PURPOSE:The central augmentation index (cAIx) is an indirect measure of arterial stiffness. The influence of heart rate variability (HRV) on cAIx remains unexplored in a military cohort and was the aim of this analysis. METHOD:The first follow-up data from the ArmeD serVices trAuma rehabilitatioN outComE (ADVANCE) study were analysed. Participants were male British servicemen who served in Afghanistan (2003-2014) and were divided into two groups at recruitment: injured (who sustained severe combat injury) and uninjured. The uninjured were frequency-matched to the injured by age, rank, role-in-theatre and deployment. HRV was reported as root-mean-square-of-successive-differences (RMSSD) using a five-minute single-lead electrocardiogram. The cAIx was measured using pulse waveform analysis and was adjusted for heart rate at 60 beats/minute (cAIx@60). Effect modification by injury was assessed via interaction analysis. Linear models reported the association between RMSSD (HRV) and cAIx@60 adjusting for a priori confounders. RESULTS:1052 participants (injured n = 526; uninjured 526; median age at follow-up 37.4 years) were examined. Effect modification by injury was not statistically significant; therefore, was adjusted for along with other confounders. RMSSD and cAIx@60 exhibited a moderate inverse correlation (-0.40; p < 0.001). The association between natural log-transformed RMSSD (LnRMSSD) and cAIx@60 was non-linear and statistically significant, suggesting that a 10% decrease in LnRMSSD would be associated with 0.30% increase in cAIx@60. CONCLUSION:Lower RMSSD (HRV) is associated with an increase in cAIx@60, independent of injury status and other traditional cardiovascular risk factors. The efficacy of positive HRV modification on cardiovascular risk in military populations needs to be examined.

Abstract The ambulatory arterial stiffness index (AASI) is a novel measure of both blood pressure (BP) variability and arterial stiffness. This systematic review and meta‐analysis was designed to evaluate the strength of the association between AASI and mortality and major adverse cardiovascular events (MACE). PubMed, Scopus, CINAHL, Google Scholar. and the Cochrane library were searched for relevant studies to July 31, 2023. Two investigators independently extracted data. The Newcastle‐Ottawa Scale (NOS) was used to assess the quality of all included articles. The relationship between baseline AASI and outcomes were examined using relative risk (RR) ratios with 95% confidence intervals (CI) with RevMan web. Thirteen studies were included and representing 28 855 adult patients who were followed up from 2.2 to 15.2 years. A 1‐standard deviation (1‐SD) increase in AASI was associated with a significant increase in all‐cause death (RR 1.12; 95% CI: 0.95‐1.32), stroke (RR 1.25; 95% CI: 1.09‐1.44), and MACE (RR 1.07; 95% CI: 1.01‐1.13; [I2 = 32%]). Higher dichotomized AASI (above vs. below researcher defined cut‐offs) was associated with a significant increase in all‐cause mortality (RR 1.19; 95% CI: 1.06‐1.32), cardiovascular death (RR 1.29; 95% CI: 1.14‐1.46), stroke (RR 1.57; 95% CI: 1.33‐1.85), and MACE (RR1.29; 95% CI: 1.16‐1.44). There was a significant risk of bias in more than 50% of studies with no evidence of significant publication bias. Higher AASI is associated with an increased risk of all‐cause and cardiovascular death, stroke, and MACE. Further high‐quality studies are warranted to determine reproducible AASI cut‐offs to enhance its clinical risk precision.

