Circulation: Arrhythmia and Electrophysiology
After device infection, strategies for whether to reimplant hardware and the timing of this decision vary. This observational study analyzes the MEDIC database, a prospective multicenter registry of cardiac implantable electronic device infections in patients from 10 institutions in the United States, Spain, and Germany. The results show repeat infection rates were low for patients who underwent new device implantation in the first few days to weeks after extraction of infected hardware. Rates of recurrent infection were high in those who did not undergo extraction. While the observational nature of the study is a limitation, it suggests that device extraction is critical in clearing device-related infection and in appropriate patients, device reimplantation may carry a low risk for recurrent infection.
Reimplantation and Repeat Infection After Cardiac Implantable Electronic Device Infections
Experience From the MEDIC (Multicenter Electrophysiological Device Infection Cohort) Database
Thomas A. Boyle, BS
Daniel Z. Uslan, MD, MBA
Jordan M. Prutkin, MD, MHS
Arnold J. Greenspon, MD
Larry M. Baddour, MD
Stephan B. Danik, MD
Jose M. Tolosana, MD, PhD
Katherine Le, MD
Jose M. Miro, MD, PhD
James Peacock, MD
Muhammad R. Sohail, MD
Holenarasipur R. Vikram, MD
Roger G. Carrillo, MD
Correspondence to: Thomas A. Boyle, BS, Department of Surgery, Division of Cardiothoracic Surgery, University of Miami Hospital, 1295 NW 14th Street, Suite H, Miami, FL 33125 or Roger G. Carrillo MD FHRS, Department of Cardiothoracic Surgery, University of Miami Hospital, 1295 NW 14th Street, Suite H, Miami, FL 33125. E-mailor
BACKGROUND: Infection is a serious complication of cardiovascular-implantable electronic device implantation and necessitates removal of all hardware for optimal treatment. Strategies for reimplanting hardware after infection vary widely and have not previously been analyzed using a large, multicenter study.
METHODS AND RESULTS: The MEDIC (Multicenter Electrophysiological Device Infection Cohort) prospectively enrolled subjects with cardiovascular-implantable electronic device infections at multiple institutions in the United States and abroad between 2009 and 2012. Reimplantation strategies were evaluated overall, and every patient who relapsed within 6 months was individually examined for clinical information that could help explain the negative outcome. Overall, 434 patients with cardiovascular-implantable electronic device infections were prospectively enrolled at participating centers. During the initial course of therapy, complete device removal was done in 381 patients (87.8%), and 220 of them (57.7%) were ultimately reimplanted with new devices. Overall, the median time between removal and reimplantation was 10 days, with an interquartile range of 6 to 19 days. Eleven of the 434 patients had another infection within 6 months, but only 4 of them were managed with cardiovascular-implantable electronic device removal and reimplantation during the initial infection. Thus, the repeat infection rate was low (1.8%) in those who were reimplanted. Patients who retained original hardware had a 11.3% repeat infection rate.
CONCLUSIONS: Our study findings confirm that a broad range of reimplant strategies are used in clinical practice. They suggest that it is safe to reimplant cardiac devices after extraction of previously infected hardware and that the risk of a second infection is low, regardless of reimplant timing.
Circ Arrhythm Electrophysiol. 2017;10:e004822. DOI: 10.1161/CIRCEP.116.004822.
Circulation: Cardiovascular Genetics
There are likely heterogeneous etiologies for heart failure with preserved ejection fraction (HFpEF). This study investigated inflammatory biomarkers in HFpEF and their correlation to diastolic dysfunction, functional class, pathophysiological processes, and prognosis in 86 patients in the Karolinska Rennes biomarker substudy using orthogonal partial least square and Ingenuity Pathway Analysis core analyses. This novel analysis suggests that systemic inflammation plays a role in HFpEF and is associated with HFpEF severity.
Inflammatory Biomarkers Predict Heart Failure Severity and Prognosis in Patients With Heart Failure With Preserved Ejection Fraction
A Holistic Proteomic Approach
Camilla Hage, RN, PhD
Erik Michaëlsson, PhD
Cecilia Linde, MD, PhD
Erwan Donal, MD, PhD
Jean-Claude Daubert, MD, PhD
Li-Ming Gan, MD, PhD
Lars H. Lund, MD, PhD
Correspondence to: Camilla Hage, RN, PhD, Department of Cardiology, Research Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden. E-mail
BACKGROUND: Underlying mechanisms in heart failure (HF) with preserved ejection fraction remain unknown. We investigated cardiovascular plasma biomarkers in HF with preserved ejection fraction and their correlation to diastolic dysfunction, functional class, pathophysiological processes, and prognosis.
