bluuebunny/crossref_metadata_2025 huggingface dataset:
Long-term prognostic value of left atrial longitudinal strain in a low-risk community-based cohort
Authors: Zhubi Bakija F , Bagyura Z , Fabian A , Ferencz A , Lakatos B , Ujvari A , Kiss L , Csobay-Novak C , Jermendy A , Szelid Z , Soos P , Kovacs A , Merkely B
Published: October 2022

Numerous studies established the significant predictive value of left ventricular (LV) global longitudinal strain (GLS) on adverse clinical outcomes in various cardiac diseases. Despite the well-known importance of left atrial (LA) mechanics in diastolic function, data are scarce regarding the prognostic power of LA longitudinal strain and its potential added value in the risk stratification of a low-risk population.

Accordingly, our aim was to determine the long-term prognostic importance of 2D speckle-tracking echocardiography-derived peak atrial longitudinal strain (PALS) in a community-based screening sample comprising of low-risk adult individuals.

Three hundred fourteen volunteers were retrospectively identified from a population-based screening program (mean age 62±11, 58% female) with a median follow-up of 9.5 years. All subjects who participated in the screening program underwent 2D echocardiography to measure LV volumes and ejection fraction (EF), LV GLS and PALS, as well as low-dose cardiac CT to determine the Agatston score. The primary endpoint was all-cause mortality.

Thirty-nine subjects (12.4%) met the primary endpoint. Subjects with adverse outcome had significantly decreased LV GLS (dead vs. alive; −19.2±4.3 vs. −20.6±3.5%, p<0.05) and PALS (32.3±12.0 vs. 41.8±14.2%, p<0.001), whereas LV EF did not show a difference between the two groups (51.1±7.0 vs. 52.1±6.2, %, p=NS). By multivariable Cox regression analysis, PALS (hazard ratio 0.970 [95% CI: 0.943–0.998], p<0.05) and Agatston score were independently associated with all-cause mortality, whereas GLS was not (hazard ratio 1.008 [95% CI, 0.919–1.105], p=NS). Furthermore, we dichotomised the population based on PALS values using a guideline-directed cut-off of 39%. In subjects with lower PALS values, the risk of all-cause mortality was almost 2.5 times higher than in subjects with PALS values above 39% (hazard ratio 2.499 [95% 1.334–4.682], p<0.05) as shown on the Kaplan-Meier curve (Figure 1).

Beyond the assessment of LV EF and LV GLS, PALS offers incremental value in cardiovascular risk stratification in a community-based cohort. PALS was found to be the only significant and independent predictor of long-term mortality among other echocardiographic functional parameters. Our results emphasize the importance of a thorough evaluation of LA mechanics even in a low-risk population.

Funding Acknowledgement

Type of funding sources: None.
Analysis of myocardial function by deformation imaging in patients with transthyretin gene mutation
Authors: Comparato F , Di Lisi D , Puglisi C , Portelli M C , Cannizzo N , Damerino G , Di Caccamo L , Ortello A , Galassi A R , Novo G
Published: October 2022

Introduction

Hereditary transthyretin (TTR) amyloidosis is a rare disease that can affect various organs. The early identification of cardiac involvement through echocardiography allows to corroborate the diagnosis and to start therapy at an early stage.

Purpose

The aim of our study was to detect early signs of cardiac involvement in patients with TTR gene mutation and neurological phenotype or absence of any organ disease (carriers) compared to patients with TTR gene mutation and cardiac amyloidosis (CA).

Material and methods

An observational study was conducted on a sample of 31 patients with TTR gene mutation. Patients were divided into 3 groups (23% CA, 42% amyloid neuropathy and 35% carriers). All patients underwent echocardiography with evaluation of left ventricular myocardial deformation indices (apical/basal strain ratio and relative apical sparing).

Results

Carriers and patients with amyloid neuropathy had normal left ventricular systolic and diastolic function. Analyzing left ventricular longitudinal global strain (GLS) we didn't find significant differences between carriers and neuropathy, but we found a significant difference about apical/basal strain ratio and relative apical sparing (respectively 1.33±0.20 vs 1.58±0.25, p value 0.001 and 0.62±0.07 vs 0.72±0.08, p value 0.039).

Conclusion

Relative apical sparing is specific to identify CA; the apical/basal ratio seems to gradually increase from carriers to patients with cardiac amyloidosis and it could be used to monitor patients with TTR mutation, before developing CA.

Funding Acknowledgement

Type of funding sources: None.
The impact of cardiovascular risk factors on left atrial strain over a decade
Authors: Saed Alhakak A , Skaarup K G , Lassen M C H , Johansen N D , Jensen G B , Schnohr P , Mogelvang R , Biering-Sorensen T
Published: October 2022

Background

Peak atrial longitudinal strain (PALS) has previously been shown to predict cardiovascular morbidity and mortality in the general population. However, the impact of cardiovascular risk factors on PALS over a decade in participants from the general population is unknown.

Purpose

The aim of this study was to investigate the impact of cardiovascular risk factors (age, sex, mean arterial pressure (MAP), body mass index (BMI), smoking, total plasma cholesterol, HbA1c, physical activity level, socioeconomic and psychosocial status) on change in PALS over a 10-year period in participants from the general population.

Methods

The present study included a total of 208 (mean age 61±14 years, 60% female) participants from the general population, who underwent a health examination including two-dimensional speckle tracking echocardiography of the left atrium at baseline examination and follow-up examination. The median time between the examinations was 10 years (interquartile range, 10.2–10.7 years). PALS was calculated as the average from the three apical views.