IntroductionCombat-related traumatic injury (CRTI) has been linked to an increased cardiovascular disease (CVD) risk. The long-term impact of CRTI on heart rate variability (HRV)-a robust CVD risk marker-has not been explored. This study investigated the relationship between CRTI, the mechanism of injury and injury severity on HRV.MethodsThis was an analysis of baseline data from the ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) prospective cohort study. The sample consisted of UK servicemen with CRTI sustained during deployment (Afghanistan, 2003-2014) and an uninjured comparison group who were frequency matched to the injured group based on age, rank, deployment period and role in theatre. Root mean square of successive differences (RMSSD) was measured as a measure of ultrashort term HRV via <16 s continuous recording of the femoral arterial pulse waveform signal (Vicorder). Other measures included injury severity (New Injury Severity Scores (NISS)) and injury mechanism.ResultsOverall, 862 participants aged 33.9 +/- 5.4 years were included, of whom 428 (49.6%) were injured and 434 (50.3%) were uninjured. The mean time from injury/deployment to assessment was 7.91 +/- 2.05 years. The median (IQR) NISS for those injured was 12 (6-27) with blast being the predominant injury mechanism (76.8%). The median (IQR) RMSSD was significantly lower in the injured versus the uninjured (39.47 ms (27.77-59.77) vs 46.22 ms (31.14-67.84), p<0.001). Using multiple linear regression (adjusting for age, rank, ethnicity and time from injury), geometric mean ratio (GMR) was reported. CRTI was associated with a 13% lower RMSSD versus the uninjured group (GMR 0.87, 95% CI 0.80-0.94, p<0.001). A higher injury severity (NISS >= 25) (GMR 0.78, 95% CI 0.69-0.89, p<0.001) and blast injury (GMR 0.86, 95% CI 0.79-0.93, p<0.001) were also independently associated with lower RMSSD.ConclusionThese results suggest an inverse association between CRTI, higher severity and blast injury with HRV. Longitudinal studies and examination of potential mediating factors in this CRTI-HRV relationship are needed.

Purpose: A temporal reduction in the cardiovascular autonomic responses predisposes patients to cardiovascular instability after a viral infection and therefore increases the risk of associated complications. These findings have not been replicated in a bacterial infection. This pilot study will explore the prevalence of cardiovascular autonomic dysfunction (CAD) in hospitalized patients with a bacterial infection. Methods: A longitudinal observational pilot study was conducted. Fifty participants were included: 13 and 37 participants in the infection group and healthy group, respectively. Recruitment and data collection were carried out during a two-year period. Participants were followed up for 6 weeks: all participants’ cardiovascular function was assessed at baseline (week 1) and reassessed subsequently at week 6 so that the progression of the autonomic function could be evaluated over that period of time. The collected data were thereafter analyzed using STATA/SE version 16.1 (StataCorp). The Fisher Exact test, McNemar exact test, Mann–Whitney test and Wilcoxon test were used for data analysis. Results: 32.4% of the participants in the healthy group were males (n = 12) and 67.6% were females (n = 25). Participants’ age ranged from 33 years old to 76 years old with the majority being 40–60 years of age (62.1%) (Mean age 52.4 SD = 11.4). Heart rate variability (HRV) in response to Valsalva Maneuver, metronome breathing, standing and sustained handgrip in the infection group was lower than in the healthy group throughout the weeks. Moreover, both the HRV in response to metronome breathing and standing up showed a statistically significant difference when the mean values were compared between both groups in week 1 (p = 0.03 and p = 0.013). The prevalence of CAD was significantly higher in the infection group compared to healthy volunteers, both at the beginning of the study (p = 0.018) and at the end of follow up (p = 0.057), when all patients had been discharged. Conclusions: CAD, as assessed by the HRV, is a common finding during the recovery period of a bacterial infection, even after 6 weeks post-hospital admission. This may increase the risk of complications and cardiovascular instability. It may therefore be of value to conduct a wider scale study to further evaluate this aspect so recommendations can be made for the cardiovascular autonomic assessment of patients while they are recovering from a bacterial infectious process.

