bluuebunny/crossref_metadata_2025 huggingface dataset:
Polygraphy as a new screening method for obstructive sleep apnea in patients with atrial fibrillation?
Authors: Delesie M , Knaepen L , Miljoen H , Willemen M , Verbraecken J , Weytjens K , Dendale P , Heidbuchel H , Desteghe L ,   Research Group Cardiovascular Diseases, University of Antwerp, Belgium
Published: October 2021

Background

Obstructive sleep apnea (OSA) is a modifiable risk factor of atrial fibrillation (AF) but is underdiagnosed in these patients. According to the 2020 European Society of Cardiology guidelines for the diagnosis and management of AF, it seems reasonable to test for OSA in symptomatic AF patients before initiation of rhythm control therapy. A good OSA screening pathway is lacking in the guidelines and in daily clinical practice in most centers today. Polysomnography (PSG) is the gold standard for diagnosing OSA but it is not an ideal screening method, due to its expensiveness, labour-intensiveness and limited availability.

Purpose

The aim of this study was to validate and examine the performance of different (cardiorespiratory) polygraphy (PG) devices, used with their automated algorithm to detect OSA in an AF cohort, compared with PSG as gold standard.

Methods

Prospective study with three PGs (ApneaLink Air (ALA), SOMNOtouch RESP (STR) and SpiderSAS (SpS) combined with ResMed Airview-, SomnoMedics DOMINO- and Microport SYNESCOPE software respectively) in consecutive AF patients who were referred for a PSG evaluation. Patients received the three devices with instructions for use after their PSG and were requested to use each one during three consecutive nights at home. Severity of OSA was classified according to the Apnea-Hypopnea Index (AHI) with <5 events/hour= no OSA, 5–14= mild-, 15–30= moderate-, >30= severe OSA.

Results

A total of 100 AF patients presenting for PSG were included (64.0±8.6 years, 73% male, 87% non-permanent AF, mean Body Mass Index 30.6±5.9 kg/m2, mean CHA2DS2-VASc score 2.4±1.7, mEHRA≥2 in 64%; mean AF history 5.4±5.6 years). PSG diagnosed ≥mild OSA in 90% of patients, ≥moderate in 69%, and severe OSA in 33%. Successful PG execution to determine the AHI, i.e. ≥4 hours of data on automated analysis, was obtained in 72.0%, 73.0% and 79.0% of patients with the ALA, STR and SpS respectively. In screening for clinically relevant OSA (i.e. at least moderate OSA), the PGs had an area under the curve of 0.802, 0.761 and 0.803 for the ALA, STR and SpS respectively (Figure 1).

Conclusions

This first analysis shows that PGs combined with an automated algorithm for AHI determination, can be used as OSA screening tools in AF patients before referral for PSG. Further optimisation is likely by choosing an appropriate AHI cut-off value for each PG.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): This study is supported by the Antwerp University Cardiology Research Fund, and is part of Limburg Clinical Research Center, supported by the foundation Limburg Sterk Merk, province of Limburg, Flemish government, Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital. Figure 1
Safety and efficacy of His-bundle pacing/left bundle branch area pacing versus right ventricular pacing: a systematic review and meta-analysis
Authors: Peng X.Y , Chen Y , Li X.X
Published: October 2021

Background

Recent studies have demonstrated that right ventricular pacing (RVP) has deleterious effects on non-synchronized ventricular contraction, while His-bundle pacing (HBP) or left bundle branch area pacing (LBBaP) contribute to improvements in patients' mid- and long-term outcomes. This meta-analysis aimed to compare the safety and efficacy of physiologic pacing (HBP/LBBaP) versus those of RVP.

Methods

A systematic search of PubMed, Cochrane Library, and Embase was conducted for studies that compared the effects of physiologic pacing and RVP. All eligible studies were published before January 1, 2021 and were conducted in humans. STATA software version 15.0 was used for all the data analyses.

Results

Twenty articles (n=2787 patients) were included in this meta-analysis. Compared to RVP, physiologic pacing were associated with a shorter QRS duration (weight mean difference [WMD] −41.84, 95% confidence interval [CI] −50.74, −32.94), better cardiac function (57.95±9.72% vs. 52.35±13.75%), and lower rates of mitral regurgitation (standardized mean difference [SMD] −0.33, 95% CI −0.76, 0.10), pacing-induced cardiomyopathy (odds ratio [OR] 0.77, 95% CI 0.52, 1.15), death (OR 0.94, 95% CI 0.78, 1.12), heart failure hospitalization (OR 0.94, 95% CI 0.79, 1.12) and atrial fibrillation (OR 0.95, 95% CI 0.76, 1.18), although some results were not statistically significant. In addition, RVP led to the achievement of higher success rates than physiologic pacing (OR 0.05, 95% CI 0.02, 0.13), a shorter fluoroscopic time and mean procedure duration (WMD 6.21, 95% CI 2.00, 10.42; WMD 20.75, 95% CI 13.78, 27.72), a lower pacing threshold (WMD 0.48, 95% CI 0.24, 0.72), and fewer surgical complications (OR 1.02, 95% CI 0.88, 1.19). Compared with HBP, LBBaP appeared to have some advantages in R wave amplitudes, pacing threshold, fluoroscopic time, procedure time, and success rate, however, some results were not statistically significant.

Conclusion

Physiologic pacing (HBP/LBBaP) might be a better strategy than RVP and improve long-term clinical outcomes like cardiac function. Although LBBaP appears to have some advantages over HBP, the long-term benefits are still controversial. More large-scale randomized clinical trials are needed for further verification.