Crude and multivariable linear regression analyses were performed to determine the impact of cardiovascular risk factors on the change in PALS. The multivariable regression model was adjusted for age, sex, MAP, BMI, smoking, total plasma cholesterol, HbA1c, heart rate, eGFR, proBNP and previous ischemic heart disease. All analyses were adjusted for baseline value of PALS (baseline value). Restricted cubic spline curves were constructed to illustrate the relationship between the PALS and continuous cardiovascular risk factors.

Results

During 10-year follow-up, the average decrease in PALS was 4±16%. In the crude regression model increasing age (standardized = −0.27, p<0.001), MAP (standardized = −0.19, p<0.001), BMI (standardized = −0.19, p<0.001), smoking (standardized = −0.12, p=0.013), higher cholesterol levels (standardized = −0.16, p=0.001), and higher levels of HbA1c (standardized = −0.14, p=0.004) were associated with an accelerated decrease in PALS. Relationship between the PALS and significant continuous cardiovascular risk factors are displayed in restricted cubic spline curves (Figure 1).

In the multivariable regression model, age (standardized = −0.19, p=0.001), BMI (standardized = −0.18, p=0.001) and smoking (standardized = −0.15, p=0.003) remained independent predictors of an accelerated decrease in PALS.

Conclusion

In the general population, increasing age, BMI and smoking were independently associated with an accelerated decrease in PALS over a decade.

Funding Acknowledgement

Type of funding sources: None.
The prognostic value of speckle tracking echocardiography in patients hospitalized with COVID-19
Authors: Cwiek-Rebowska E , Kasprzak J D , Filipiak-Strzecka D , Szymczyk E , Wdowiak-Okrojek K , Wejner-Mik P , Cygulska K , Kupczynska K , Michalski B , Miskowiec D , Lipiec P
Published: October 2022

Introduction

In COVID-19 patients, both preexisting cardiovascular disease as well as cardiac injury resulting from SARS-CoV-2 infection are associated with increased mortality. We hypothesized that novel parameters of myocardial function may be useful in the assessment of in-hospital and long-term prognosis.

Aim

The aim of study was to determine the prevalence of myocardial dysfunction revealed by speckle tracking echocardiography and its association with in-hospital and one-year mortality.

Methods

The study group comprised 192 patients hospitalized in the cardiology department due to COVID-19. All patients underwent transthoracic echocardiographic examination with off-line analysis. Using speckle tracking technique, we measured the following parameters: left ventricular global longitudinal strain (GLS), right ventricular global longitudinal strain (RV-GLS), right ventricular free wall strain (RV-FWS) and myocardial work parameters – global work index (GWI), global wasted work (GWW), global constructive work (GCW) and global work efficiency (GWE). The primary outcome was in-hospital and one-year mortality.

Results

112 patients (mean age 68±14 years, 76 (68%) male) had adequate image quality to evaluate strain-derived parameters. 27 patients died during hospitalization and 44 patients died within one-year after discharge. In-hospital non-survivors were older, had lower baseline oxygen saturation (SpO2) and had higher NTproBNP (Table 1). In non-survivors speckle-tracking echocardiography revealed significant impairment of left and right ventricular function compared to the group of survivors (Table 1). The independent predictors of in-hospital death were GWE (OR 0.85; 95% CI 0.78–0.93) and SpO2 on admission (OR 0.91; 95% CI 0.86–0.96). Based on the ROC curve analysis, the optimal cut-off points for predicting in-hospital death were identified: GWE ≤87% (sensitivity 63%, specificity 89%) and baseline SpO2 value ≤88% (sensitivity 81%, specificity 71%).

The independent predictors of one-year mortality were: age (OR 1.28 [1.13–1.46]), NTproBNP (OR 1.002 [1.001–1.003]), baseline SpO2 (OR 0.71 [0.59–0.86]) and RV-GLS (OR 1.32 [1.12–1.55]). Based on the ROC curve analysis, the cut-off points optimal for predicting death within 12 months after COVID-19 were also identified: baseline SpO2 value ≤88% (sensitivity 69.8%, specificity 77.3%), age >60 years (sensitivity 90%, specificity 43%), NTproBNP >500 pg/ml (sensitivity 95%, specificity 41.8%), RV-GLS >−18.5 (sensitivity 93%, specificity 64.2%).

Conclusions

Two-dimensional speckle tracking echocardiography is a useful technique to evaluate myocardial function in COVID-19 patients and provides good prognostic value for identifying patients at risk of death during hospitalization and in long term follow-up.

Funding Acknowledgement

Type of funding sources: None.
Prognostic value of coronary flow and heart rate reserve in emergency department chest pain
Authors: Cortigiani L , Vecchi A , Bovenzi F , Picano E
Published: October 2022

Aims

To estimate the prognostic value of stress echo (SE) with the assessment of coronary flow velocity reserve (CFVR) and heart rate reserve (HRR) in patients admitted for chest pain with non-diagnostic EKG, negative troponin, and without inducible regional wall motion abnormalities (RWMA).

Methods

658 patients (age 67±12 years) admitted to our Emergency Department with chest pain, non-diagnostic EKG, and negative serial troponin underwent dipyridamole (0.84 mg/kg in 6') SE with simultaneous assessment of RWMA, CFVR in the left anterior descending artery, and HRR as peak/rest heart rate. The outcome measure was all-cause mortality.

