% CI 0.53 1.79, p=0.942), thrombotic events (OR: 1.02, 95% CI 0.22 4.83, p=0.98) and major acute cardiovascular events (OR: 0.88, 95% CI 0.48 1.60, p=0.665). Conclusions: In conclusion, COVID-19 infection had no effect on the emergence of cardiovascular or thrombotic events taking into account the 6-month prognosis, defined as mortality, heart failure, or major acute cardiovascular events.

Fast track triage for COVID-19 based on a population study: The SODA score

Background: Healthcare systems are under prominent stress due to the COVID-19 pandemic. A fast and simple triage is mandatory to screen patients who will benefit from early hospitalization, from those that can be managed as outpatients. There is a lack of all-comers scores, and no score has been proposed for western-world population. Aims: To develop a fast-track risk score valid for every COVID-19 patient at diagnosis. Methods: Single-center, retrospective study based on all the inhabitants of a healthcare area. Logistic regression was used to identify simple and wide-available risk factors for adverse events (death, intensive care admission, invasive mechanical ventilation, bleeding >BARC3, acute renal injury, respiratory insufficiency, myocardial infarction, acute heart failure, pulmonary emboli, or stroke). Results: Of the total healthcare area population, 447.979 inhabitants, 965 patients (0.22%), were diagnosed with COVID-19. A total of 124 patients (12.85%) experienced adverse events. The novel SODA score (based on sex, peripheral O2 saturation, presence of diabetes, and age) demonstrated good accuracy for adverse events prediction (area under ROC curve 0.858, CI: 0.82-0.98). A cut-off value of <2 points identifies patients with low risk (positive predictive value [PPV] for absence of events: 98.9%) and a cut-off of >5 points, high-risk patients (PPV 58.8% for adverse events). Conclusions: This quick and easy score allows fast-track triage at the moment of diagnosis for COVID-19 using four simple variables: age, sex, SpO2, and diabetes. SODA score could improve preventive measures taken at diagnosis in high-risk patients and also relieve resources by identifying very low-risk patients.

Prognostic impact of treatment with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in the acute phase and medium-term on COVID-19 infected patients

Introduction: The first case of COVID-19 infection was described in Wuhan, China, in December 20191. Shortly after, cases of limited humanto-human transmission were reported in other countries, which made the WHO declare the outbreak a Public Health Emergency of International Concern (ESPII) on January 30, 20202. Recent studies suggest that treatment with angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARAB) during acute COVID-19 infection has no effect on mortality3, but it is no evidence regarding the medium-term clinical implication of previous treatment with ACEI/ARAB on the prognosis of patients with COVID-19 infection. Purpose: The aim of this study is to evaluate the clinical implication of the use of ACEI/ARB in the acute moment and in medium-term follow-up in patients after COVID-19. Methods: It is a single-centre, retrospective, analytical observational study of cohorts based on all consecutive patients diagnosed with COVID-19 who were admitted during the first wave (March 10th until May 31st), of the pandemic in our health area. Survival analysis of main outcomes (mortality, heart failure, and major acute cardiovascular events [a composite of cardiovascular mortality, myocardial infarction and stroke]) were adjusted by multivariate logistic regression. Results: Of the total population studied, 447,979 inhabitants, 1,030 (0.23%) were diagnosed with COVID-19 infection, of which 196 (19%) were under treatment with ACEI/ARB at the time of diagnosis. The main results showed that ACEI/ARB treatment (combined and individually) had no effect on mortality (Hazard Ratio [HR]: 1.64, 95% Confidence Interval [CI] 0.98 2.76, p=0.062), heart failure (HR: 0.98, 95% CI 0.53 1.79, p=0.942), thrombotic events (HR: 1.02, 95% CI 0.22 4.83, p=0.98) and major acute cardiovascular events (HR: 0.88, 95% CI 0.48 1.60, p=0.665). Conclusions: In conclusion, previous treatment with ACEI/ARB in patients with COVID-19 had no effect on the 6-month prognosis, defined as mortality, heart failure, or major acute cardiovascular events. Withdrawal of ACEI/ARB in patients testing positive for COVID-19 would not be justified, in line with current recommendations of scientific societies and government agencies.