bluuebunny/crossref_metadata_2025 huggingface dataset:
Cardiac changes after cardiac resynchronization therapy assessed using cardiac magnetic resonance imaging during biventricular pacing
Authors: Czimbalmos C , Papp R , Szabo L , Toth A , Csecs I , Suhai F.I , Molnar L , Kosztin A , Geller L , Merkely B , Vago H
Published: November 2020

Cardiac magnetic resonance (CMR) is a valuable tool in the assessment of left and right ventricular volumes and functions therefore establishing the effect of cardiac resynchronization therapy (CRT), but in majority of the devices MR safe mode does not include biventricular pacing as an option. We aimed to assess the effect of cardiac resynchronization using CMR with resynchronization on.

NYHA class II-III patients with LVEF≤35% despite optimal medical therapy and complete LBBB with broad QRS (>150 ms) were prospectively recruited (n=16, 65±7 years, 56% male, 69% nonischaemic). CMR examination was performed at baseline and at 6-month follow-up, applying both biventricular and AOO pacing. The following data were measured: conventional CMR parameters including left and right ventricular ejection fraction (LVEF), end-diastolic index (LVEDVi) and end-systolic volume index (LVESVi), stroke volume and mass, remodelling indices such as 3D sphericity and relative wall thickness (RWT: 2x end-diastolic wall thickness /end-diastolic long-axis diameter). Using feature tracking analysis global longitudinal, circumferential, radial strain, global dyssynchrony (mechanical dispersion (MD)) and regional dyssynchrony was measured.

Comparing the baseline and follow-up CMR parameters measured during biventricular pacing, we found a significant increase in LVEF (27±7 vs 45±9%; p<0.001) and decrease in LVEDVi and LVESVi (LVEDVi: 149±28 vs 91±20ml/m2; LVESVi: 108±31 vs 51±17ml/m2; p<0.001). Based on decrease in LVESVi 14 patients were classified as super-responder (>30%), one responder (>15%) and one non-responder (<15%). ProBNP levels significantly decreased (1186±83 vs 323±271 pg/ml, p<0.05). LV remodelling indices (3D sphericity: 0.46±0.13 vs 0.61±0.11, RWT: 0.33±0.07 vs 0.43±0.10), global longitudinal, circumferential and radial strain values showed significant improvement. Circumferential MD decreased (18.3±6.7 vs 13.3±3.4, p<0.01), while longitudinal MD did not change. Regional dyssynchrony drastically improved (358±108 vs 98±61ms, p<0.001). Applying AOO pacing resulted in an immediate deterioration in LVEF (45±9 vs 38±9%), LVESVi (51±17 vs 58±19 ml/m2), global circumferential and radial strain and regional dyssynchrony.

In conclusion CMR imaging during biventricular pacing is feasible and enables a more precise quantification of LV function, morphology and mechanics. As a result, it may contribute to a better understanding of the effects of resynchronization therapy and might improve responder rate in the future.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Office of Hungary (NKFIA)
Total remote pacemaker follow-up versus standard follow-up reduces global health care utilization
Authors: Ayala Valani L , Badra Verdu M , Dussault C , Roux J.F , Ayala Paredes F
Published: November 2020

Background

Remote pacemaker monitoring reduces in person pacemaker clinic visits, but a complete remote follow-up could be associated with an increase in total clinical encounters or even admissions, as patients (pts) have less access to a cardiologist or health care provider in a regular basis.

Methods

Due to a shortage in EP cardiologists between 2009 and 2012 a cohort of 296 pts implanted with a pacemaker, were offered Biotronik home monitoring only follow-up (HM f-p); gradually since 2012, pts came back to usual schedule (once or two a year in clinic follow-up). We matched the same amount of time in HM f-p to standard pacemaker follow-up (STD f-p), aiming to detect any difference in health care utilisation (clinical visits and admissions of all cause). For non de novo implants, the STD f-p period was calculated backwards until pacemaker replacement.