Results

Of the 658 patients initially enrolled, 20 (3%) showed RWMA during SE and were referred to ischemia-driven revascularization. In the remaining 638, CFVR was abnormal (<2.0) in 148 patients (23%). HRR was abnormal (<1.22 in patients in sinus rhythm, or <1.17 in patients with permanent atrial fibrillation) in 196 patients (31%). The main clinical and echocardiographic characteristics according to CFVR and HRR response are shown in Table 1. During a follow-up of 7.3±4.3 years, 151 (24%) patients died. Survival at 8 years was 93% in patients with normal CFVR and HRR, 76% in patients with abnormal CFVR only, 73% in patients with abnormal HRR only, and 38% in those with abnormal CFVR and HRR (p<0.0001) (Figure 1). At multivariable analysis, abnormal CFVR (HR 1.49, 95% CI 1.05–2.10, p=0.02) and abnormal HRR (HR 2.01, 95% CI 1.43–2.84, p<0.0001) were independent predictors of survival.

Conclusions

In admitted patients with non-ischemic EKG, negative serial troponin, and whitout RWMA during dipyridamole SE, a reduced CFVR and blunted HRR independently identify a subset with worse survival in the long-term.

Funding Acknowledgement

Type of funding sources: None.
Assessment of the right ventricular-pulmonary circulation unit during stress in ankylosing spondylitis and psoriatic arthritis patients
Authors: Morvai-Illes B , Burcsar S Z , Monoki M , Varga A , Kovacs L , Balog A , Agoston G
Published: October 2022

Background

Cardiopulmonary complications are common in ankylosing spondylitis (AS) and arthritis psoriatica (APs), which have an unfavourable impact on mortality and quality of life. APs may be connected with pulmonary hypertension, while AS is linked to interstitial lung disease and chest wall restriction.

We aimed to assess the response of the pulmonary circulation unit during stress in AS and APs patients.

Methods

A total of 71 patients were enrolled in the study: 28 of them had AS (age 50.8±11.8 years), 17 APs (age 52.1±13.5 years), and 26 were healthy individuals (age 54.23±9.9 years). To the maximally tolerated workload, all subjects underwent resting and exercise stress echocardiography on a supine bicycle ergometer. Echocardiographic measurements were taken at rest, at 50 watts workload, and at maximal exercise.

Results

AS patients had significantly higher pulmonary artery systolic pressure (PASP; AS: 32.6±16.8 mmHg, APs: 21.6±12.7 mmHg, p<0.05) and pulmonary vascular resistance (PVR; AS: 1.3±0.4 WU, PsA: 1.1±0.3 WU, p<0.05) at maximal workload, while the right ventricular-pulmonary arterial (RV-PA) coupling at peak stress was higher in APs patients (AS: 1.2±0.6 mm/mmHg, PsA: 1.8±1.1 mm/mmHg, p<0.05). Comparing to the control group, AS and PsA patients had significantly higher resting PASP (control: 12.6±6.4 mmHg; AS: 22.8±7.6 mmHg, p<0.001; PsA: 21.4±7.0 mmHg, p<0.001), lower resting RV-PA coupling (control: 2.7±1.4 mm/mmHg; AS: 1.3±0.4, p<0.001; PsA 1.3±0.4 mm/mmHg, p<0.001), and higher peak PVR (control: 0.6±0.4 WU; AS: 1.3±0.4, p<0.001; PsA: 1.1±0.3 WU, p<0.005). One-way analysis of variance of the three groups also showed significant differencies in the resting PASP (p<0.001), peak PASP (p<0.05), resting RV-PA coupling (p<0.001), peak PVR (p<0.001).

Conclusion

Stress echocardiography is a promising, radiation-free method for assessing the subclinical cardiopulmonary changes among AS and PsA patients. The changes of PVR during stress may highlight the pulmonary complications in the subclinical stage.

Funding Acknowledgement

Type of funding sources: None.
Left ventricular myocardial and cavity velocity disturbances are stronger predictors of stress induced ischaemia in patients with significant coronary artery disease
Authors: Bytyci I , Alves L , Lopes L , Henein M Y
Published: October 2022

Background and aim

Dobutamine stress echocardiography (DSE) is a well-established non-invasive investigation for significant coronary artery disease (CAD). The aim of this study was to evaluate the accuracy of cardiac Doppler parameters in predecting CAD.

Methods

We prospectively studied 103 consecutive patients with suspected CAD based on typical symptoms, 59 proved to have CAD and 44 patients proved to have no-CAD (n=44). All patients underwent a complete stress Doppler echocardiographic examination, including tissue Doppler, long axis velocities and total isovolumic time (T-IVT) as a marker of cavity dyssynchrony, determined as [60 − (total ejection time (ET) + total filling time (FT))]. The wall motion score index (WMSI) was also calculated.

Results

CAD patients were older, had less females, less prevalent cardiac risk factors and higher CT calcium score compared to patients with no-CAD (p<0.05, for all). At peak dobutamine stress the compromised LV longitudinal excursion (MAPSE), systolic septal and lateral velocities (s'), TAPSE and diastolic indices were more pronounced in the CAD patients compared to those without CAD, but LV dimension did not differ between groups (p>0.05). The WMSI was higher and t-IVT more prolonged in patients with CAD (p<0.01, for both). Similarly, the changes were more pronounced in patients with significant CAD compared to insignificant CAD.

On multivariate model, delta mean s' OR 2.016 (1.610–3.490, p<0.001), delta E velocity OR 1.822 (1.179–2.360, p<0.001), delta t-IVT OR 1.406 (1.180–2.180, p<0.001), and delta FT OR 1.911 (1.401–2.710, p=0.001), were the most powerful independent predictors of the presence of CAD, particularly when significant (>50%). Delta mean s' <5.0 was 85% sensitive, 89% specific with AUC 0.92. Respective values for delta E velocity <6.0 cm/s were 82%, 90% and 0.91; for delta t-IVT >4.5, 78%, 77% and 0.81 and for delta FT ≥150ms, 76%, 78% and 0.84 in predicating significant CAD. WMSI≥0.7 was 75% sensitive, 77% specific with AUC of 0.81 in predicting significant CAD. The accuracy of DSE was higher in significant CAD compared to insignificant CAD (80% vs 74%; p=0.03).