Funding Acknowledgement

Type of funding sources: None.
Frequency and predictors of physical trauma during reflex syncope
Authors: Tavolinejad H , Yadangi S , Sadeghian S , Bozorgi A , Tajdini M
Published: October 2021

Background

Reflex syncope is a common and generally benign condition; however, the occurrence of secondary trauma can be a potentially harmful complication. Identification of characteristics and conditions associated with trauma after syncope are important for clinicians.

Purpose

We aimed to investigate the frequency and predictors of secondary injury during reflex syncope in a large dataset from a tertiary syncope unit.

Methods

All patients referred with an episode of transient loss of consciousness between December 2017 and November 2020 were evaluated. Patients who received a diagnosis of reflex syncope based on 2018 European Society of Cardiology guidelines entered the study. Clinical characteristics, conditions surrounding syncope, and – in patients with a history of previous episodes – a detailed history of up to three prior syncopal attacks were documented. The primary outcome was the presence of any clinically relevant injury that was related to syncope. In a secondary per-episode analysis, the outcome was a combination of traumatic injuries related to the current and past syncopal episodes.

Results

Among 1258 consecutive patients with reflex syncope (Mean age: 42.3 years; 49.6% female), 239 (23.3%) had evidence of trauma in their initial visit. Female sex (prevalence ratio [PR]: 1.24; P=0.037), body mass index ≥25 kg/m2 (PR: 1.28; P=0.016), previous injury caused by syncope (PR: 1.63; P<0.001), occurrence of syncope in morning hours (PR: 1.90; P<0.001), occurrence of syncope at home (PR: 1.61; P<0.001), absence of prodromes (PR: 1.32; P=0.024), and standing position at the time of syncope (PR: 1.61; P<0.001) were associated with injury. Although family history of syncope was not related to injury, history of syncope in brother showed a significant association with secondary trauma (PR: 2.19; P=0.003). In multivariable logistic regression, five characteristics (previous injury after syncope, occurrence of syncope in the morning, occurrence of syncope at home, absence of prodromes, and standing position at the time of syncope) were independent predictors of injury. In the absence of all five conditions, the risk of injury was <3%. In the secondary per-syncope analysis, of 2849 syncopal episodes, 1028 (36.1%) were associated with trauma. Having syncope in the morning (PR: 1.34; P<0.001), occurrence of syncope at home (PR: 1.51; P<0.001), absence of prodromes (PR: 1.34; P<0.001), and standing position at the time of syncope (PR: 1.55; P<0.001) were again associated with injury.

Conclusions

Secondary trauma after reflex syncope is a common complication. Specific conditions at the time of syncope are associated with traumatic injuries, suggesting that interventions to avoid syncopal attacks in those conditions might reduce secondary trauma.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Tehran University of Medical Sciences
Prognosis of apical hypertrophic cardiomyopathy in patients with an implantable cardioverter defibrillator
Authors: Nakano M , Kondo Y , Nakano M , Kajiyama T , Ito R , Takahira H , Kitagawa M , Sugawara M , Chiba T , Kobayashi Y
Published: October 2021

Background

Prophylactic use of implantable cardioverter-defibrillators (ICDs) to prevent sudden cardiac death (SCD) is widely spread all over the world in patients with hypertrophic cardiomyopathy (HCM). Apical HCM is a phenotype variant of HCM, with hypertrophy predominantly affecting apex, that was initially described 30 years ago. Apical HCM patients may have different clinical prognosis compared with other subsets of HCM. In previous studies, apical HCM patients seem to have a more benign prognosis than other types of HCM. However, little is known about the long-term outcomes of apical HCM and there are many unclear points. Moreover, there are few reports about the clinical prognosis in apical HCM patients with an ICD.

Objective

The aim of this study is to identify the difference between the prognosis of apical and the other HCM patients with an ICD.

Methods

We retrospectively analyzed the database of our ICD clinic. All subjects had been implanted with an ICD from October 2006 to August 2017. We classified HCM patients into LV outflow tract obstruction (LVOTO) and midventricular obstruction (MVO), apical HCM and other non-obstructive types. We divided all the patients into apical and other types of HCM, and examined their background, incidence of appropriate ICD therapies, hospitalization for heart failure, electrical storm and death.

Results

A total of consecutive 62 Japanese HCM patients with an ICD (follow-up period, 86±25 months; age, 67±14 years; male sex, 85%; left ventricular ejection fraction, 57±12%; LV max wall-thickness, 19±5mm; LV apical aneurysm, 9.7%; HCM Risk-SCD, 4.4±3.0) were enrolled in this study. We classified them into 14 apical HCM and 48 other types of HCM patients. The clinical characteristics and major events of these patients are shown in the Figure. During the follow-up periods, there were no significant differences in the incidence of hospitalization for heart failure, electrical storm and death between the 2 groups (p=0.40; p=0.22; p=0.23). Appropriate therapies occurred in 5 of 14 (36%) patients with apical HCM and 4 of 48 (8.3%) patients with other types of HCM (p=0.022).

Conclusions

Appropriate ICD therapy was more prevalent in patients with apical HCM, compared to patients with other types of HCM. However, the incidences of hospitalization for heart failure, electrical storm and death were not significantly different between two groups.

Funding Acknowledgement

Type of funding sources: None.
Frequency and distribution of J waves in survivors of ventricular fibrillation relationship with presence of myocardial fibrotic and or fat change and coronary arterial stenosis on cardiac CT
Authors: Funabashi N , Nakamura K , Sasaki T , Naito S , Kobayashi Y
Published: October 2021

Background

The presence and distribution of J waves, the occurrence of ventricular fibrillation (VF), and the presence of left ventricular (LV) myocardial fibrotic or fat change or coronary stenosis may be related.