Results

One third of pts refused, were non compliant or were disconnected early (less than 6 months) to HM f-p only; 200 patients completed a median of 804 days in RM f-p only (range 88–3003 days). Mean age at implant was 74.9 years old (range 22.9–92.3, median 78 y.o.), 57.5% were male and 76% had de novo implants (15% VVI, 82% DDD and 3% CRT-P devices). The median of unscheduled pacemaker visits was 1 (range 0 to 7, 22.5% of pts never required a pacemaker clinic visit during HM f-p). The load of HM messages (number and type -i.e. administrative, clinical and clinical triggering a visit) was similar between both periods of follow-up. During HM f-p there were a median of 3 pacemaker clinic visits saved (range −3 to 16) as expected, but total number of visits were also reduced significantly from a median of 12 (range 1–115) to 8 (0–90) visits p<0.05, between STD f-p versus HM f-P (mean visits reduced from 16.96±16.4 versus 13.91±15.7). Finally, there was not an increase in total admissions between these two periods of f-up (mean of 0.8±1.3 for STD f-p versus 0.4±0.8 for HM f-p, median of 0 hospitalizations for both groups range de 0–8 versus 0–5, p=NS)

Conclusion

Total remote pacemaker follow-up is feasible in two thirds of patients, and when achieved, it saves in person pacemaker follow-up visits and visits of any cause, without increasing the number of admissions during the same period.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Centre de recherche du CHUS - CIUSSS de l'Estrie
Success and complication rate of Tightrail mechanical percutaneous lead extraction: a multicenter French study
Authors: Artus A , Guenancia C , Behar N , Leclercq C , Schatz A , Mansourati J , Garnier F
Published: November 2020

Background

Our objective was to assess Philips TightRail™ rotating dilator sheath efficacy and safety for extraction of endocardial leads. No large scale multicenter data is available on this mechanical lead extraction device, now commonly used in France.

Methods and results

We conducted a retrospective, multicenter (from 4 French university hospitals) study. These centers that only perform mechanical lead extraction using this device were selected on the basis of the annual volume of procedures (>10 leads/year). All patients from January 2015 to January 2020 who underwent at least one extraction of an endocardial lead with using TightRail™ were included. All of the extracted leads were >12 months old and indications for extraction were based on ESC guidelines.

Overall, 395 leads were extracted using TightRail™ in 203 patients (mean age 70 years, 75% male sex).

Indications for lead removal included cardiac device infection in 172 (85%) cases, lead malfunction in the 25 (12%) cases, vein thrombosis in 3 (1.5%) cases and 3 for other indications (1,5%). The extracted devices were pacemaker in 134 (66%) cases, implantable cardioverter-defibrillator (ICD) in 69 (44%) cases. The mean time from implantation was 124 months. Complete procedural success with TightRail™ system alone was achieved in 180 (89.1%) patients (352 leads) and overall clinical success was 93% (367 leads). Fifteen right sided leads were completely removed with the help of femoral snare. Ten (5%) patients had at least one major perioperative complication: 3 cardiac tamponades, 1 haemothorax, 1 stroke, 5 vascular breaches requiring surgical intervention. No in-hospital death was observed.

Conclusion

Our large scale retrospective study in 4 high-volume mechanical lead extraction centers shows that TightRail™ is highly effective for chronically implanted lead extraction. The safety profile appears similar to the rate recently described with power sheaths.

Funding Acknowledgement

Type of funding source: None
The relationship between the key markers of myocardial fibrosis and gut microbiota composition in patients with heart failure and preserved ejection fraction
Authors: Kaburova A.N , Drapkina O.M , Uydin S.M , Pokrovskaya M.S , Koretsky S.N , Efimova I.A , Makarov V.V
Published: November 2020

Background

Increased myocardial fibrosis may play a key role in heart failure with preserved ejection fraction (HFpEF) pathophysiology. The current gold standard for the diagnosis and assessment of myocardial fibrosis is endomyocardial biopsy. A number of circulating biomarkers have been proposed for the assessment of myocardial fibrosis, however the most consistent results have been found for C-terminal propeptide of procollagen type I (PICP) and N-terminal propeptide of pro-collagen type III (PIIINP). Some evidence suggests the possible link between the gut microbiota composition and myocardioal fibrosis.

Purpose

The aim of the study was to investigate the association between the serum markers of myocardial fibrosis (PICP and PIIINP) with gut microbial genera in patients with HFpEF.

Methods

42 patients with confirmed HF-pEF (mediana and interquartile range of age 67 [64; 72] years, 47% men, body mass index <35 kg/m2 with no history of myocardial infarction or diabetes mellitus) were enrolled in the study. The patients underwent transthoracic echocardiography with Doppler study, HF-pEF was confirmed according to the recent ESC guidelines (based on E/e' ratio, N-terminal pro-B type natriuretic peptide >125 pg/ml and symptoms of HF). The levels of PICP and PIIINP were evaluated in patients' serum using enzyme-linked immunosorbent assay. The intestinal microbiome was investigated using high-throughput sequencing of bacterial 16S rRNA gene.