Conclusions

Compromised LV longitudinal systolic function, lower delta E wave, prolonged t-IVT and increased WMSI were the most powerful independent predictors of the presence and significance of CAD. These finding strengthen the role of comprehensive DSE analysis in diagnosing ischaemic disturbances secondary to significant CAD.

Funding Acknowledgement

Type of funding sources: None.
Acute impact of transcatheter edge-to-edge repair for mitral regurgitation on left ventricular function
Authors: Kassar M , Madhkour R , Praz F , Hunziker L , Windecker S , Brugger N
Published: October 2022

Introduction

Transcatheter Edge-to-Edge repair (TEER) for the therapy of mitral valve regurgitation (MR) is an alternative to surgery for high risk patients. It is a minimal invasive procedure but the acute impact of the pre- and afterload decrease, due to the reduction of both MR and mitral valve area (MVA), on the left ventricle (LV) systolic function was never formally evaluated.

Method

Fifty patients with mixed MR etiologies from our TEER register with complete 3D datasets of the LV before and after TEER were included in this study. LV volumes and function, as evaluate by ejection fraction (LVEF), global longitudinal strain (LV-GLS) and global circumferential strain (LV-GCS), and the MR (3D vena contracta area, 3D VCA) were evaluated before and at the end of the therapy.

Results

The majority of patients suffered from secondary MR (54%), one TEER device was implanted in 64% and two in 36% of the population. TEER leads to a significant reduction of all the LV volume and function parameters excepted for the end-diastolic volume which increased non-significantly (Table 1). The decrease of the LVEF was linked to a decrease of both GLS and GCS in a multivariate analysis (r 0.85), the decrease of GCS having a higher influence (beta −0.606 vs −0.435). In the univariate linear analysis, the reduction of LVEF, GLS and GCS were inverse proportional to the LVEF before TEER and direct proportional to the reduction of the 3D VCA. LVEF decrease was also directly linked to MVA percental reduction. After multivariate evaluation, LVEF reduction kept linked to LVEF before TEER and VCA 3D reduction (r=0.51, p=0.001), GCS decrease only to VCA 3D reduction (r=0.371, P=0.08) and GLS diminution only to LVEF before TEER (r=0.313, p=0.027).

Conclusion

After TEER, left ventricular function reduction seems principally linked to the afterload increase (i.e. the MR reduction); the circumferential function and the left ventricles with the highest ejection fractions being apparently maximally impacted.

Funding Acknowledgement

Type of funding sources: None.
Tricuspid annulus deformation indices predicting severe functional tricuspid regurgitation: 3D echocardiographic study
Authors: Krivickiene A , Verikas D , Kreckauskiene R , Gujyte G , Vaskelyte J J , Ereminiene E
Published: October 2022

Introduction

In these past few years tricuspid valve (TV) got its appreciation due to the latest focus of complications driven by tricuspid regurgitation (TR). Even though severe TR may require surgical repair, precise analyses performed by 3D echocardiographic tools to determine severe functional TR (FTR) are scarce.

Aim

To determine the accuracy of 3D echo-derived TV parameters in predicting severe FTR.

Methods

Prospective observational cohort study enrolled 90 patients (pts) with functional moderate (70%) or severe (30%) TR. Pts with FTR of various aetiologies (due to left-sided valvular heart disease, pulmonary arterial hypertension [invasively measured pulmonary capillary wedge pressure <15 mmHg]) were included in this study. Pts with ischemic heart disease (assessed by coronary angiography) were excluded from the analysis. TR severity was measured quantitatively: severe FTR was defined by 2 parameters: vena contracta ≥7 mm and TR effective regurgitant orifice area ≥40 mm2. The transthoracic echocardiography was performed and included the following 2D and 3D-derived TV parameters: the systolic and diastolic 4-chambers (septal – lateral), 2-chambers (anterior-posterior), major and minor axis TA diameters, TA area, perimeter, leaflet tenting height and volume. The 3D TV analysis was made using the 4D Auto TVQ quantification software package. Receiver Operating Characteristic (ROC) curves, area under the curve (AUC), specificity and sensitivity were analysed.

Results

Study cohort included 66% females; mean age was 65±11 years. The results of the ROC analysis are shown in Table 1. Of all TA 3D parameters, septal-lateral systolic (AUC 0.859) and diastolic (AUC 0.840) diameter, major axis systolic (AUC 0.816) and diastolic (AUC 0.810) diameter, as well as leaflet tenting volume (AUC 0.769) have the highest predictive value for severe FTR. 3D TA analysis provides 75–88% sensitivity for defying pts with severe FTR. Meanwhile, septal-lateral diameter, major axis diameter and annulus perimeter are the most specific to determine severe FTR. 2D echo-derived TA 4-chamber diastolic diameter index has a lower predictive value with worse sensitivity and specificity, compared to 3D parameters.

Conclusions

Analysis of three-dimensional echocardiographic parameters is an accurate method, suggesting that dilation of tricuspid annulus is a precise measure for identifying patients with severe FTR.

Funding Acknowledgement

Type of funding sources: None.
Response and long-term outcomes with resynchronization therapy: the role of heart failure etiology
Authors: Brandao M , Goncalves Almeida J , Fonseca P , Santos E , Rosas F , Tavares A J , Nogueira Ribeiro J , Oliveira M , Goncalves H , Primo J , Fontes-Carvalho R
Published: October 2022

Background

Resynchronization therapy (CRT) reduces mortality across all etiologies of heart failure (HF). Reverse left ventricular (LV) remodelling has been reported to occur more often in non-ischemic patients.