METHODS AND RESULTS: In 86 stable patients with HF and EF ≥45% in the Karolinska Rennes (KaRen) biomarker substudy, biomarkers were quantified by a multiplex immunoassay. Orthogonal projection to latent structures by partial least square analysis was performed on 87 biomarkers and 240 clinical variables, ranking biomarkers associated with New York Heart Association (NYHA) Functional class and the composite outcome (all-cause mortality and HF hospitalization). Biomarkers significantly correlated with outcome were analyzed by multivariable Cox regression and correlations with echocardiographic measurements performed. The orthogonal partial least square outcome-predicting biomarker pattern was run against the Ingenuity Pathway Analysis (IPA) database, containing annotated data from the public domain. The orthogonal partial least square analyses identified 32 biomarkers correlated with NYHA class and 28 predicting outcomes. Among outcome-predicting biomarkers, growth/differentiation factor-15 was the strongest and an additional 7 were also significant in Cox regression analyses when adjusted for age, sex, and N-terminal probrain natriuretic peptide: adrenomedullin (hazard ratio per log increase 2.53), agouti-related protein; (1.48), chitinase-3–like protein 1 (1.35), C–C motif chemokine 20 (1.35), fatty acid–binding protein (1.33), tumor necrosis factor receptor 1 (2.29), and TNF-related apoptosis-inducing ligand (0.34). Twenty-three of them correlated with diastolic dysfunction (E/e′) and 5 with left atrial volume index. The IPA suggested that increased inflammation, immune activation with decreased necrosis and apoptosis preceded poor outcome.
CONCLUSIONS: In HF with preserved ejection fraction, novel biomarkers of inflammation predict HF severity and prognosis that may complement or even outperform traditional markers, such as N-terminal probrain natriuretic peptide. These findings lend support to a hypothesis implicating global systemic inflammation in HF with preserved ejection fraction.
Circ Cardiovasc Genet. 2017;10:e001633. DOI: 10.1161/CIRCGENETICS.116.001633.
Circulation: Cardiovascular Imaging
Although several echo parameters have been described for distinguishing cardiac amyloidosis from other causes of myocardial thickening, it is unclear which performs best. In this study of a challenging diagnostic subgroup of patients with thickened myocardium due to cardiac amyloidosis, hypertrophic cardiomyopathy, or hypertension, the authors found that global longitudinal strain ratio has the best accuracy in distinguishing cardiac amyloidosis.
Echo Parameters for Differential Diagnosis in Cardiac Amyloidosis
A Head-to-Head Comparison of Deformation and Nondeformation Parameters
Efstathios D. Pagourelias, MD, PhD
Oana Mirea, MD, PhD
Jürgen Duchenne, MSc
Johan Van Cleemput, MD, PhD
Michel Delforge, MD, PhD
Jan Bogaert, MD, PhD
Tatyana Kuznetsova, MD, PhD
Jens-Uwe Voigt, MD, PhD
Correspondence to: Jens-Uwe Voigt, MD, PhD, Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium. E-mail
BACKGROUND: A plethora of echo parameters has been suggested for distinguishing cardiac amyloidosis (CA) from other causes of myocardial thickening with, however, scarce data on their head-to-head comparison. This study aimed at comparing the diagnostic accuracy of various deformation and conventional echo parameters in differentiating CA from other hypertrophic substrates, especially in the gray zone of mild hypertrophy (maximum wall thickness ≤16 mm) or normal ejection fraction (EF).
METHODS AND RESULTS: We included 100 subjects, of which 40 were patients with newly diagnosed, biopsy-proven CA (65.5±10.8 years, 65% male, 62.5% amyloidosis light chain [AL] type), 40 patients with hypertrophic cardiomyopathy matched for demographics and maximum wall thickness (60.1±14.8 years, 85% male), and 20 hypertensives with prominent myocardial remodeling. Quantifiable conventional morphological and functional parameters along with multidimensional strain and strain-derived ratios indices, previously suggested to diagnose CA, were analyzed. EF global longitudinal strain ratio showed the best performance to discriminate CA (area under the curve, 0.95; 95% confidence intervals, 0.89–0.98; P<0.00005). Traditional echo indices showed overall low sensitivities and high specificities (among them myocardial contraction fraction ratio had the highest area under the curve, 0.80; 95% confidence intervals, 0.7–0.87; P<0.0001). In the challenging subgroups (maximum wall thickness ≤16 mm and EF>55%), EF global longitudinal strain ratio remained the best predicting parameter of CA diagnosis (multiple logistic regression models P<0.00005 and P=0.0002, respectively) independent of the CA type.
