Showing papers by "Helge Skulstad published in 2022"

Surgery and outcome of infective endocarditis in octogenarians: prospective data from the ESC EORP EURO-ENDO registry

Abstract: High mortality and a limited performance of valvular surgery are typical features of infective endocarditis (IE) in octogenarians, even though surgical treatment is a major determinant of a successful outcome in IE. Data from the prospective multicentre ESC EORP EURO-ENDO registry were used to assess the prognostic role of valvular surgery depending on age. As compared to < 80 yo patients, ≥ 80 yo had lower rates of theoretical indication for valvular surgery (49.1% vs. 60.3%, p < 0.001), of surgery performed (37.0% vs. 75.5%, p < 0.001), and a higher in-hospital (25.9% vs. 15.8%, p < 0.001) and 1-year mortality (41.3% vs. 22.2%, p < 0.001). By multivariable analysis, age per se was not predictive of 1-year mortality, but lack of surgical procedures when indicated was strongly predictive (HR 2.98 [2.43–3.66]). By propensity analysis, 304 ≥ 80 yo were matched to 608 < 80 yo patients. Propensity analysis confirmed the lower rate of indication for valvular surgery (51.3% vs. 57.2%, p = 0.031) and of surgery performed (35.3% vs. 68.4%, p < 0.0001) in ≥ 80 yo. Overall mortality remained higher in ≥ 80 yo (in-hospital: HR 1.50[1.06–2.13], p = 0.0210; 1-yr: HR 1.58[1.21–2.05], p = 0.0006), but was not different from that of < 80 yo among those who had surgery (in-hospital: 19.7% vs. 20.0%, p = 0.4236; 1-year: 27.3% vs. 25.5%, p = 0.7176). Although mortality rates are consistently higher in ≥ 80 yo patients than in < 80 yo patients in the general population, mortality of surgery in ≥ 80 yo is similar to < 80 yo after matching patients. These results confirm the importance of a better recognition of surgical indication and of an increased performance of surgery in ≥ 80 yo patients.

Cause‐Specific Mortality in Patients During Long‐Term Follow‐Up After Atrial Switch for Transposition of the Great Arteries

Abstract: Background Little is known about the cause of death (CoD) in patients with transposition of the great arteries palliated with a Mustard or Senning procedure. The aim was to describe the CoD for patients with the Mustard and Senning procedure during short‐ (<10 years), mid‐ (10–20 years), and long‐term (>20 years) follow‐up after the operation. Methods and Results This is a retrospective, descriptive multicenter cohort study including all Nordic patients (Denmark, Finland, Norway, and Sweden) who underwent a Mustard or Senning procedure between 1967 and 2003. Patients who died within 30 days after the index operation were excluded. Among 968 patients with Mustard/Senning palliated transposition of the great arteries, 814 patients were eligible for the study, with a mean follow‐up of 33.6 years. The estimated risk of all‐cause mortality reached 36.0% after 43 years of follow‐up, and the risk of death was highest among male patients as compared with female patients (P=0.004). The most common CoD was sudden cardiac death (SCD), followed by heart failure/heart transplantation accounting for 29% and 27%, respectively. During short‐, mid‐, and long‐term follow‐up, there was a change in CoD with SCD accounting for 23.7%, 46.6%, and 19.0% (P=0.002) and heart failure/heart transplantation 18.6%, 22.4%, and 46.6% (P=0.0005), respectively. Conclusions Among patients corrected with Mustard or Senning transposition of the great arteries, the most common CoD is SCD followed by heart failure/heart transplantation. The CoD changes as the patients age, with SCD as the most common cause in adolescence and heart failure as the dominant cause in adulthood. Furthermore, the risk of all‐cause mortality, SCD, and death attributable to heart failure or heart transplantation was increased in men >10 years after the Mustard/Senning operation.