Purpose

To compare response and outcomes after CRT in non-ischemic (NIHF) and ischemic (IHF) HF patients.

Methods

Single-center retrospective study of consecutive patients submitted to CRT implantation (2007–2018). Major adverse cardiac events (MACE) included HF hospitalization or all-cause mortality (ACM). Clinical response was defined as New York Heart Association (NYHA) class improvement without MACE in the 1st year of follow-up (FU). Echocardiographic (echo) response implied left ventricle end-systolic volume reduction of >15% at 1-year. LV ejection fraction [LVEF] ≥50% during 1st year of FU defined superresponse. Survival analysis with Kaplan-Meier method and Log-rank test was performed to compare outcomes. Multivariate analysis was performed to assess if HF etiology predicted response to CRT.

Results

295 patients (mean age 67±11 years, 91.5% left bundle branch block, baseline QRS 171±22 ms) were included. Patients in NIHF group (n=208, 72.5%) were more often female (35.6% vs 15.6%, p<0.001), tended to be younger (67 vs 70 years, p=0.05), had more valve disease (36.7% vs 23.6%, p=0.037) and kidney disease (32.9% vs 18.5%, p=0.015). In NIHF patients, right ventricular dysfunction (tricuspid annular plane systolic excursion <17 mm) was less common (25.6% vs 47.1%, p=0.039). Addition of defibrillator was identical (53.8% vs 55.7%, p=0.882).

NYHA class improvement (79.4% vs 78.4%, p=0.987) and echo response (71.2% vs 74.4%, p=0.860) were similar. NIHF patients were more often superresponders (25.7% vs 9.5%, p=0.006), with greater improvement in LVEF (Δ 11.6% vs 7.6%, p<0.001). Clinical response was more frequent in NIHF patients (66.3% vs 50.6%, p=0.023).

After multivariate analysis, HF etiology was not predictive of clinical (p=0.960) or echo response (p=0.075). During a mean FU of 3.8 years, occurrence of MACE (Log rank test, p<0.001) and ACM (Log rank test, p<0.001) were lower in NIHF [Figure 1]. Ventricular arrythmias (6.4% vs 7.5%, p=0.993) or appropriate defibrillator therapies (5.3% vs 7.5%, p=0.743) did not differ.

Conclusions

In this cohort, consisting mostly of patients with LBBB and QRS ≥150 ms, HF etiology did not predict clinical or echo response to CRT. Still, NIHF patients showed a greater extent of LV remodelling. Lower MACE and ACM rates were also observed in non-ischemic patients.

Funding Acknowledgement

Type of funding sources: None.
Biventricular or left univentricular pacing in heart failure patients: is there a better strategy
Authors: Barradas M , Duarte F , Coutinho Dos Santos I , Resendes De Oliveira L , Serena C , Xavier Fontes A , Viveiros Monteiro A , Machado C , Dourado R , Santos E , Pelicano N , Pacheco M , Tavares A , Martins D
Published: October 2022

Background

Cardiac resynchronization therapy (CRT) is a cornerstone in treatment of heart failure (HF) with reduced left ventricular ejection fraction (LVEF) and ventricular dyssynchrony. Biventricular (BiV) pacing is often the preferred method and corrects electrical and mechanical dyssynchrony but Left ventricular (LV) preferential pacing is may preserve conduction via the right bundle branch, preventing deleterious effects from right ventricular. The evidence is sparse and there is doubts whether which programming strategy is better.

Purpose

We hypothesized that BiV is non-inferior to preferential LV pacing in HF patients with reduced LVEF and CRT devices in cardiovascular death and HF hospitalizations.

Methods

We retrospectively evaluated 147 patients with HF patients with reduced LVEF and CRT devices. Two groups were defined: LV pacing (group 1) and BiV pacing (group 2). Primary outcome was defined as cardiovascular death and secondary outcome as HF hospitalizations and NYHA class after CRT.

Results

Mean age was 70,26±10,6 years, 68,1% were males and follow-up was 52,22±44,51 months. One hundred and twenty six (85,7%) patients had implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D) and 21 (14,3%) CRT pacemaker (CRT-P). Mean LVEF was 31,1±8,5% and mean QRS duration before CRT implantation was 149,5±48,6 ms. Thirty-nine (36,4%) patients were in NYHA III–IV. HF aetiology was idiopathic in 51 (47,2%), ischemic in 36 (33,3%) and alcoholic cardiomyopathy in 9 (8,3%). Forty-five (40,5%) patients had atrial fibrillation and 37 (35,6%) coronary disease. Patients in group 2 were more frequently males than group 1 patients (46 (78,0%) vs 32 (56,1%) respectively, p=0,012). There were no differences in regard to age, LVEF, HF aetiology or other comorbidities between groups. In 57 (49,1%) CRT was programming in preferential LV pacing and 50 (50,9%) in BiV pacing. There were 2 deaths in group 1 and 3 in group 2 (OR 0.80, 95% CI 0.27–2.40). There were 0,98±3,17 hospitalizations per patient and there were no differences in HF hospitalizations between groups (OR 1.01, 95% CI 0.92–1.18) or NYHA after 6 months of CRT (p=0,364).

Conclusion

BiV pacing was not inferior to LV-only pacing in regard to cardiovascular death, HF hospitalizations and NYHA class improvement. There was no clear advantage for one pacing strategy over the other but more studies are still required.