Various non-electrocardiogram (ECG) based methods are considered reliable sources of heart rate variability (HRV) measurement. However, the ultra-short recording of a femoral arterial waveform has never been validated against the gold-standard ECG-based 300s HRV and was the aim of this study. A validity study was conducted using a sample from the first follow-up of the longitudinal ADVANCE study UK. The participants were adult servicemen (n = 100); similar in age, rank, and deployment period (Afghanistan 2003–2014). The femoral arterial waveforms (14s) from the pulse wave velocity (PWV) assessment, and ECG (300s) were recorded at rest in the supine position using the Vicorder™ and Bittium Faros™ devices, respectively, in the same session. HRV analysis was performed using Kubios Premium. Resting heart rate (HR) and root mean square of successive differences (RMSSD) were reported. The Bland-Altman

ABSTRACTBackgroundHeart rate variability (HRV) is a marker of autonomic function. However, the reliability of short‐term HRV measurement in individuals with combat‐related traumatic injury (CRTI) remains undetermined.MethodsAn intra‐ and inter‐rater reliability study was conducted using a subsample (n = 35) of British servicemen with CRTI enrolled in the ongoing ADVANCE study. A five‐minute epoch of single‐lead electrocardiogram data collected during spontaneous breathing was used to measure HRV. HRV analyses were independently performed by two examiners using Kubios. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimum detectable change (MDC), and coefficient of variance were calculated for linear [root mean square of successive difference (RMSSD), standard deviation of NN interval, low‐frequency, high‐frequency, total power] and nonlinear (SD1‐2, acceleration and deceleration capacities, sample entropy) measures. Bland–Altman %plots were used to assess bias in intra‐ and inter‐rater HRV data.ResultsThe mean age of participants was 39.3 ± 6.3 years. An excellent ICC score of 0.9998 (95% CI 0.9997, 0.9999) was observed for intra‐rater analyses of RMSSD, and similar excellent ICC scores were seen for all other HRV measures. The inter‐rater reliability analyses produced an excellent ICC score (range 0.97–1.00). Comparatively, frequency‐domain measures produced higher MDC% and SEM% scores than time‐domain and nonlinear measures in both inter‐ and intra‐rater analyses. The Bland–Altman plots revealed relatively higher bias for frequency‐domain and nonlinear measures than time‐domain measures.ConclusionECG‐related short‐term HRV measures were reliable in injured servicemen under spontaneous breathing. However, the reliability appeared better with the time‐domain measure than frequency‐domain and nonlinear measures in this sample.

BACKGROUND:Respiration is a crucial determinant of autonomic balance and heart rate variability (HRV). The comparative effect of spontaneous versus paced breathing on HRV has been almost exclusively explored in healthy adults and never been investigated in an injured military cohort. OBJECTIVE:To examine the effect of spontaneous versus paced breathing on HRV in veterans with combat-related traumatic injury (CRTI). DESIGN:Observational cohort study. SETTING:ArmeD serVices trAuma rehabilitatioN outComE (ADVANCE) study, Stanford Hall, UK. PARTICIPANTS:The sample consisted of 100 randomly selected participants who sustained CRTI (eg, amputation) during their deployment (Afghanistan 2003-2014) and were recruited into the ongoing ADVANCE prospective cohort study. INTERVENTION:Not applicable. MAIN OUTCOME MEASURE:HRV was recorded using a single-lead ECG. HRV data were acquired during a sequential protocol of 5-minute spontaneous breathing followed immediately by 5 minutes of paced breathing (six cycles/minute) among fully rested and supine participants. HRV was reported using time domain (root mean square of successive differences), frequency domain (low frequency and high frequency) and nonlinear (sample entropy) measures. The agreement between HRV during spontaneous versus paced breathing was examined using the Bland-Altman analysis. RESULTS:The mean age of participants was 36.5 ± 4.6 years. Resting respiratory rate was significantly higher with spontaneous versus paced breathing (13.4 ± 3.4 vs. 7.6 ± 2.0 breaths/minute; p < .001), respectively. Resting mean heart rate and root mean square of successive differences were significantly higher with paced breathing than spontaneous breathing (p < .001). Paced breathing significantly increased median low frequency power than spontaneous breathing (p < .001). No significant difference was found in the absolute power of high frequency between the two breathing protocols. The Bland-Altman analysis revealed poor agreement between HRV values during spontaneous and paced breathing conditions with wide limits of agreement. CONCLUSION:Slow-paced breathing leads to higher HRV than spontaneous breathing and could overestimate resting "natural-state" HRV.