CONCLUSIONS: Our study demonstrated that in patients with thickened hearts, EF global longitudinal strain ratio has the best accuracy in detecting CA, even among the most “challenging” patient subgroups as those with mild hypertrophy and normal EF.
Circ Cardiovasc Imaging. 2017;10:e005588. DOI: 10.1161/CIRCIMAGING.116.005588.
Circulation: Cardiovascular Interventions
There is limited information available on pregnancy-associated spontaneous coronary artery dissection. This literature review of 120 cases reported between 2000 and 2015 showed that reported cases of pregnancy-associated spontaneous coronary artery dissection are associated with high rates of left main, left anterior descending, or multivessel involvement. The reported cases suggest high rates of cardiogenic shock, life-threatening arrhythmias, emergent coronary artery bypass surgery, use of mechanical support and cardiac transplantation, and a high maternal and fetal mortality. There were marginal success rates of percutaneous coronary intervention in the reported literature, with a significant proportion requiring bypass surgery or more advanced therapies.
Pregnancy and the Risk of Spontaneous Coronary Artery Dissection
An Analysis of 120 Contemporary Cases
Ofer Havakuk, MD
Sorel Goland, MD
Anil Mehra, MD
Uri Elkayam, MD
Correspondence to: Uri Elkayam, MD, Division of Cardiovascular Medicine, Department of Medicine, University of Southern California, 2020 Zonal Ave, Los Angeles, CA 90033. E-mail
BACKGROUND: Because of the rarity of this condition, information on pregnancy-associated spontaneous coronary artery dissection is limited. We reviewed a large number of contemporary pregnancy-associated spontaneous coronary artery dissection cases in an attempt to define the clinical characteristics and provide management recommendations.
METHODS AND RESULTS: A literature search for cases of pregnancy-associated spontaneous coronary artery dissection reported between 2000 and 2015 included 120 cases; 75% presented with ST-segment–elevation myocardial infarction, and 80% had anterior myocardial infarction. Left anterior descending coronary artery was involved in 72% of cases, left main segment in 36%, and 40% had multivessel spontaneous coronary artery dissection. Ejection fraction was reduced to <40% in 44% of cases. Percutaneous coronary intervention was successful in only 50% of cases. Coronary artery bypass surgery was performed in 44 cases because of complex anatomy, hemodynamic instability, or failed percutaneous coronary intervention. Maternal complications included cardiogenic shock (24%), mechanical support (28%), urgent percutaneous coronary intervention (28%), urgent coronary artery bypass surgery (27.5%), maternal mortality (4%), and fetal mortality (2.5%). During follow-up for 305±111 days, there was a high incidence of symptoms because of persistent or new spontaneous coronary artery dissections, and 5 women needed heart transplantation or ventricular assist device implantation.
CONCLUSIONS: Pregnancy-associated spontaneous coronary artery dissection is commonly associated with left anterior descending, left main, and multivessel involvement, which leads to a high incidence of reduced ejection fraction, and life-threatening maternal and fetal complications. Percutaneous coronary intervention is associated with low success rate and high likelihood of complications, and coronary artery bypass surgery is often required. Recurrent ischemic events because of persistent or new spontaneous coronary artery dissection are common during long-term follow-up.
Circ Cardiovasc Interv. 2017;10:e004941. DOI: 10.1161/CIRCINTERVENTIONS.117.004941.
Circulation: Cardiovascular Quality and Outcomes
This is a nationwide cohort study of adult patients undergoing percutaneous coronary intervention in 93 English and Welsh National Health Service hospitals between 2007 and 2013. The study analyzes the uncertain relationship between procedural volume and prognosis after percutaneous coronary intervention using a Bayesian inference approach. The results show that after risk adjustment, mortality outcomes were similar in lower volume centers compared with higher volume centers.
Total Center Percutaneous Coronary Intervention Volume and 30-Day Mortality
A Contemporary National Cohort Study of 427 467 Elective, Urgent, and Emergency Cases
Darragh O’Neill, PhD
Owen Nicholas, PhD
Chris P. Gale, BSc, MBBS, PhD, MEd, MSc
Peter Ludman, MA, MD
Mark A. de Belder, MA, MD
Adam Timmis, MA, MD
Keith A.A. Fox, BSc, MBChB, F Med Sci
Iain A Simpson, MD
Simon Redwood, MBBS, MD
Simon G. Ray, MD
Correspondence to: Darragh O’Neill, PhD, Research Department of Epidemiology and Public Health, University College London, 1 - 19 Torrington Place, London WC1E 6BT, United Kingdom. E-mail
BACKGROUND: The relationship between procedural volume and prognosis after percutaneous coronary intervention (PCI) remains uncertain, with some studies finding in favor of an inverse association and some against. This UK study provides a contemporary reassessment in one of the few countries in the world with a nationally representative PCI registry.