Funding Acknowledgement

Type of funding sources: None.
Prediction of response to cardiac resynchronization therapy using cardiac magnetic resonance imaging in non-ischemic dilated cardiomyopathy
Authors: Kim S E , Chun K H , Oh J , Yu H T , Lee C J , Kim T H , Pak H N , Lee M H , Joung B , Kang S M
Published: October 2022

Background

Cardiac resynchronization therapy (CRT) is a well-established therapy for symptomatic heart failure with reduced ejection fraction, but the response is different for individuals. Although many modalities have been conducted to predict CRT response, cardiac magnetic resonance (CMR) to predict CRT response has still insufficient usefulness.

Purpose

We determine whether the parameters including late gadolinium enhancement (LGE) identified in CMR could act as predictors of CRT response.

Methods

We retrospectively investigated 124 patients with non-ischemic dilated cardiomyopathy who underwent CMR before CRT implantation between Jan 2010 and July 2021 in a single center. CRT response was defined as a decrease in left ventricular end-systolic volume (LVESV) >15% on echocardiography after at least 3 months after CRT implantation.

Results

Among the study population (mean age 65.7±11.2 years, mean EF 25±6.5%, 50% of female), 85 (69%) patients were defined as CRT responder. The CRT responders had more left bundle branch block (LBBB) compared with non-responders [79 (92.9%) vs. 23 (59.0%), p<0.001], but there was a no difference of QRS duration (158.7 vs 165.0ms, p=0.054) between two groups. CMR analysis showed that there were no significant differences in the left ventricular (LV) chamber volume and LV ejection fraction between CRT-responder and non-responder. However, the right ventricular (RV) chamber volume was smaller (RV end-diastolic volume index, 86.3 vs 103.5 ml/m2, p=0.039; RV end-systolic volume index, 49.3 vs 68.5 ml/m2, p=0.013) and the RV ejection fraction (RVEF) was higher (46.9 vs 37.6%, p=0.002) in CRT-responders compared with non-responders. The LGE on CMR was more shown in non-responders than in CRT-responders [33 (84.6%) vs 45 (52.9%), p<0.001]. In CMR parameters, RV dysfunction (RVEF <45%) [Odds ratio (OR), 0.21 (0.05–0.93), p=0.045] and LGE [OR, 0.21 (0.05–0.58), p=0.01] were significantly associated with poor CRT response.

Conclusions

The presence of LGE and RV dysfunction on CMR were associated with poor CRT response in patients with non-ischemic dilated cardiomyopathy. Further investigation with CMR for pre-CRT patients is needed to support these results.

Funding Acknowledgement

Type of funding sources: None.
Concomitant left atrial appendage closure with left ventricular assist device surgery can reduce ischemic cerebrovascular accidents
Authors: Nishida H , Jeevanandam V , Salerno C , Song T , Onsager D , Nguyen A , Grinstein J , Chung B , Smith B , Kalantari S , Sarswat N , Kim G , Pinney S , Ota T
Published: October 2022

Background

It remains unknown if concomitant left atrial appendage closure (LAAC) at the time of left ventricular assist device (LVAD) surgery can reduce ischemic cerebrovascular accidents.

Purpose

The purpose of this study is to assess the impact of LAAC at LVAD surgery on the incidence of ischemic cerebrovascular accidents.

Methods

Between January 2012 and November 2021, 310 patients underwent LVAD surgery with HeartMate II or III. Out of 310 patients, 98 patients (31.6%) underwent concomitant LAAC. The cohort was divided into two groups: patients with LAAC (Group A, n=98) and without LAAC (Group B, n=212). To minimize device bias, LVAD surgery with HeartWare HVAD device was excluded. The ischemic cerebrovascular accident was defined as ischemic stroke, hemorrhagic stroke or transient ischemic attack. We reviewed early and long-term clinical outcomes. The incidence of ischemic cerebrovascular accidents was compared between two groups using the Kaplan-Meier method. We also investigated if LAAC was associated with ischemic cerebrovascular accidents by Cox proportional hazards analysis.

Results

There were no significant differences in baseline characteristics between two groups including age (Group A: 55.0±12.3 years old, Group B: 56.9±14.1 years old, p=0.26), preoperative CHADS2 score (Group A: 2.40±1.1, Group B: 2.58±1.1, p=0.19) and history of atrial fibrillation (Group A: 42.9%, Group B: 42.5%, p=0.95). In-hospital mortality was not significantly different between the two groups (Group A: 7.1%, Group B: 12.3%, p=0.16). In terms of postoperative complications, there were no significant differences between two groups in requiring extracorporeal membrane oxygenation, re-exploration for bleeding and newly required hemodialysis. Median follow up period was 474 days. Thirty-five patients (11.2%) developed ischemic cerebrovascular accidents (5 patients in Group A and 30 patients in Group B). The rate of freedom from ischemic cerebrovascular accidents in Group A (94.1% at 500 days and 94.1% at 1500 days) was significantly higher than that in Group B (88.2% at 500 days and 77.4% at 1500 days; log rank=0.024). In a Cox proportional hazards regression analysis including LAAC, age, history of atrial fibrillation, diabetes mellitus and Heartmate 3 device implantation, LAAC was associated with reducing the incidence of ischemic cerebrovascular accidents (hazard ratio 0.37, 95% CI 0.13–0.89, p=0.02).

Conclusion

Concomitant LAAC at the time of LVAD surgery can reduce ischemic cerebrovascular accidents without increasing perioperative mortality and complications.