Purpose

To determine the relationship of frequency and distribution of J waves with presence of myocardial fibrotic or fat change and coronary arterial stenosis on cardiac computed tomography (CT) in survivors of VF.

Methods

We conducted a retrospective analysis of 21 survivors of VF (17 males; mean age, 61±14 years) that were implanted with a cardioverter defibrillator and underwent cardiac CT.

Results

On ECG, four subjects had atrial fibrillation. The mean corrected QT interval was 442±39 msec. On CT, two subjects had significant coronary artery stenosis and 12 had LV myocardial fibrotic and/or fat change. The distribution of J waves were as follows: five subjects had J waves in II, III and aVF leads (three had myocardial fibrotic and/or fat change); and 2 had J waves in III lead (one had myocardial fibrotic and/or fat change). One subject each had J waves in V1 lead; V1, 2 leads; II, III, aVF and V1 leads; II, III, aVF and V1–3 leads; II, III, aVF, aVL and V1–6 leads; II, III, aVF and V1–6 leads; II, III, aVF and V4,5 leads; II, III, aVF and V2–5 leads; and III and aVF leads, respectively. The first two subjects did not have LV myocardial fibrotic and/or fat change and the remaining six subjects had myocardial fibrotic and/or fat change (Figure).

Conclusions

Survivors of VF with organized LV myocardial fibrotic and/or fat change showed more frequent J waves with a wider distribution (reached LV inferior wall leads) than survivors without these changes. Monitoring these characteristics on CT may be useful to predict VF.

Funding Acknowledgement

Type of funding sources: None. CT images of fat in a VF survivorJ waves and fibrotic and/or fat change
The efficacy of three dimensional echocardiography in assessment of aortic atherosclerotic plaques compared to two dimensional echocardiography
Authors: Behjati M , Mirdamadi A , Rahimi R.S
Published: October 2021

Background

Complex aortic atherosclerotic plaques (AAPs) carry a significant risk of embolism. Currently, two-dimensional (2D) transesophageal echocardiography (TEE) is the principal diagnostic tool of AAPs. However, we hypothesized that the data obtained from three-dimensional (3D) imaging may improve AAPs' spatial assessment.

Purpose

This study was aimed to evaluate the efficacy of 3DTEE in assessment of AAPs.

Methods

This study includes 96 patients who underwent routine TEE in our center within 2018–2019. The entire aorta including aortic root, ascending aorta, aortic arch, and descending thoracic aorta was investigated using both 2D and 3D TEE. The size and grade of aortic atherosclerotic plaques were compared using both 2D and 3D TEE. In addition, we examined to see if there is any correlation between the grade and size of the plaque, and patient's cardiac risk factors including their history of atherosclerotic diseases.

Results

Patients with atherosclerotic plaque in the ascending aorta had a larger plaque thickness in both two-dimensional and three-dimensional echocardiography. Obesity was an important risk factor for development of AAPs. Also, patients with a history of cerebrovascular attack (CVA) or transient ischemic attach (TIA) had larger AAPs. While age and gender showed no impact on the thickness of AAPs. According to the results obtained from comparing three-dimensional over two-dimensional echocardiography, one patient (1.04%) showed a decrease in grading scale, while nine patients (9.38%) showed enhancement in their grading (P-value=0.03). For the rest of 86 patients (89.58), atherosclerotic plaque grading was similar using both methods. This means that in almost 9% of cases 3D TEE increases the grading of the attributed atherosclerotic plaque, while it is the same to 2DTEE in most cases.

Conclusions

The information obtained from three-dimensional echocardiography would be most often very similar to the two-dimensional echocardiography, while in few cases, it would improve the grading scale. Cases with obesity and history of CVA and TIA had larger thickness of AAPs in both 2D and 3DTEE, while age and gender had no impact on plaque thickness.

Funding Acknowledgement

Type of funding sources: None.
Intraoperative echocardiography for electrode implantation into the left bundle branch region in patients with indications for cardiac resynchronization therapy
Authors: Karpenko I , Pavlinova N , Volkov D , Bochonko O
Published: October 2021

Background

Left bundle branch (LBB) pacing recently became a novel pacing modality for cardiac resynchronization therapy (CRT).

Purpose

We evaluated the feasibility and utility of intraoperative Echocardiography (TTE) for implantation Select Secure pacing lead 3830 through interventricular septum (IVS) into the LBB area.

Methods

60 patients with LBB block and indications for CRT in the period 2019–2020 underwent electrode implantation into the LBB area. Immediately before implantation, the IVS thickness and density (color scale ZOOM function, Siemens SC 2000 Prime) in the basal and middle region of IVS was assessed. White color corresponds to areas with a large amount of fibrosis, gray – conditionally viable myocardium. The implantation of the electrode by screwing it clockwise was carried out under constant echocardiographic control of the electrode advance from the right ventricle perpendicular to the IVS to the left ventricular (LV) endocardium. The ultimate target was the LV subendocardial region. After reaching the end position, the duration of mechanical LV systole was assessed (Velocity Vector 2D Speckle Analysis). Opposite wall delay (OWD) <120 ms – considered as a marker of good mechanical resynchronization.

Results

Technically, the procedure was successful in 54 from 60 patients (90%). The average IVS thickness at the site of successful implantation was 11±3, the maximum thickness was 18 mm. Average number of attempts to screw in the electrode in IVS per patient – 4.2±2.1. Predictors of failure were: 2 – IVS thickness over 15 mm throughout entire length and in 4 cases – total IVS fibrosis, despite the normal thickness (9±3). In two cases IVS perforation was detected, corrected by immediate electrode repositioning. In 4 (6.6%) cases, the initial point of implantation was not effective: OWD >120 ms, which required reimplantation of the lead in a more optimal position.