Improved Detection Of Thromboembolic Complications In Left Ventricular Assist Device By Novel Accelerometer-Based Analysis

Abstract: We have previously demonstrated that accelerometer-based vibration analysis detects thromboembolism and pump thrombosis in HeartWare Left Ventricular Assist Device (HVAD) using the third harmonic frequency (pump_speedx3). Thromboembolism also affected the amplitude of the nonharmonic frequencies. The aim of this study was to determine whether nonharmonic-amplitude (NHA) analysis can improve the diagnosis of thromboembolic complications. An accelerometer was attached to HVAD in three in vitro and seven in vivo experiments. Control interventions, including load and pump speed alternations (n = 107), were followed by thromboembolic events (n = 60). A sliding fast-Fourier-transform was analyzed, and changes in NHAs were quantified in the acute phase and in a steady state. Receiver operating characteristic curves were constructed with cutoff values of NHA to detect thromboembolic events. Positive predictive values were calculated on the basis of a specificity of 1. In the acute phase, NHA change was 6.5 times higher under thromboembolism than under control interventions (p < 0.001). Most thromboembolic events lead to concomitant changes in both NHA and third-harmonic amplitude. Combining the two methods improved the PPV by 8.3%. At steady state, signal changes predominantly demonstrated either NHA or third-harmonic changes. Combined signal analysis improved the PPV by 36%. This method enhanced the detection of thromboembolism and pump thrombosis in the HVAD.

Myocardial electrophysiological and mechanical changes caused by moderate hypothermia—A clinical study

Abstract: Moderate hypothermia has been used to improve outcomes in comatose out‐of‐hospital cardiac arrest survivors during the past two decades, although the effects remain controversial. We have recently shown in an experimental study that myocardial electrophysiological and mechanical relationships were altered during moderate hypothermia. Electromechanical window positivity increased, and electrical dispersion of repolarization decreased, both of which are changes associated with decreased arrhythmogenicity in clinical conditions. Mechanical dispersion, a parameter also linked to arrhythmic risk, remained unaltered. Whether corresponding electrophysiological and mechanical changes occur in humans during moderate hypothermia, has not been previously explored. Twenty patients with normal left ventricular function were included. Measurements were obtained at 36 and 32°C prior to ascending aortic repair while on partial cardiopulmonary bypass and at 36°C after repair. Registrations were performed in the presence of both spontaneous and comparable paced heart rate during standardized loading conditions. The following electrical and mechanical parameters were explored: (1) Electromechanical window, measured as time difference between mechanical and electrical systole, (2) dispersion of repolarization from ECG T‐wave, and (3) mechanical dispersion, measured as segmental variation in time to peak echocardiographic strain. At moderate hypothermia, mechanical systolic prolongation (425 ± 43–588 ± 67 ms, p < 0.001) exceeded electrical systolic prolongation (397 ± 49–497 ± 79 ms, p < 0.001), whereby, electromechanical window positivity increased (29 ± 30–86 ± 50 ms, p < 0.001). Dispersion of repolarization and mechanical dispersion remained unchanged. Corresponding electrophysiological and mechanical relationships were present at comparable paced heart rates. After rewarming, the increased electromechanical window was reversed in the presence of both spontaneous and paced heart rates. Moderate hypothermia increased electromechanical window positivity, while dispersion of repolarization and mechanical dispersion remained unchanged. This impact of hypothermia may be clinically relevant for selected groups of patients after cardiac arrest.

Pregnancy history and long-term progression of cardiomyopathy in LMNA genotype-positive women

Abstract: Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Precision Health Center for optimized cardiac care (ProCArdio), Oslo, Norway Fripro gene positive, Norwegian Research Council, Oslo, Norway Competitive and non-competitive exercises have been reported to be deleterious on prognosis of LMNA genotype-positive patients. Comparable to exercise, pregnancy is a prolonged hemodynamic stress situation. We aimed to assess the association between pregnancy history and long-term progression of cardiomyopathy in women with pathogenic or likely pathogenic variants of LMNA (LMNA+). We retrospectively included consecutive LMNA+ females and recorded pregnancy data. We analyzed repeated echocardiographic examinations, including data on left ventricular (LV) end-diastolic diameter (EDD), LV ejection fraction (EF) and LV global longitudinal strain (GLS). We recorded the occurrence of atrial fibrillation (AF), atrioventricular block, sustained ventricular arrhythmias (VA), and implantation of cardiac electronic devices (ICD/CRT-D). We analysed retrospectively complications during pregnancy and peripartum period. We included 89 LMNA+ women (28% probands, age 41 ± 16 years), of which 60 had history of pregnancy. Follow-up duration was 5 [IQR: 3-9] years. We analysed 452 repeated echocardiographic examinations. Women with previous pregnancy and nulliparous had a similar annual deterioration of LV EF (-0.5/year vs -0.3/year, p = 0.37, figure left panel), LV GLS (0.1/year vs 0.0/year, p = 0.35, figure right panel) and LV EDD (0.1/year vs 0.2/year, p = 0.09). Number of pregnancies was not associated with increased long-term risk of AF, atrioventricular block, sustained VA or ICD/CRT-D implantation. Pregnancy history was not associated with worse survival free from death, left ventricular assist device or need for cardiac transplantation. Arrhythmias occurred in 9% of pregnancies. No increase of maternal and fetal complications was observed. In our cohort of LMNA+ women, pregnancy was not associated with long-term adverse progression of cardiac dysfunction, worsening in arrhythmic progression or reduced event-free survival. Likewise, LMNA+ women generally tolerated pregnancy well, with a small proportion of patients experiencing arrhythmias. Abstract Figure.