Funding Acknowledgement

Type of funding sources: None.
The effects of combined hyperbaric oxygenation and erythropoietin therapy in treatment of heart failure
Authors: Mitrovic P , Tepic S
Published: October 2022

It well known that hyperbaric oxygenation (HBO) and erythropoietin (EP) are growth factors. Because of that, it is logical to apply them together as a therapeutic procedure in the regeneration and recovery of the heart muscle. Hyperbaric oxygen therapy has increased the amount of oxygen which “presents” to cardiac muscle, while the use of EP is reduced the intensity of apoptosis of heart muscle. The aim of this study was to analyze if combined therapy of HBO and EP can be usefulness in patients (pts) with heart failure (HF), especially in chronic type of HF.

Material and methods

The study was designed as a cross-sectional study in the field of new procedures of HF treatment. From January 2017 to January 2019, there were analyzed 92 patients (pts) with chronic HF. There were more men (69.6%). All pts were divided in two groups: Group I – 72 pts (78.3%) with ischemic HF and Group II – 20 pts (21.7%) with non-ischemic HF. Hyperbaric oxygen therapy protocol was defined as protocol for pts with sever cardiac diseases (total of 15 treatment, once daily, on pO2 1.3–1.7 ATA). Recombined EP was administered deeply subcutaneous, every second day 2000 IU, until dose of 18000 IU. In all pts, on admission and one month after therapy, next procedures were arranged: hemoglobin level, distribution of NYHA class, 6-minutes walking test and EF (by radionuclide ventriculography).

Results

There were no differences between two groups in gender (p=0.0170) and hemoglobin level before and after therapy (p=0.4400). There were significant changes in distribution of NYHA class in both group of pts, from NYHA class III to NYHA class I and II (p=0.0179) one month after therapy, as well as in 6-minutes walking test one month after therapy (p=0.0148), too. Ejection fraction was significantly better in both groups of pts, one month after therapy (p=0.0040).

Conclusion

The results of this study open up completely new aspects of the combined use of comparative therapeutic procedures with significant final positive effect in the treatment of chronic HF, ischemic, as well as in non-ischemic type of HF.

Funding Acknowledgement

Type of funding sources: None.
Device-based remote monitoring strategies for guided management of patients with heart failure: a systematic review and meta-analysis
Authors: Zito A , Princi G , Romiti G F , Basili S , Liuzzo G , Sanna T , Restivo A , Ciliberti G , Trani C , Burzotta F , Cesario A , Savarese G , Crea F , D'Amario D
Published: October 2022

Background

Preclinical predictors of worsening heart failure can be monitored by implanted devices and may support the management of patients with heart failure. However, clinical results of such an approach are controversial.

Purpose

We aimed to assess if guided heart failure management according to device-based remote monitoring strategies is more effective than standard therapy.

Methods

A comprehensive literature research for randomized controlled trials (RCTs) comparing a strategy of guided heart failure management versus standard therapy was performed on PubMed, Embase, and CENTRAL databases. Incidence rate ratios (IRRs) and associated 95% confidence intervals (CIs) were calculated using the Poisson regression model with random study effects. The primary outcome was a composite of all-cause death and hospitalizations for heart failure. Secondary endpoints included the individual components of the primary outcome.

Results

A total of 9216 patients from 14 RCTs were included. The average follow-up duration was of 16 months. Compared with standard therapy, guided heart failure management reduced the risk of the composite of all-cause death and hospitalizations for heart failure (IRR 0.86, 95% CI 0.79–0.94, p<0.001), driven by a reduction in both all-cause death (IRR 0.88, 95% CI 0.77–1.00, p=0.049) and hospitalizations for heart failure (IRR 0.83, 95% CI 0.75–0.92, p<0.001). Findings varied according to the type of parameters monitored, with haemodynamic-guided and multiparameter-guided strategies yielding favorable effects, while impedance-guided strategy was not able to provide significant benefits.

Conclusion

Device-based remote monitoring systems as a tool to guide the management of patients with heart failure were associated with a valuable reduction in the risks of death, hospitalizations for heart failure, and the composite of both, supporting their routine use in clinical practice.

Funding Acknowledgement

Type of funding sources: None.
Coffee consumption and cardiovascular health in the general population
Authors: Wenzel J , Senftinger J , Borof K , Ojeda F , Aarabi G , Beikler T , Mayer C , Behrendt C , Walther C , Zyriax B C , Twerenbold R , Blankenberg S , Nikorowitsch J
Published: October 2022

Background

Coffee, next to water the most widespread beverage, is attributed both harmful and protective characteristics concerning cardiovascular health. This study aimed to evaluate associations of coffee consumption with cardiac biomarkers, echocardiographic, and electrocardiographic parameters as well as major cardiovascular diseases.

Methods and results

We performed a cross-sectional analysis of 9,009 participants a large German population-based cohort study, enrolled between 2016 and 2018 median age 63 [IQR: 55; 69] years. Coffee consumption was classified into three groups: <3 cups/day (low), 3–4 cups/day (moderate), >4 cups/day (high). In linear regression analyses adjusted for age, sex, body mass index, diabetes, hypertension, and smoking, moderate and high coffee consumption were associated with LDL-cholesterol (β=2.08; 95% CI: 0.14, 4.03, p=0.036; β=5.69; 95% CI: 2.91, 8.47; p<0.001). Moderate and high coffee consumption were negatively associated with systolic (β=−1.6; 95% CI: −2.66, −0.54; p=0.003; β=−2.63; 95% CI: −4.15, −1.12; p=0.001) and diastolic blood pressure (β=−0.8; 95% CI: −1.38, −0.22; p=0.007; β=1.28; 95% CI: −2.11, −0.45; p=0.002). Different levels of coffee consumption did neither correlate with any investigated electrocardiographic or echocardiographic parameter nor with prevalent major cardiovascular diseases, including prior myocardial infarction and heart failure.