Results

The mediana and interquartile range in PICP was 918 [700; 1044] pg/ml, in PIIINP it was 6.215 [3.99; 8.29] pg/ml. The analysis revealed significant correlations between PICP and the following bacterial genera of Firmicutes:Ruminococcus (r=−0,36); Gemmiger (r=−0,35), Allisonella (r=0,32) and Howardella (r=−0,30). PIIINP significantly correlated with 2 genera: Blautia which belongs to Firmicutes phylum (r=0,36) and Bilophila which belongs to Proteobacteria phylum (r=−0,33). All values with p<0,05.

Conclusion

Both PICP and PIIINP had negative significant correlations with beneficial bacterial genera and positive correlations with several potencially harmful gut bacterial genera. This type of relationship might become the novel field of research in the group of patients with HF-pEF due to myocardial fibrosis.

Funding Acknowledgement

Type of funding source: None
The link between left ventricular extracellular volume determined by T1 myocardial mapping and gut microbiota composition in individuals with heart failure and preserved ejection fraction
Authors: Kaburova A.N , Drapkina O.M , Uydin S.M , Vishnyakova M.V , Pokrovskaya M.S , Koretsky S.N , Abramenko A.S , Chermensky G.V , Efimova I.A , Makarov V.V
Published: November 2020

Introduction

Heart failure with preserved ejection fraction (HFpEF) represents a major challenge in modern cardiology. As described previously, in HFpEF comorbidities promote a systemic inflammatory state, leading to diffuse myocardial fibrosis resulting in myocardial stiffening. Gut dysbiosis which is considered as the novel source of chronic systemic inflammation has been actively investigated as the risk factor for the development and aggravation of cardiovascular diseases including heart failure. Cardiac magnetic resonance T1-mapping is a novel tool, which allows noninvasive quantification of the extracellular space and diffuse myocardial fibrosis. Moreover, the extracellular volume (ECV) fraction can be calculated, providing information on the relative expansion of the extracellular matrix, thus being a noninvasive alternative to myocardial biopsy studies.

Purpose

The research was aimed at investigating the correlation between the left ventricular ECV and gut microbial genera in patients with HFpEF.

Methods

42 patients with confirmed HF-pEF (mediana and interquartile range of age 67 [64; 72] years, 47% men, body mass index <35 kg/m2 with no history of myocardial infarction or diabetes mellitus) were enrolled in the study. The patients underwent transthoracic echocardiography with Doppler study, HF-pEF was confirmed according to the recent ESC guidelines (based on E/e' ratio, N-terminal pro-B type natriuretic peptide >125 pg/ml and symptoms of heart failure). The intestinal microbiome was investigated using high-throughput sequencing of bacterial 16S rRNA gene. As the last step of research T1-myocardial mapping with the modified look-locker inversion-recovery protocol (MOLLI) sequence at 1.5 Tesla was performed to assess left ventricular extracellular volume fraction.

Results

The mean±std in ECV was 31.02±4.4%. The relative abundance (%) of the most prevalent phyla in gut microbiota was 48±22.5 for Firmicutes, 47.4±22.8 for Bacteroidetes and 1.5 [1.5; 2.5] for Proteobacteria. The analysis showed significant negative correlations between ECV and the following bacterial genera: Faecalibacterium (r=−0.35), Blautia (r=−0.43), Lachnoclostridium (r=−0.32). Moreover ECV positively correlated with Holdemania (r=0.4), Victivallis (r=0.38), Dehalobacterium (r=0.38), Enterococcus (r=0.33) and Catabacter (r=0.32). All correlation values with p<0.05.

Conclusion

We discovered both negative and positive significant correlations between ECV – the non-invasive marker of myocardial fibrosis and several bacterial genera, which may have negative impact on myocardial remodeling in HF-pEF.