ABSTRACT Introduction Combat-related traumatic injury (CRTI) adversely affects heart rate variability (HRV). The mediating effect of mental and physical health factors on the relationship between CRTI, its severity and HRV has not been previously studied and investigated. Materials and Methods A cross-sectional mediation analysis of the ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) prospective cohort study was performed. The sample consisted of injured and uninjured British male servicemen who were frequency-matched based on their age, rank, role-in-theater, and deployment to Afghanistan (2003-2014). CRTI and injury severity (the New Injury Severity Scores [NISS] [NISS < 25 and NISS ≥ 25]) were included as exposure variables. HRV was quantified using the root mean square of successive differences (RMSSD) obtained using pulse waveform analysis. Depression and anxiety mediators were quantified using the Patient Health Questionnaire and Generalized Anxiety Disorder, respectively. Body mass index and the 6-minute walk test (6MWT) represented physical health measures. Two mediation pathways between exposure and outcome variables were examined in comparison with the uninjured group using structural equation modeling. Results Of 862 servicemen, 428 were injured and 434 were uninjured with the mean age at assessment of 33.9 ± 5.4 (range 23-59) years. Structural equation modeling revealed that depression, anxiety, and body mass index did not significantly mediate the relationship between injury/injury severity and RMSSD. However, the 6MWT significantly mediated the relationship between CRTI and RMSSD (27% mediation). The indirect effect of 6MWT on the relationship between injury severity (NISS ≥ 25 vs. uninjured) and RMSSD was −0.06 (95% CI: −0.12, −0.00, P < .05). Conclusions The findings suggest that greater physical function may improve HRV following CRTI. Longitudinal studies are warranted to further validate these findings.

Heart Rate Variability (HRV) is an indirect measure of autonomic function. Attenuated HRV is linked to worsening health outcomes including Major Adverse Cardiovascular Events (MACE). The relationship between traumatic injury (TI) and HRV has been limitedly studied. This research protocol has been designed to conduct a systematic review of the existing evidence on the association between non-acute TI and HRV in adults. Four electronic bibliographic databases (Web of Science, CINAHL, Medline, and Scopus) will be searched. The studies on non-acute (>7 days post injury) TI and HRV in adults will be included, followed by title-abstract screening by two reviewers independently. The quality and risk of bias of the included studies will be assessed using Axis and a six-item Risk of Bias Assessment tool for of Non-randomized Studies (RoBANS) respectively. Grading of Recommendations Assessment, Development and Evaluation (GRADE) will assess the quality of evidence. The extracted data will be synthesized using narrative syntheses and a Forest plot with or without meta-analysis- whichever permitted by the pooled data. This will be the first systematic review to examine the relationship between generalized TI and HRV in adults. Trial registration : (PROPSERO registration number: CRD: CRD42021298530 ) https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021298530 .

During a bacterial infection, individuals may present with behavioral changes referred to as sickness behavior, which has been suggested is induced by the inflammatory markers that are released because of the infective immunological challenge. However, few studies have explored this multidimensional phenomenon in naturally occurring conditions. A longitudinal observational study was conducted to explore the role of inflammatory cytokines in mediating the sickness behavior during a bacterial infection. There were 13, 11 and 37 participants in the infection, hospital control and healthy groups, respectively. They were all followed up for 6 weeks and their inflammatory markers were quantified throughout those weeks. Cognitive function and depressive state were assessed by means of the Mini-Mental State Examination (MMSE) and Cornell Scale for Depression in Dementia (CSDD). Reductions in proinflammatory markers C-Reactive protein (CRP), interleukin – 6 (IL6) and tumor necrosis factor-α (TNFα) and increments in anti-inflammatory markers (interleukin – 4 (IL4)) were associated with an improvement in CSDD and MSEE in patients recovering from a bacterial infection. The correlation between inflammatory makers and CSDD was statistically significant for the CRP (r = 0.535, p = 0.001), the IL6 (r = 0.499, p < 0.001), the TNFα (r = 0.235, p = 0.007) and the IL4 (r = −0.321, p = 0.018). Inflammatory cytokines may mediate sickness behavior during acute illness. These results may enhance the understanding of the pathophysiology and potential treatment strategies to palliate this sickness behavior.