Conclusion

The use of intraoperative echocardiography during electrode implantation in the IVS allows choosing an optimal site for successful implantation, reliably monitoring the electrode position during implantation, and assessing LV intraventricular asynchronism and effectiveness of resynchronization

Funding Acknowledgement

Type of funding sources: None.
Heart failure with preserved ejection fraction (HFpEF) pathophysiology study (IDENTIFY-HF): rise in arterial stiffness associates with HFpEF with increase in comorbidities
Authors: Ali D , Tran P , Weight N , Ennis S , Weickert M , Miller M , Cappuccio F , Banerjee P
Published: October 2021

Background

There has been a shift in paradigm proposing that comorbidities play a significant role towards the pathophysiology of the heart failure with preserved ejection fraction (HFpEF) syndrome. Further, HFpEF patients have abnormal macrovascular function, potentially contributing significantly in altered ventricular-vascular coupling in these patients. However, our full understanding of the role of comorbidities, arterial stiffness and it relationship with HFpEF remains incomplete.

Purpose

The IDENTIFY-HF study aims to shed light on the HFpEF pathophysiology and investigates whether gradually increase in arterial stiffness (in addition to ageing) due to increasing common comorbidities, such as hypertension and diabetes, is associated with HFpEF.

Methods

Arterial compliance was assessed in five groups (Groups A to E) matched for age, (≥70 years), sex and renal function: Group A; normal healthy volunteers without major comorbidities (control). Group B; patients with hypertension only. Group C; patients with hypertension and diabetes mellitus only. Group D; patients with HFpEF. Group E; patients with heart failure and reduced ejection fraction (HFrEF); the parallel group. Arterial compliance was assessed using pulse wave velocity (PWV), as the primary outcome measure and was compared between Group A to D. A separate comparison was made between Groups D and E. To avoid confounding factors, participants were asked to omit their morning blood pressure medication and abstain from caffeine for 12 hours prior to the study.

Results

From the 95 volunteers recruited, PWV was obtained in 94 subjects. The mean PWV in group A, B, C, D and E was 10.2-, 12.2-, 13.0-, 13.7- and 10.0 m/s respectively. After adjusting for covariance (age, sex, BMI and renal function), the mean difference between Group A (healthy volunteers) and D (HFpEF) was 2.14 m/s (p=0.023). Whilst the mean difference between the HFpEF and HFrEF group D and E respectively was 2.68 m/s (p=0.003).

Conclusion

Rise in comorbidities increases arterial stiffness, as measured by pulse wave velocity, which in turn significantly associates with HFpEF (p=0.023). It is therefore possible that the HFpEF syndrome may not be due to a primary cardiac pathology but rather an end-result of non-cardiac comorbidities affecting vascular resistance with perhaps some secondary cardiac involvement.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): 1)West Midlands Clinical Research Network, National Institute of Health Research, UK2)Research, Development & Innovation department of the University Hospitals Coventry & Warwickshire NHS Trust (RDI, UHCW), UK.
Systolic blood pressure visit-to-visit variability and clinical outcomes of heart failure with preserved ejection fraction
Authors: Zhang Q , Zhou B.Y , Ma Y.U , Hu Y.C , Li X.M , Cong H.L
Published: October 2021

Background

Previous studies have shown that increased systolic blood pressure visit-to-visit variability (SBP-VVV) is associated with higher risk for cardiovascular events in patients with hypertension, atrial fibrillation, and heart failure with reduced ejection fraction, However, no studies have reported the relationship between SBP-VVV and adverse outcomes in heart failure with preserved ejection fraction (HFpEF).

Methods

This was a post-hoc analysis of the TOPCAT trial, a multicentered, randomized, placebo-controlled trial of spironolactone in patients with HFpEF. SBP-VVV was assessed during the first year of the trial and clinical outcomes were analysed from the end of the first year to the end of the follow-up period. SBP-VVV was primarily assessed by SBP-SD, the standard deviation (SD) of the mean SBP across these six visits of every patient. The primary study outcome was the composite outcomes of cardiovascular death, hospitalization for heart failure or aborted cardiac arrest occurring after the first 12 months after randomization. The secondary outcomes included cardiovascular mortality, first HF hospitalization event, and all-cause mortality occurring beyond the first 12 months following randomization.

Results

Of the 2907 patients from the TOPACT trial, SBP-VVV was categorized into quartiles (1st, <6.05; 2nd, 6.06–8.94; 3rd, 8.95–12.81; and 4th, ≥12.82 mmHg) and as a continuous variable. During the subsequent median follow-up of 2.48 years, 373 (12.8%) patients met the primary outcome. On multiple Cox regression, patients in the 4th quartile were at higher risk for a primary outcome (hazard ratio for 4th vs. 1st quartile, 1.79;, 95% CI, 1.28–2.49; P<0.001). Patients in the 4th quartile were also at higher risk of HF hospitalization (hazard ratio for 4th vs. 1st quartile, 2.49; 95% CI, 1.54–4.02; P<0.001) and all-cause mortality (hazard ratio for 4th vs. 1st quartile, 1.52; 95% CI, 1.08–2.15; P=0.017). SBP-SD as a continuous variable was also associated with an increased risk of all outcomes.

Conclusions

In patients with HFpEF, high SBP-VVV was associated with an increased risk of adverse outcomes, independent of baseline and on-treatment SBP.