Funding Acknowledgement

Type of funding source: None
Evaluating diastolic and systolic reserve by strain imaging during resistance exercise training in heart failure with preserved ejection fraction
Authors: Jain V , Nhola B.L , Larsen C.M , Villarraga N , Anastasius M , Badawy M , Zahid A , Bruhn E.J , Smith J.R , Bonikowske A , Olson T.P , Villarraga H.R
Published: November 2020

Background

Exercise intolerance is the cardinal manifestation of heart failure (HF), yet its underlying mechanism(s) remain poorly understood. Measures of ventricular function such as ejection fraction often have no relationship with exercise capacity in HF. 2D-STE has proved to be more reliable method to evaluate myocardial mechanical function. Our hypothesis is Resistance exercise training (Resist-HFpEF) will improve exercise tolerance and exertional symptoms in patients with HFpEF.

Purpose

The study aims to evaluate myocardial mechanical function by strain imaging during resistance exercise training in Heart Failure patients with Preserved Ejection Fraction (HFpEF)

Methods

This is a single centre prospective pilot study. 24 HFpEF patients were enrolled and their baseline comorbidities were recorded. Baseline 2D-STE imaging was performed at rest and during exercise (Visit 1). Patients were then randomized to either a novel resistance exercise training program for 36 sessions (3 sessions per week for 12 weeks) or a standard of care control group. 2D STE imaging was then repeated at follow-up (Visit 2). Peak Global Longitudinal strain (GLS), systolic strain rate (SSR), early diastolic strain rate (SRe) were measured offline.

Results

Mean age of the Rehab cohort was 68.57±10.52 years and the control cohort was 68.1±6.47 years. 23 study subjects were male (96%). 17% of the study subjects were hypertensive, 63% were diabetic, 42% had NYHA I, 46% had NYHA II and 13% had NYHA III of heart failure. The mean LV ejection fraction in the control and Rehab group after the training program at rest was 61.88±2.26% & 54.74±2.07% (p-value 0.04) and during exercise was 59.90±2.05% and 53.13±2.05% (p-value 0.04). The peak GLS was −18.80±4.29% and −17.7±2.21% in controls during rest and exercise at Visit 1 (p-value 0.27) while the rehab cohort had −18.71±4.7% and −20.82±2.4% respectively (p-value 0.0268). The peak GLS was −17.40±3.05% and −17.96±2.65% in controls during rest and exercise at Visit 2 (p-value 0.3430) while rehab cohort had −17.97±6.21% and −16.57±3.82% respectively (p-value 0.67). (Figure 1a and 1b shows GLS, SRS, SRe at Baseline and after exercise program respectively)

Conclusion

This pilot study suggest systolic and diastolic reserve can be measured reliably during low grade exercise. These results could reflect improvement in clinical status and exercise tolerance.

Figure 1. Comparison of peak GLS, SSR, SRe amongst HFpEF patients at rest and during exercise before and after the rehab training program.

Funding Acknowledgement

Type of funding source: None
Effect of sacubitril/valsartan on cognitive function in patients with HFpEF: a prespecified analysis of PARAGON-HF
Authors: Dewan P , Jhund P.S , Anand I.S , Desai A.S , Gong J , Lefkowitz M.P , Pieske B , Rizkala A.R , Shah S.J , Van Veldhuisen D.J , Zannad F , Zile M.R , Solomon S.D , McMurray J.J.V
Published: November 2020

Background

A theoretical concern has been raised about detrimental effects of sacubitril/valsartan (sac/val) on cognitive function as neprilysin is one of many pathways involved in clearance of amyloid beta peptides from brain tissue.

Purpose

To examine effect of sac/val, compared with valsartan, on cognitive function in patients with heart failure (HF) and preserved ejection fraction (HFpEF).

Methods

In the PARAGON-HF trial, cognitive function was tested in a subgroup of patients at baseline and follow-up, using Mini-Mental State Examination [MMSE] having a maximum score of 30 (higher scores reflect better cognitive function). Change in MMSE score from baseline to 96 wks was a prespecified exploratory endpoint. Other post hoc analyses included “cognitive decline” (fall in MMSE ≥3 pts) and assessment of cognition-related adverse events (AEs).

Results

Among 2895 patients (60% of total) in PARAGON-HF with baseline MMSE measurement, mean (SD) score was 27.4 (3.0) in patients receiving sac/val (1453) and 27.4 (2.9) in patients receiving valsartan (1442). There was no difference between sac/val and valsartan in MMSE score change from baseline to wk 96: sac/val −0.02 (SE 0.07) and valsartan 0.00 (0.07); between-treatment difference −0.02 (95% CI: −0.22 to 0.18); p-value = 0.83. Cognitive decline at 96 weeks occurred in 115 of 1071 evaluable patients (10.7%) in sac/val group and 121 of 1053 patients (11.5%) in valsartan group; risk ratio 0.97 (0.75–1.26), p-value = 0.82. Cognition-related AEs were more frequent, than in PARADIGM-HF (likely as patients in PARAGON-HF were older) but, as in PARADIGM-HF, did not differ between sac/val and comparator treatment (Table).