METHODS AND RESULTS: A nationwide cohort study was performed using the national British Cardiovascular Intervention Society registry. All adult patients undergoing PCI in 93 English and Welsh NHS hospitals between 2007 and 2013 were analyzed using hierarchical modeling with adjustment for patient risk. Of 427 467 procedures (22.0% primary PCI) in 93 hospitals, 30-day mortality was 1.9% (4.8% primary PCI). 87.1% of centers undertook between 200 and 2000 procedures annually. Case mix varied with center volume. In centers with 200 to 399 PCI cases per year, a smaller proportion were PCI for ST-segment–elevation myocardial infarction (8.4%) than in centers with 1500 to 1999 PCI cases per year (24.2%), but proportionally more were for ST-segment–elevation myocardial infarction with cardiogenic shock (8.4% versus 4.3%). For the overall PCI cohort, after risk adjustment, there was no significant evidence of worse, or better, outcomes in lower volume centers from our own study, or in combination with results from other studies. For primary PCI, there was also no evidence for increased or decreased mortality in lower volume centers.
CONCLUSIONS: After adjustment for differences in case mix and clinical presentation, this study supports the conclusion of no trend for increased mortality in lower volume centers for PCI in the UK healthcare system.
Circ Cardiovasc Qual Outcomes. 2017;10:e003186. DOI: 10.1161/CIRCOUTCOMES.116.003186.
Circulation: Heart Failure
This study investigated heart failure incidence and postheart failure survival by race and sex among 27 078 low-income individuals enrolled in the Southern Community Cohort Study. The results show that individuals of lower socioeconomic status in the southeastern United States are at particularly high risk for the development of heart failure and population and that individual level resources are needed in this segment of the population.
Heart Failure Incidence and Mortality in the Southern Community Cohort Study
Elvis A. Akwo, MD, MS
Edmond K. Kabagambe, DVM, PhD
Thomas J. Wang, MD
Frank E. Harrell Jr, PhD
William J. Blot, PhD
Michael Mumma, MS
Deepak K. Gupta, MD
Loren Lipworth, ScD
Correspondence to: Loren Lipworth, ScD, Division of Epidemiology, Vanderbilt University School of Medicine, 2525 West End Ave, Suite 600, Nashville, TN 37203. E-mail
BACKGROUND: There is a paucity of data on heart failure (HF) incidence among low-income and minority populations. Our objective was to investigate HF incidence and post-HF survival by race and sex among low-income adults in the southeastern United States.
METHODS AND RESULTS: Participants were 27 078 white and black men and women enrolled during 2002 to 2009 in the SCCS (Southern Community Cohort Study) who had no history of HF and were receiving Centers for Medicare and Medicaid Services. Incident HF diagnoses through December 31, 2010 were ascertained using International Classification of Diseases 9th Revision codes 428.x via linkage with Centers for Medicare and Medicaid Services research files. Most participants were black (68.8%), women (62.6%), and earned <$15 000/y (69.7%); mean age was 55.5 (10.4) years. Risk factors for HF were common: hypertension (62.5%), diabetes mellitus (26.5%), myocardial infarction (8.6%), and obesity (44.8%). Over a median follow-up of 5.2 years, 4341 participants were diagnosed with HF. The age-standardized incidence rates were 34.8, 37.3, 34.9, and 35.6/1000 person-years in white women, white men, black men, and black women, respectively, remarkably higher than previously reported. Among HF cases, 952 deaths occurred over a median follow-up of 2.3 years. Men had lower survival; hazard ratios and 95% confidence intervals were 1.63 (1.27–2.08), 1.38 (1.11–1.72), and 0.90 (0.73–1.12) for white men, black men, and black women compared with white women.
CONCLUSIONS: In this low-income population, HF incidence was higher for all race–sex groups than previously reported in other cohorts. The SCCS is a unique resource to investigate determinants of HF risk in a segment of the population underrepresented in other existing cohorts.
Circ Heart Fail. 2017;10:e003553. DOI: 10.1161/CIRCHEARTFAILURE.116.003553.
Circulation is available at http://circ.ahajournals.org.
- © 2017 American Heart Association, Inc.