Funding Acknowledgement

Type of funding sources: None. Relationship between SBP-SD and HR
Prognostic impact of left atrial function in heart failure with preserved ejection fraction in sinus rhythm vs. atrial fibrillation
Authors: Schoenbauer R , Kammerlander A.A , Duca F , Aschauer S , Koschutnik M , Dona C , Nitsche C , Loewe C , Hengstenberg C , Mascherbauer J
Published: October 2021

Background

Left atrial (LA) function is related with outcome in heart failure with preserved ejection fraction (HFpEF). However, how LA function contributes to outcome in the context of atrial fibrillation (AF) versus sinus rhythm (SR) remains unclear.

Purpose

To determine the prognostic impact of LA size and phasic function in patients with HFpEF in SR vs. AF.

Methods

We enrolled consecutive HFpEF patients and assessed indexed LA volumes (LAVi) and emptying fractions (LA-EF) on cardiac magnetic resonance (CMR) imaging. We prospectively followed patients and used Cox regression models to determine the association of LA size and function with a composite endpoint of heart failure hospitalization and cardiovascular death.

Results

A total of 188 patients (71% female, 70±8 y/o) were included of whom 92 (49%) were in persistent AF (Figure 1A). Patients in persistent AF were older (p=0.017) and had a worse NYHA functional class (p=0.003). Compared to SR, peak and minimal LAVi were increased and LA-EF impaired (each p<0.001 respectively) in persistent AF patients (Figure 2A).

A total of 65 patients reached the combined endpoint during a follow-up of 31 (9–57) months. Multivariate Cox regression adjusted for established risk factors revealed that LA-EF was significantly associated with outcome in patients in SR (adj.HR 2.14; 95% CI [1.32–3.47] per 1-SD decline, p=0.002). In persistent AF, however, no LA imaging parameter was related to outcome (Figure 1B). By receiver operating characteristic curve and restricted cubic spline- analyses, we identified an LA-EF ≥40% as best indicator for favorable outcomes in patients with HFpEF and SR (Figure 2B). Persistent AF carried a similar risk for adverse outcome compared to impaired LA-EF (<40%) in SR (log-rank, p=0.340) (Figure 1A).

Conclusions

In HFpEF patients in SR, impaired LA-EF is independently associated with worse cardiovascular outcome, which is similar to persistent AF. With disease progression including development of persistent AF, LA parameters lose their prognostic ability and thus, are not helpful for further risk stratification.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
The role of left ventricular remodeling in functional mitral regurgitation: functional and prognostic implications in patients with heart failure
Authors: Sugimoto T , Boveri S , Bandera F , Barletta M , Alfonzetti E , Guazzi M
Published: October 2021

Background

Left ventricular (LV) dilatation plays a key role on functional mitral regurgitation (MR) in patients with heart failure (HF) and exercise MR causes an additional LV remodeling. This study sought to investigate the different phenotypes and prognostic impact of LV end-diastolic volume (EDV) and MR during exercise in HF patients of any left ventricular ejection fraction (LVEF) categorization.

Methods

201 HF patients with reduced (n=119), mildly-reduced (n=46), and preserved (n=36) EF underwent exercise with gas exchange analysis combined with echocardiography for assessment of MR and were divided by 3 groups according to EDV index tertiles (T1 <70.1, T2 70.1–95.6, T3 >95.6 ml/m2).

Results

There was no significant difference in age (67±12 years) and peak oxygen consumption (VO2: 13.1±3.7 ml/kg/min) among the 3 groups but VE/VCO2 slope was higher in T3 group (T1 31±7, T2 31±5, T3 37±11, P<0.05). EDV index was positively correlated with VE/VCO2 slope (R=0.33, P<0.001) and effective regurgitant orifice area (EROA) of MR at rest (R=0.27, P=0.01) and exercise (R=0.45, P<0.001). During follow up, 48 patients had the composite end point of all cause death or HF hospitalization. The age and gender adjusted hazard ratio for the events in patients with MR >2+ was 1.8 (P=0.049) at rest and 1.9 (P=0.026) at exercise. The age, gender, peak VO2, VE/VCO2 slope, and exercise MR >2+ adjusted hazard ratio of EDV index 10 ml/m2 increase was 1.1 (P=0.041) and the ratio in patients with EDV index >95.6 ml/m2, derived by ROC curve (AUC=0.69, P<0.05), was 2.0 (P<0.033, figure).

Conclusions

Functional MR with LV dilation combines with the worse exercise gas exchange phenotype. Given also the predictive role of a EDV index cutoff of 95.6 ml/m2 attention for chamber geometry during exercise might become an indicator of mitral valve reparation.

Funding Acknowledgement

Type of funding sources: None.
The impact of marathon running on atrial remodeling in male and female amateur athletes assessed by three-dimensional echocardiography
Authors: Lasocka Z.B , Dabrowska-Kugacka A , Kaleta-Duss A , Lewicka-Potocka Z , Faran A , Danilowicz-Szymanowicz L , Nowak R , Kaufmann D , Raczak G , Lewicka E
Published: October 2021

Introduction

Endurance athletes have an increased risk of atrial remodeling and atrial arrhythmias. However, data regarding atrial adaptation to physical exercise in non-elite athletes are limited. We aimed to assess exercise-induced alternations in atrial morphology and function in male and female amateur marathon runners, using real-time three-dimensional (3D) echocardiography.