Background Combat-related traumatic injury (CRTI) has been linked to an increased cardiovascular disease (CVD) risk in servicemen returning from military operations. While Heart Rate Variability (HRV) has been established as an objective and non-invasive marker of CVD risk, the long-term impact of unselected CRTI on HRV has not been explored to date. This study aimed to investigate the impact of CRTI, injury mechanism and injury severity on HRV. We hypothesised that HRV would be lower in injured servicemen than in uninjured servicemen. Methods This was a baseline analysis from the ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) prospective cohort study. The sample consisted of British servicemen with CRTI sustained during deployment to Afghanistan (2003–2014) and an uninjured comparison group who were frequency-matched to the injured group based on age, rank, deployment period and role-in-theatre. Root mean square of successive differences between normal heartbeats (RMSSD) was reported as a measure of HRV. RMSSD was measured over an ultra-short time period (HRVUST) of up to 16s continuous recording of the femoral arterial pulse waveform signal via the Vicorder device. Other measures included the New Injury Severity Scores (NISS) as a measure of injury severity and injury mechanism (blast and others). Results Overall 862 participants aged 33.9±5.4 years (range 23–59 years) were included, of who 428 (49.6%) were injured and 434 (50.3%) were uninjured. The median (interquartile range) NISS for those injured was 12 (6–27; range 1–66) with blast being the predominant injury mechanism (76.8%). The median (IQR) RMSSD was significantly lower in the injured versus the uninjured [39.47 ms (27.77–59.77) vs 46.22 ms (31.14–67.84), p<0.001]. Using multiple linear regression (adjusting for age, rank, ethnicity and time from injury), CRTI was associated with a 13% lower geometric mean ratio (GMR) RMSSD versus the uninjured group (GMR 0.87, 95%CI 0.80–0.94, p<0.001). A higher injury severity (NISS>25) (GMR 0.78, 95%CI 0.69–0.89, p<0.001) and blast mechanism of injury (GMR: 0.86, 95%CI 0.79–0.93, p<0.001) were also independently associated with lower RMSSD. Conclusion These results suggest an inverse association between CRTI, its worsening severity and blast mechanism of injury with HRV. These findings may help understand the cardiovascular profile of the population with traumatic injuries. Further research from longitudinal studies and examination of the potential mediating factors in this CRTI-HRV relationship are needed to better understand the cardiovascular profile of the military personnel.

In this study, the comparative precision of carotid versus femoral arterial waveforms to measure ultra-short term heart rate variability (HRVUST) following traumatic injury was investigated for the first time. This was an inter-rater reliability study of 50 British servicemen (aged 23–44 years) with non-acute combat-related traumatic injury (CRTI). Paired continuous arterial waveform data for HRVUST analysis, were simultaneously sampled at the carotid and femoral arterial sites (14–16 seconds) during pulse wave velocity (PWV) measurement. HRVUST was reported as the root mean square of the successive differences (RMSSD). Following the determination of the superior sampling site (carotid versus femoral), the blinded inter-rater agreement in RMSSD for the preferred site was quantified using the Intra-class Correlation Coefficient (ICC) and the Bland-Altman plot. The mean age of participants was 34.06±4.88 years. The femoral site was superior to the carotid site with a significantly higher number of reliable signals obtained (Fisher’s Exact test; p<0.001). The inter-rater agreement in femoral-derived RMSSD was excellent [ICC 0.99 (95%CI: 0.994–0.997)] with a moderate level of agreement (mean difference [bias]: 0.55; 95% CI: -0.13–1.24 ms). In this study, we demonstrated that the femoral artery is a more reliable site than the carotid artery for HRVUST measurement and post-trauma risk stratification following CRTI.