Pre-intervention left ventricular mechanical dispersion is increased in patients in need for pacemaker after TAVI

Abstract: Type of funding sources: None. Transcatheter Aortic Valve Implantation (TAVI) is an effective therapy for patients with severe aortic stenosis. Complete atrioventricular block (AVB) that requires permanent pacemaker treatment is a common complication of TAVI and it is reported in up to one fifth of patients. Prediction of this complication could be important. Global longitudinal strain (GLS) and left ventricular mechanical dispersion (LVMD) by speckle tracking echocardiography (STE) are novel techniques that detect subtle changes in myocardial function and are related to myocardial fibrosis. Thus, we aimed to investigate the association between LVMD and AVB development after TAVI. We retrospectively screened 168 consecutive patients after TAVI. Patients with abnormal ECG and changed conduction pre- and post-TAVI were excluded. Data from the remaining 61 patients were compared to the group of 16 patients in need for a permanent pacemaker. Baseline echocardiograms recorded before TAVI were used to assess GLS and LVMD by STE (Figure). Of the 77 patients analysed, 60% were female (82 ± 7 years old). The mean GLS values were -16.8 ± 4.2% and -16.9 ± 3.7% in AVB and no AVB groups, respectively (p = 0.9). The mean LVMD was 60 ± 19 ms in AVB group and 50 ± 16 ms in no-AVB group (p = 0.04). (Table) LVMD was increased in patients who developed TAVI-induced complete AVB, while GLS could not differentiate between post-procedural normal and abnormal electrical conduction. This finding may be important to identify myocardial properties associated with complete AVB after TAVI. Abstract Table Abstract Figure

Is left ventricular function reduced after ultra-endurance exercise?

Abstract: Type of funding sources: Foundation. Main funding source(s): Norwegian Health Association Ultra-endurance exercise can be harmful according to previous studies, indicated by reduction in functional parameters and increase in cardiac biomarkers. Changes in load and heart rate with exercise influence left ventricle systolic function, making assessment of standard echocardiographic examination difficult. We investigated the effect of ultra-endurance exercise on myocardial function acutely and at restitution. We investigated 10 participants aged 46 ±7 years, before (baseline), within 142 ± 78 minutes after finish (post run) and 5-10 days after (restitution) an ultra-endurance race (3.8 km swimming, 180 km bicycling and 42 km running with a total elevation of 5200 m). Echocardiography was performed at the three time points, including cardiac morphology and -function. Ejection fraction (EF) and stroke volume (SV) were measured by Simpson biplane. Cardiac output was calculated from SV and heart rate (HR). Cardiac power was calculated as the product of CO, mean arterial blood pressure and the conversion factor to Watt (W) 0.00222. Global longitudinal strain (GLS) was calculated using speckle-tracking echocardiography, and myocardial work was calculated by non-invasive pressure-strain analysis. Acutely after exercise, myocardial function by GLS (p = 0.002), myocardial work (p < 0.001), mitral annular plane systolic excursion (MAPSE, p = 0.003) and EF (p = 0.004) were substantially reduced compared to baseline, whereas cardiac power and cardiac output (CO) were maintained (see table and figure). Heart rate was moderately increased (p < 0.001). End-diastolic volume (EDV) as an index of preload was numerically, but not significantly reduced. End systolic volume (ESV) was numerically increased (p = NS) even though systolic blood pressure (sBP) was reduced (p = 0.01) post race. After restitution all parameters returned to baseline levels. The temporary reduced strain and EF may be a physiologic response due to the higher heart rate. However, despite reduced systolic pressure the heart did not contract to a lower end systolic volume. This suggests loss of contractile function compensated by increase in heart rate. The findings should be explored in further studies. Abstract Figure Abstract Table