Methods

The study group consisted of 40 male (39±8 years) and 27 female (40±7 years) amateur athletes. 3D echocardiography was performed 2–3 weeks before (Stage 1) and immediately after (Stage 2) the marathon run. Right (RA) and left atrial (LA) remodeling was assessed by volumetric measures, total ejection fraction (EF) and volume (EV). Speckle tracking was used to determine the temporal evaluation of atrial function by strain analysis.

Results

The main results are presented in Table 1. At rest, male athletes demonstrated greater RA size and decreased RA contractility, as assessed by EF and atrial strains, in comparison to females. At Stage 1, LA morphology and function did not differ significantly between genders. After the marathon, a remarkable increase in RA maximal volume (RAVmax, 32.9±8.6 vs. 36.4±8.2 ml/m2, p=0.016) and RAEF (49.5±9.7 vs. 57.3±9.2%, p=0.002) was observed only in female athletes (p<0.05 for both interactions sex and stage). Whereas in male runners, LA measures, such as LAVmax (30.7±6.4 vs. 26.8±6.2 ml/m2, p=0.007), LAEF (56.7±4.3 vs. 52.7±5.3%, p=0.037) and LA conduit strain (LAScd, −18.7±8 vs. −13.6±8%, p=0.045), significantly decreased postrace. This observation was absent in females (p<0.05 for all interactions sex and stage).

Conclusions

In amateur athletes, marathon running promotes biatrial remodelling with significant gender discrepancies. Females are more susceptible to exercise-induced morphological and functional changes of RA, while postrace alternations in males concern principally LA. 3D echocardiography of the atria is a useful indicator of exercise capacity, not only in elite, but also in amateur athletes.

Funding Acknowledgement

Type of funding sources: None.
Usefullness of 2D/3D-TEE for guiding transapical beating heart neochordae implantation in mitral regurgitation
Authors: Mahia P , Cobiella J , Carnero M , Enriquez D , De Agustin J.A , Macaya C , Maroto L
Published: October 2021

Background

Transapical beating-heart neochord implantation (Neochord) to repair mitral valve regurgitation has been demonstrated to be a safe and effective minimally invasive alternative to open surgical repair in selected patients with mitral leaflet prolapse. Successful neochordae implantation depends on accurate localization of the site of regurgitation and careful assessment of MV morphology.

The objective of this study is to demonstrate that 3D-transesophageal echocardiography (3D-TEE) has become a fundamental tool, essential in both the preoperative study and to guide the procedure and for follow-up.

Methods

All consecutive patients with severe symptomatic DMR due to prolapse or flail of one or both mitral leaflets that underwent the NeoChord procedure between March 2017-Jan 2021 were included. Patients were categorized according to MV anatomy by 3D-TEE; Type A isolated central posterior leaflet prolapse and/or flail, Type B posterior multi-segment prolapse and/or flail, Type C anterior and/or bi-leaflet prolapse or flail, Type D paracommissural prolapse and/or flail and/or significant leaflet and/or annular calcifications.

Results

43 patients were included. Median age was 67.7±13.4 y. Median EuroSCOREII 2.7%±1.91. There were 35 Type A patients (81.4%), 4 Type B (9.3%), 1 Type C (2.3%), and 3 Type D (7%). Type A was considered the more favorable morphology. 2D/3D TEE were employed for guiding the device from the apex of the left ventricle across the mitral annulus (Figure 1, A–C), orientation of the tip of the device with regards to the prolapsing segment of the leaflet positioning and leaflet grasping (Figure 1, D, E) and evaluation of the final length and tension of the neochordae to obtain a satisfactory mitral valve competence. (Figure 1, F). Procedural success was achieved in 38 patients (88,4%). 5 patients, 2 type A and 3 type D, underwent conversion to open surgery for immediate failure. 1 high-risk patient considered inoperable died before discharge. At 19 (IQR 13–23) months median follow-up, MR ≤II was present in 29 (76.3%). Overall 2 year survival was 100%. Freedom from reintervention was 89% for overall population.

Conclusions

TEE-Guided Transapical beating-heart neochord implantation is a feasible, low-risk technique. 2D and 3D TEE are the fundamental and essential diagnostic tools for the correct selection and monitoring of the procedure, as well as its possible complications.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Prognostic value of sST2 in heart failure patients with diabetes
Authors: Castiglione V , Chiriaco' M , Aimo A , Januzzi J , Richards A.M , Lam C.S.P , Latini R , Anand I.S , Ueland T , Brunner-La Rocca H.P , Bayes-Genis A , De Boer R.A , Huber K , Emdin M , Vergaro G
Published: October 2021

Background

Soluble suppression of tumorigenesis-2 (sST2) is released in response to inflammation and vascular injury, and holds prognostic value in heart failure (HF). Type 2 diabetes (T2D) is characterized by a pro-inflammatory status and is highly prevalent among HF patients, with adverse impact on outcomes. The clinical value of sST2 in HF patients with T2D has never been characterized.

Purpose

We aimed to assess sST2 clinical correlates and prognostic value in HF patients with T2D.

Methods

Individual data of 3476 patients with stable chronic HF from 5 cohorts from the BIOS (Biomarkers In Heart Failure Outpatient Study) dataset were analysed, with available N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hs-TnT), and sST2 levels.