Conclusions

In this cross-sectional analysis, moderate and high coffee consumption was positively associated with LDL-cholesterol and negatively associated with systolic and diastolic blood pressure. However, major cardiovascular diseases including heart failure and its diagnostic precursors were not associated with coffee consumption, connoting a neutral role of coffee in the context of cardiovascular health.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Deutsche Forschungsgemeinschaft [Grant Number TH1106/5-1; AA93/2-1]The Foundation Leducq [Grant Number 16 CVD 03]
Sodium glucose co-transporter 2 inhibition prevents muscle energy metabolism changes in infarcted rats
Authors: Souza L M , Brandao B B , Pagan L U , Gatto M , Rodrigues E A , Borim P A , Murata G M , Zornoff L A M , Okoshi K , Okoshi M P
Published: October 2022

Introduction

Skeletal muscle energy metabolism is commonly altered in heart failure patients, with a metabolic shift from oxidative to glycolytic muscle fiber. These changes contribute to reduced functional capacity. Sodium glucose co-transporter type 2 (SGLT2) inhibitors improve cardiovascular outcomes in both diabetic and non-diabetic patients, as well as those with and without heart failure. However, the effects of SGLT2 inhibitors on skeletal muscle during heart failure have not been established. The aim of this study was to assess the metabolic effect of empagliflozin (EMPA) on skeletal muscle of rats with myocardial infarction (MI)-induced heart failure.

Methods

One week after MI induction or simulated surgery, male Wistar rats were divided into four groups: Sham (n=10), Sham+Empa (n=12), MI (n=10), and MI+Empa (n=09). EMPA was added to rat chow (5 mg/kg/day). Rats were supplied with ad libitum water and chow for 12 weeks. Infarct size was measured by histological analysis. Metabolic enzyme activity in the soleus muscle was assessed by spectrophotometry. Statistical analysis: ANOVA and Tukey, and Student's t tests.

Results

Only rats with infarction size greater than 35% of total left ventricle area were included in this study. Infarction size did not differ between infarcted groups (MI 41.8±4.2; MI+Empa 40.7±5.7 of total left ventricle area). In the MI soleus muscle, metabolic enzyme activity of glucose-6-phosphate-dehydrogenase, citrate synthase and beta-hydroxy-acyl-dehydrogenase was higher than the Sham group. These changes were not observed in the MI+Empa group. MI+Empa had lower hexokinase, phosfructokinase, and pyruvate kinase activity (glycolytic metabolism enzymes), and lower citrate synthase and glucose-6-phosphate-dehydrogenase activity than MI.

Conclusion

Chronic treatment with SGLT2 inhibitor empagliflozin prevents metabolic abnormalities in skeletal muscle in infarcted rats.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): CAPES, CNPq, FAPESP
The I4RON-HF study, Intravenous Iron Isomaltoside for Inpatients veRsus Outpatient Asians with Heart Failure
Authors: Lee T , Teh K C , Sundram R , Ariff A , Roslan A , Sundarajoo M , Low M Y , Ong C S H , Goay S E , Palaniappan G , Norasiah N , Syamira N , Fatini N , Ghazi A
Published: October 2022

Background and purpose

Iron deficiency (ID) impacts ∼50% of heart failure (HF) patients [1] and is a risk factor and strong predictor for death and mortality with or without anaemia [2]. Oral iron appears to be ineffective whilst intravenous iron (IV-iron) has proven to be efficacious however data is primarily from a Caucasian population [3] despite ID being more prevalent amongst Asians. The I4RON-HF study assesses efficacy of high-dose IV-iron versus oral iron in stable outpatients and inpatients amongst an Asian population recovering from episodes of decompensated HF.

Methods

This is a single-centre randomized controlled study, where patients who had symptomatic heart failure (Ejection Fraction <50% and New York Heart Association class 2–3) were randomized into two groups. The intervention arm received anywhere from 500mg to 1500mg of IV Iron Isomaltoside as a single infusion, whereas the control arm received routine iron supplements.

The primary study endpoint was the percentage of patients achieving iron repletion at 4,8 and 12 months after enrolment. Secondary endpoints included clinical parameters (6-minute walk test, NYHA status and 2D-Echocardiogram), and biochemical parameters (Serum NTproBNP, Cardiac Troponin-T and hemogloblin) at 4,8 and 12 months.

Results

A total of 65 patients were enrolled (male 55%), 33 in the interventional arm and 32 in the control arm. There were no patients lost to follow up. 96.9% of patients in the IV Iron arm achieved the primary endpoint at 4 months, compared to 68.7% in the control group. These findings we consistent at 8 months (90.9% vs 65.6%) and 12 months (90.9% vs 56.2%). Looking at the secondary endpoints, the IV Iron cohort recorded a 11.14% increase in Hemogloblin levels versus the control arm which recorded a reduction of 16.23%. There was also lower NTproBNP levels in the IV iron group (81.6% reduction) versus the control group (66.3% reduction). Clinically, the patients who received IV iron had a 42.98% increase in their 6-minute walk test from baseline, compared to an increase of 8.61% in the control arm. There were no significant echocardiographic changes.

Conclusion

These findings in our single-centre study support the efficacy of IV iron over oral supplements in the treatment of iron deficiency amongst Asian heart failure patients. The secondary endpoints also indicate better clinical and biochemical outcomes when iron stores are successfully repleted. Lastly, this study demonstrates the feasibility and safety of outpatient administration of high-dose IV-iron. Results from large-scale clinical studies looking at hard endpoints (mortality, HF hospitalization) are expected to further advance understandings.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Heart Institute (Institut Jantung Negara) FoundationCompai Pharma