This chapter presents a critical review of the potential benefits of theophylline as a means to reduce the burden of post-acute inflammation in older age groups. A pro-inflammatory state often persists, or is extended, after sepsis, trauma and other acute illnesses in old age, particularly above the age of 80 years. The presence of inflammation at above-baseline amplitudes or excessive duration is associated with a higher likelihood of delirium, anorexia, unplanned weight loss, lethargy, depression, weakness and other markers of frailty. There is also an association with less favourable clinical outcomes and a higher risk of losing personal independence. Theophylline has been shown to have an anti-inflammatory effect, probably mediated through the induction of histone deacetylase-dependent gene switching in immune competent cells, that has been observed at cellular and whole organism levels. The main effects are a reduction in the production and release of TNF, IL-1 and IL-6, with a sequential fall in CRP and increase in IL-10, and a change of immune cells to their anti-inflammatory phenotypes. This happens when theophylline levels are between 5 and 10 mg/L, which is lower than the range for bronchodilators (10 to 15 mg/L) and presents a relatively low risk of toxicity. We hypothesize that low-dose theophylline treatment given to elderly subjects with acute inflammation, for example due to respiratory infection, septicaemia or trauma, will change the setting of their biochemical status from an inappropriately extended pro-inflammatory pattern toward a more normalized baseline pattern and consequently reduce the risk of adverse clinical outcomes.

Heart rate variability (HRV) is a known measure of cardiac autonomic function. A cardiovascular autonomic dysfunction (CAD), measured as changes in HRV, is usually presented after an infectious process. The aim of the present study is to assess the association between serum inflammatory markers and CAD. For this purpose, 50 volunteers (13 of them recovering from an infection) were recruited and followed-up for 6 weeks. Their serum inflammatory biomarkers (CRP, IL1, IL4, IL6, IL10, and TNFalpha) were quantified throughout those weeks, along with their HRV resting, in response to the Valsalva maneuver, metronome breathing, standing and sustained handgrip. The correlation of within-subject changes in both HRV and inflammatory biomarkers was assessed to evaluate the concurrent changes. An inverse within-subject correlation was found between CRP and HRV in response to the Valsalva maneuver (rho (95% CI): −0.517 (−0.877 to −0.001); p = 0.032) and HRV standing (rho (95% CI): −0.490 (−0.943 to −0.036); p = 0.034). At the beginning, increased values of CRP are found along with reduced levels of HRV. Then, the CRP was reduced, accompanied by an improvement (increase) in HRV. These results suggest that CRP is a potential marker of CAD. Whether it is the cause, the consequence or a risk indicator non-causally associated is still to be determined.

BACKGROUND:Scarce data exist on patients with previous left valve surgery (PLVS) undergoing transcatheter tricuspid valve intervention (TTVI). This study sought to investigate the procedural and early outcomes in patients with PLVS undergoing TTVI. METHODS:This was a subanalysis of the multicenter TriValve registry including 462 patients, 82 (18%) with PLVS. Data were analyzed according to the presence of PLVS in the overall cohort and in a propensity score-matched population including 51 and 115 patients with and without PLVS, respectively. RESULTS:Patients with PLVS were younger (72 ± 10 vs 78 ± 9 years; p < 0.01) and more frequently female (67.1% vs 53.2%; P = 0.02). Similar rates of procedural success (PLVS 80.5%; no-PLVS 82.1%; P = 0.73), and 30-day mortality (PLVS 2.4%, no-PLVS 3.4%; P = 0.99) were observed. After matching, there were no significant differences in both all-cause rehospitalisation (PLVS 21.1%, no-PLVS 26.5%; P = 0.60) and all-cause mortality (PLVS 9.8%, no-PLVS 6.7%; P = 0.58). At last follow-up (median 6 [interquartile range 1-12] months after the procedure), most patients (81.8%) in the PLVS group were in NYHA functional class I-II (P = 0.12 vs no-PLVS group), and TR grade was ≤ 2 in 82.6% of patients (P = 0.096 vs no-PVLS group). A poorer right ventricular function and previous heart failure hospitalization determined increased risks of procedural failure and poorer outcomes at follow-up, respectively. CONCLUSIONS:In patients with PLVS, TTVI was associated with high rates of procedural success and low early mortality. However, about one-third of patients required rehospitalisation or died at midterm follow-up. These results would support TTVI as a reasonable alternative to redo surgery in patients with PLVS and suggest the importance of earlier treatment to improve clinical outcomes.