Results

Mean age was 65±12 years (75% males). T2D was present in 1386 patients (40%), who had higher body mass index (BMI, 27 [24–30] vs. 26 [23–29] kg/m2, p<0.001), lower estimated glomerular filtration rate (eGFR, 56±22 vs. 60±19 mL/min/1,73 m2, p<0.001), higher sST2 (33 [24–47] vs. 27 [20–40] ng/mL, p<0.001), NT-proBNP (1735 [742–3963] vs. 1450 [514–3299] ng/L, p<0.001), hs-TnT (28 [16.2–51.5] vs. 17 [9–31] ng/L, p<0.001) and high-sensitivity C-reactive protein (hs-CRP, 6 [2–11] vs. 4. [2–9] mg/L, p=0.003) (Figure). Differences between sST2 levels in patients with or without T2D were influenced by hs-CRP (p for interaction=0.010) and hs-TnT (p=0.031), but not by NT-proBNP and eGFR. At multivariate linear regression analysis, NT-proBNP, hs-TnT and hs-CRP were independently associated with sST2 levels in both T2D and non-T2D patients. Compared with patients without T2D, those with T2D showed higher 1-year all-cause mortality (12% vs. 10%, p=0.034), cardiovascular mortality (9% vs. 7%, p=0.011), and HF hospitalization rate (22% vs. 12%, p<0.001). In a prognostic model including age, sex, eGFR, ischemic vs- non-ischemic aetiology, left ventricular ejection fraction class, New York Heart Association class, NT-proBNP, hs-TnT, and hs-CRP, sST2 retained independent prognostic value in both patients with or without T2D for 1-year all-cause and cardiovascular mortality, and 1-year HF hospitalization, with higher optimal cut-offs for mortality prediction in T2D vs. non-T2D (39 and 45 vs. 29 and 29 ng/mL respectively for 1-year all-cause and cardiovascular mortality).

Conclusions

sST2 is higher in HF patients with T2D and likely linked to a pro-inflammatory status. sST2 maintains its prognostic value both in diabetic and non-diabetic HF patients, independently of NT-proBNP, hs-TnT and hs-CRP.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Clinical and prognostic significance of the inflammatory markers GlycA and GlycB in chronic heart failure of both ischemic and non-ischemic etiologies
Authors: Cediel Calderon G , Teis A , Codina P , Domingo M , Santiago-Vacas E , Spitaleri G , Zamora E , Santasmases J , Alonso N , Lupon J , Bayes-Genis A
Published: October 2021

Background

N-acetylglucosamine/galactosamine (GlycA) and sialic acid (GlycB) constitute evolving nuclear magnetic resonance (NMR) biomarkers of systemic inflammation. They have been increasingly studied and associated with cardiovascular (CV) disease and incident heart failure (HF), but little is known about its value in chronic HF population.

Purpose

We aimed to examine the association on long-term CV outcomes of GlycA and GlycB in chronic HF relative to aetiology.

Methods

We prospectively included a cohort of 429 HF patients admitted to an ambulatory HF Unit. Plasma GlycA and GlycB concentrations were determined using NMR spectroscopy. The primary endpoint was a composite of CV death and readmission due to HF. Competing risk regression models were performed with non-CV death as the competing event. Because an interaction existed between GlycA and GlycB with ischemic etiology (p<0.01), we examined this further.

Results

The mean (SD) follow-up was 4.5±2.9 years. Median concentrations (IQR) for GlycA and GlycB were 5.4 (4.9–6.2) mmol/L and 1.9 (1.7–2.2) mmol/L, respectively. A total of 92 (41.1%) and 123 (60.0%) patients from non-ischemic and ischemic etiology, respectively, the clinical endpoint. In ischaemic HF patients (47.8%; n=205) both markers were not associated with the primary endpoint. Conversely, in non-ischemic HF patients (52.2%; n=224), GlycA and GlycB exhibited association with the primary endpoint in univariable and after multivariable adjustment (HR 1.14; 95% confidence interval [CI]: 1.02–1.28, p=0.018 and HR 1.91; 95% CI: 1.27–2.88, p=0.002; respectively. Figure 1 and 2). In this subgroup, a correlation analysis with well-known biomarkers (NT-proBNP, hs-TnT and ST2) only evidenced a positively and significantly correlation of GlycB with ST2 (r=0.26, p<0.001). No association was found with NYHA functional class.

Conclusions

GlycA and GlycB represent an evolving approach of inflammation status with prognostic value of long-term CV related events in non-ischemic HF patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Probability of MACE by GlycA tertilesFigure 2. Probability of MACE by GlycB tertiles
Right ventricular ejection fraction as predictor of outcome in acute heart failure using RV ellipsoid model. A retrospective analysis of a prospective cross-sectional study
Authors: Ashcroft E.A , Belsey J , Berrill M , John I , Baltabaeva A
Published: October 2021

Introduction

Echocardiography (TTE) is an essential imaging modality for assessment of RV function in acute heart failure. Established parameters are useful and easy to perform but fail to reflect on global volumes due to reliability on one acoustic window. It is therefore attractive to calculate RV volumes and ejection fraction using an ellipsoid model (RVEF/E) which has been validated against MRI in healthy adults but not in the HF patients.

Purpose

Predictive value of RVEF/E were compared with two established echo parameters of RV function over two-year follow-up period in patients with acute HF. Primary outcome measure was all-cause mortality.

Methods

Prospective cross-sectional study enrolling 418 consecutive patients with symptoms of acute HF according to a predefined study protocol. All patients underwent TTE assessment of RV function using Tricuspid Annular Plane Systolic Excursion (TAPSE) and RV fractional area change (RVFAC) and RVEF/E. RV Volumes calculated using formula, RVIT is RV inflow tract diameter, RVLAX is RV length and LVD is LV maximal diameter in 2 chamber view.