Reduced left ventricular function and sustained hypertension in women seven years after severe preeclampsia

Abstract: Abstract Objective. To study left ventricular (LV) function and blood pressure (BP) at a long-term follow-up in women after severe pre-eclampsia. Design. In this single-centre, cross-sectional study, 96 patients were eligible for inclusion. LV function was examined by transthoracic echocardiography including tissue Doppler echocardiography and speckle tracking. BP was measured at rest using repeated non-invasive techniques. Results. We compared 36 patients with early-onset and 33 patients with late-onset pre-eclampsia with 28 healthy controls. Mean age (40 ± 3 years) and median time since delivery (7 ± 2 years) were similar across the study groups. The patients had 18% higher systolic BP (139 ± 15 mmHg) and 24% higher diastolic BP (87 ± 19 mmHg) than controls (p < .01). Hypertension was present in 23 patients (33%), where the estimated LV mass was 16% higher (p = .05) than in controls. The LV ejection fraction was 19% lower in the early-onset group (51 ± 4%; p = .01) and 14% lower in the late-onset group (54 ± 6; p = .04) compared with controls. LV global longitudinal strain was 18% lower in the patient group (–17.7 ± 2.1%) compared with controls (p = .01). Indicative of a more restrictive filling pattern, the diastolic indices showed a lower e′ mean (p < .01) and subsequently higher E/e′ ratio (p < .01). There were no significant differences in BP, systolic or diastolic function indices between the patient groups. Conclusion. We found sustained hypertension, higher LV mass and reduced LV systolic and diastolic function 7 y after severe pre-eclampsia. Our findings emphasize the importance of early risk stratification and clinical counselling, and follow-up for such cases.

Left ventricular mechanical dispersion by speckle tracking echocardiography is a predictor of atrioventricular block after transcatheter aortic valve implantation

Abstract: Transcatheter Aortic Valve Implantation (TAVI) is an effective therapy for patients with severe aortic stenosis (AS). Complete atrioventricular block (AVB) that requires permanent pacemaker implantation is a common complication of TAVI. Direct mechanical effect of the prosthetic valve, QRS duration and underlying myocardial fibrosis are proposed mechanisms of AVB after TAVI. Left ventricular mechanical dispersion (LVMD) by Speckle Tracking Echocardiography (STE) is an index of contraction heterogeneity and a marker of myocardial fibrosis. We aimed to evaluate the association between LVMD, QRS duration and AVB to assess markers used to predict AVB after TAVI. A total of 163 consecutive TAVI patients were enrolled in the study. Echocardiograms andelectrocardiograms were recorded the day before TAVI procedure to assess global longitudinal strain (GLS), LVMD and QRS duration. AVB and pacemaker (PM) implantation information was obtained by telephone interviews three months after TAVI. Ten patients were excluded due to poor image quality. Of the 153 patients analyzed, 45% were female. Mean age was 80±7 years. In our patient cohort 15.7% of the patients received PM within three months after TAVI. GLS and QRS duration was not different between AVB group and No-AVB group (−15.8±4.5% vs −16.9±4.4%, p=0.26 and 107±31ms vs 102±18ms, p=0.24 respectively). LVMD was prolonged in patients with subsequent AVB compared to patients with No-AVB (60±19ms vs 48±13ms, p<0.001) (Figure 1). LVMD predicted AVB after TAVI with area under the curve 0.71. LVMD predicted AVB independently of QRS duration (odds ratio 1.68; 95% confidence interval 1.23–2.3; p=0.001 by 10ms increments) (Table 1). LVMD predicted AVB after TAVI independent of QRS duration. LVMD may be of added value as a myocardial functional echocardiographic predictor of this important and frequent complication of TAVI. Type of funding sources: Foundation. Main funding source(s): EACVI Research Grant 2020