OBJECTIVES The interference of a transtricuspid cardiac implantable electronic device (CIED) lead with tricuspid valve function may contribute to the mechanism of tricuspid regurgitation (TR) and poses specific therapeutic challenges during transcatheter tricuspid valve intervention (TTVI). Feasibility and efficacy of TTVI in presence of a CIED is unclear. BACKGROUND Feasibility of TTVI in presence of a CIED lead has never been proven on a large basis. METHODS The study population consisted of 470 patients with severe symptomatic TR from the TriValve (Transcatheter Tricuspid Valve Therapies) registry who underwent TTVI at 21 centers between 2015 and 2018. The association of CIED and outcomes were assessed. RESULTS Pre-procedural CIED was present in 121 of 470 (25.7%) patients. The most frequent location of the CIED lead was the posteroseptal commissure (44.0%). As compared with patients without a transvalvular lead (no-CIED group), patients having a tricuspid lead (CIED group) were more symptomatic (New York Heart Association functional class III to IV in 95.9% vs. 92.3%; p = 0.02) and more frequently had previous episodes of right heart failure (87.8% vs. 69.0%; p = 0.002). No-CIED patients had more severe TR (effective regurgitant orifice area 0.7 +/- 0.6 cm(2) vs. 0.6 +/- 0.3 cm(2); p = 0.02), but significantly better right ventricular function (tricuspid annular plane systolic excursion = 16.7 +/- 5.0 mm vs. 15.9 +/- 4.0 mm; p = 0.04). Overall, 373 patients (79%) were treated with the MitraClip (Abbott Vascular, Santa Clara, California) (106 [87.0%] in the CIED group). Among them, 154 (33%) patients had concomitant transcatheter mitral repair (55 [46.0%] in the CIED group, all MitraClip). Procedural success was achieved in 80.0% of no-CIED patients and in 78.6% of CIED patients (p = 0.74), with an in-hospital mortality of 2.9% and 3.7%, respectively (p = 0.70). At 30 days, residual TR <= 2+ was observed in 70.8% of no-CIED and in 73.7% of CIED patients (p = 0.6). Symptomatic improvement was observed in both groups (NYHA functional class I to II at 30 days: 66.0% vs. 65.0%; p = 0.30). Survival at 12 months was 80.7 +/- 3.0% in the no-CIED patients and 73.6 +/- 5.0% in the CIED patients (p = 0.30). CONCLUSIONS TTVI is feasible in selected patients with CIED leads and acute procedural success and short-term clinical outcomes are comparable to those observed in patients without a transtricuspid lead. (C) 2020 the American College of Cardiology Foundation. Published by Elsevier. All rights reserved.