RVV=(3.14/6) x RVIT x RVLAX x LVD

Results

ROC analyses established an RVEF/E cut-off of 46.8%, TAPSE of 1.6cm and RVFAC of 38.2%. RVEF/E was able to separate patients with higher BNP level (p≤0.0001) and lower systolic BP (p≤0.002). As expected TAPSE and RVFAC were significantly reduced in patients with impaired RVEF. RVEF/E was found equal to TAPSE & RVFAC in predicting outcome (HR 1.48 vs HR 1.48, p≤0.01 vs p≤0.01) and provided benefit of RV volume estimation.

Conclusions

This is the first study to demonstrate that RVEF/E derived from ellipsoid model is not inferior to well established measures of RV function as a prognostic indicator of medium-term outcome in the acute HF.

Funding Acknowledgement

Type of funding sources: None. Kaplan Meier survival curvesBaseline characteristics
Opportunities for clinician education in the pharmacotherapy of stable heart failure
Authors: Murray P , O'Connor C.T , Maher V , Moore D
Published: October 2021

Introduction

Heart failure (HF) is a commonly encountered clinical entity in the developed world, and is estimated to cost 660m euro annually to the Irish exchequer. Evidence supporting the benefit of multi disciplinary care in reduction of readmission rates has prompted the establishment of specialist HF clinics, resulting in improved medication adherence and early recognition and treatment of mild decompensation, thus averting the need for hospital admission. In contrast, the role of the hospital generalist and the general practitioner in the management of stable HF is under-emphasised despite evidence that optimal medical therapy reduces readmission and its attendant costs. The aim of this survey was to assess knowledge of pharmacotherapeutic options amongst generalists, and identify opportunities for education, in order to further optimise guideline-directed medical therapy while the patient awaits specialist input.

Methods

We distributed a 14 item questionnaire regarding indications for HF medications (as per ESC guidelines) to doctors in medicine and general practice throughout Ireland.

Results

There were 127 responses from 27 centres (117 analysed). Median years of practice was 4. Table 1 depicts the breakdown of clinicians who correctly identified HFrEF as an indication for each of the major drug classes. More than 20% of clinicians at all grades failed to identify HFrEF as an indication for beta blocker therapy. There was a higher level of knowledge amongst junior doctors in the prescription of mineralocorticoid receptor antagonists (p≤0.05) but no statistical difference in knowledge of other drug classes. Only 26% of participants who felt comfortable with initiation and up-titration of beta blockers (N=89) correctly identified an optimal target heart rate of less than 70 beats per minute. Twenty-four percent of respondents (N=28) were unaware of a specialist HF service that catered to their institution. Ninety-seven percent (N=113) felt that their practice would benefit from further education on HF pharmacotherapy.

Conclusion

The high prevalence of HF in Ireland and costs associated with admission for decompensation necessitates a sound knowledge of its management amongst generalists. Results of this survey suggest a need, and indeed a demand, for further education and support surrounding pharmacotherapy of stable heart failure.

Funding Acknowledgement

Type of funding sources: None.
Gender differences in reverse cardiac remodeling following initiation of sacubitril/valsartan in heart failure with reduced ejection fraction: real world experience
Authors: Savage P.S , Campbell P.C , Adams S.A
Published: October 2021

Background

Gender related differences in physiology and pharamocokinetics have long been appreciated; however, the clinical relevance of these differences are unclear (1). Sacubitril/Valsartan has become established as a guideline directed therapy for the treatment of heart failure with reduced ejection therapy (HFref) and NYHA class II-IV symptoms. Interestingly; recent secondary analysis of key trials such as PARAGON-HF and PARADIGM, have highlighted possible differential gender specific benefits from Sacubitril/Valsartan therapy (2).

We therefore sought to evaluate if there were gender specific effects of Sacubitril/Valsartan on both quantitative and qualitative measures of heart failure outcomes.

Methods

We performed a retrospective data interrogation of all patients commenced on Sacubitril/valsartan therapy in the SHSCT between 2016 and 2019. Data was extracted using electronic care records. Local ethical approval was granted.

The primary endpoint were change in LVEF% on echocardiography and improvement in QOL (defined as NYHA score) at one year following initiation of Sacubitril/Valsartan.

Differences in means between baseline and one year were assessed using a paired student's t-test. Interaction of gender on respective outcomes was assessed using a two way ANOVA. Significance defined as p<0.05. Data expressed as mean ± SD. Analysis performed using SPSS™.

Results

A total of 422 patients were included (mean age 69.1±12.1 years; 66% male). The predominant NYHA class' were II (n=298, 67.7%) and III (n=118, 26.8%). Aetiology and comorbidities were similar across male and females. In both groups, there was a statistically significant improvement in LVEF% at one year following initiation of Sacubitril/Valsartan (female; 27.1±8.6 to 34.6±9.5, n=40 p<0.01) (male; 27.4±7.5% to 32.6±9.3%, n=91, p<0.01). There was a statistically significant interaction between gender and degree of reverse cardiac remodeling defined as LVEF% on echocardiography following initiation of Sacubitril/Valsartan (F[2,52]=8.280, p=0.04, partial n2=0.27) (Figure 1).

Similarly, there was a significant improvement in NYHA scores in both groups (male; 2.2±0.5 to 2.02±0.6, n=331, p<0.05) (female; 2.29±0.6 to 2.07±0.5, n=91, p<0.05) (Figure 2). However; there was no statistically significant interaction between gender and NYHA score following initiation of Sacubitril/Valsartan (F[2,52]=0.133, P=0.716, partial n2≤0.0).

Conclusion

Sacubitril/Valsartan produced significant improvement in reverse cardiac remodelling and QOL measures in both groups. Notably, had a stronger effect of reverse cardiac remodelling in women – suggesting possible gender specific differential benefits.

Funding Acknowledgement

Type of funding sources: None.