OBJECTIVES:The interference of a transtricuspid cardiac implantable electronic device (CIED) lead with tricuspid valve function may contribute to the mechanism of tricuspid regurgitation (TR) and poses specific therapeutic challenges during transcatheter tricuspid valve intervention (TTVI). Feasibility and efficacy of TTVI in presence of a CIED is unclear. BACKGROUND:Feasibility of TTVI in presence of a CIED lead has never been proven on a large basis. METHODS:The study population consisted of 470 patients with severe symptomatic TR from the TriValve (Transcatheter Tricuspid Valve Therapies) registry who underwent TTVI at 21 centers between 2015 and 2018. The association of CIED and outcomes were assessed. RESULTS:Pre-procedural CIED was present in 121 of 470 (25.7%) patients. The most frequent location of the CIED lead was the posteroseptal commissure (44.0%). As compared with patients without a transvalvular lead (no-CIED group), patients having a tricuspid lead (CIED group) were more symptomatic (New York Heart Association functional class III to IV in 95.9% vs. 92.3%; p = 0.02) and more frequently had previous episodes of right heart failure (87.8% vs. 69.0%; p = 0.002). No-CIED patients had more severe TR (effective regurgitant orifice area 0.7 ± 0.6 cm2 vs. 0.6 ± 0.3 cm2; p = 0.02), but significantly better right ventricular function (tricuspid annular plane systolic excursion = 16.7 ± 5.0 mm vs. 15.9 ± 4.0 mm; p = 0.04). Overall, 373 patients (79%) were treated with the MitraClip (Abbott Vascular, Santa Clara, California) (106 [87.0%] in the CIED group). Among them, 154 (33%) patients had concomitant transcatheter mitral repair (55 [46.0%] in the CIED group, all MitraClip). Procedural success was achieved in 80.0% of no-CIED patients and in 78.6% of CIED patients (p = 0.74), with an in-hospital mortality of 2.9% and 3.7%, respectively (p = 0.70). At 30 days, residual TR ≤2+ was observed in 70.8% of no-CIED and in 73.7% of CIED patients (p = 0.6). Symptomatic improvement was observed in both groups (NYHA functional class I to II at 30 days: 66.0% vs. 65.0%; p = 0.30). Survival at 12 months was 80.7 ± 3.0% in the no-CIED patients and 73.6 ± 5.0% in the CIED patients (p = 0.30). CONCLUSIONS:TTVI is feasible in selected patients with CIED leads and acute procedural success and short-term clinical outcomes are comparable to those observed in patients without a transtricuspid lead.

Introduction: To investigate whether or not the threshold for subjectively detecting an increase in the resistance to airflow (LDT) during tidal breathing at rest rises in older age in patients with COPD, as it does in healthy people and asthmatics in remission. Material and methods: We conducted an open cross-sectional study of 31 older patients (age 55–89) with COPD and 60 healthy volunteers (age 55–86). Inspiratory and expiratory resistive load detection thresholds (ILDT and ELDT respectively) and spirometry were measured. Results: The mean (SD) ILDT was 5.93 (7.02) kPa.s/L in COPD patients, compared to 11.11 (8.47) in healthy people (P < 0.001) in the same age range. There was no significant correlation between ILDT and age in the COPD group (r = −0.182, P = 0.326), though significant correlation with age was found in healthy people (r = 0.591, P < 0.001). ILDT and ELDT in COPD patients correlated significantly with the FEV1/FVC ratio (r = 0.367, P = 0.048 and r = 0.481, P = 0.007 respectively) but not with other spirometry indices, height, weight, BMI, oxygen saturation or smoking pack-years. Conclusion: LDT during tidal breathing appears to be sensitized, and thereby lower, in older COPD patients, possibly due to altered central regulation of the threshold or as a consequence of the effect lung compliance, recoil and volume changes have on afferent input from mechano-receptors in COPD. Older COPD patients with good cognition are therefore likely to be as aware of changing airways resistance as younger patients and take appropriate therapeutic action.

Introduction and objective: We previously showed that inspiratory conductance (IC) can be calculated from early inspiratory pressure fall and initial acceleration of the inspiratory air column. To characterize IC further we conducted a study to determine whether its value varies with height, weight, BMI, age, sex and lung volumes. Methods: We measured IC, height, weight, FEV1, FVC and PEFR in 147 healthy volunteers’ age 18-50 years. Results: During tidal breathing at rest the mean (SD) IC was 8.31 (3.15) L s-1 kPa-1. No significant correlation was found between IC and height (r=0.04), weight (r=0.142), BMI (r=0.058), FEV1 (r=0.275), FVC (r=0.019), PEFR (r=0.182) or age (r=0.017) and there was no significant difference between men and women. The same was found for IC measured during slow deep breathing and rapid breathing. Conclusion: IC is independent of age, sex, height, weight, BMI and spirometric lung volumes so there is no imperative to correct for those factors in an individual. Within-subject directional changes in IC within the context of a short clinical timeframe might be the best potential for clinical application.