Conclusions

Cognitive change, measured by MMSE, did not differ between treatment with sac/val & valsartan in patients with HFpEF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): PARAGON-HF study was funded by Novartis Pharma.
Mortality in a well-defined group of predominantly Caucasian pulmonary sarcoidosis patients
Authors: Huitema M.P , Mathijssen H , Bakker A.L.M , Mager J.J , Grutters J.C , Post M.C
Published: November 2020

Background

Sarcoidosis is an inflammatory systemic disease. Mortality has often been described in patients with more advanced disease, especially in those awaiting lung transplant. The PULSAR study is a cross sectional study prospectively investigating at least two year follow up on mortality in a large prospective, well-defined cohort of Dutch sarcoidosis patients, newly referred to a tertiary centre for sarcoidosis, including data on echocardiography.

Methods

All patients underwent prospective screening. Patients with intermediate or high probability for PH where referred for right heart catheterisation (RHC). In accordance to the guideline PH was defined as a mean PAP ≥25mmHg by RHC. Elevated pulmonary artery pressure was defined as >20 and <25mmHg. The absence of PH was defined as a mean PAP <25mmHg or a low PH probability on echocardiography. Survival was defined as absence of mortality or transplantation at the time of evaluation.

Results

399 patients were included in the analysis. All patients had follow up of at least 2 years. Five patients had died during fallow up, and none were transplanted. The PH prevalence was 3%. PH and elevated pulmonary artery pressure was associated with worse survival. On echocardiography, high PH probability was associated with worse survival compared to low PH probability (HR 1.78, p=0.01). If measurable, RVSP differed significantly between groups.

Conclusion

Only high PH probability and RVSP measurement on echocardiography were associated with mortality

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): ZonMW
The impact of epicardial adipose tissue and right ventricular hypertrophy on diastolic and global function of right ventricle in patients with metabolic syndrome
Authors: Sedaia E , Revenco V , Gutan I , Ochisor V , Vascenco A
Published: November 2020

Background

Metabolic syndrome (MetS) and visceral obesity represent important cardiometabolic risk factors. Right ventricular (RV) function is affected in MetS. Epicardial adipose tissue is a metabolically active organ which might influence cardiac morphology and function, especially in patients with MetS. Epicardial fat thickness (EFT) is proposed as a new marker of visceral obesity.

Purpose

The objective of our study was to evaluate the role of EFT and RV hypertrophy in global (determined by Tei index) and diastolic function of RV in patients with MetS.

Methods

The study included 85 subjects with MetS (mean age 52±9.1 years) and 85 controls without MetS (mean age 50±8.9 years, P=0.06). MetS was defined by ≥3 criteria of International Diabetes Federation and American Heart Association/National Heart, Lung, and Blood Institute. All the subjects underwent complete 2D echocardiography with the assessment of the ratio of early and late diastolic tricuspid flow velocities (Et/At), the ratio of early diastolic tricuspid flow velocity and early diastolic tricuspid annular velocity (Et/e't), Et deceleration time (DT), RV end-diastolic free wall thickness (EDWT) and EFT. We determined Tei index of RV by pulsed and pulsed tissue Doppler.

Results

All the parameters of RV diastolic function, as well as Tei index, were significantly changed in MetS group: Et/At 0.85±0.39 vs. 1.17±0.43, P<0.001; Et/e't 5.1±1.3 vs. 4.5±0.8, P<0.001; DT 235±8 ms vs. 208±14 ms, P<0.001; Tei index by pulsed Doppler (0.48±0.05 vs. 0.34±0.06, P<0.001) and by pulsed tissue Doppler (0.58±0.05 vs. 0.46±0.04, P<0.001). Also, RV EDWT was significantly higher in MetS patients (6.3±0.8 mm vs. 4.6±1.2 mm, P<0.001) and positively correlated with Tei index (r=0.658, P<0.001; fig.1.A), Et/e't (r=0.269, P<0.001) and EFT (r=0.547, P<0.001). EFT was higher in MetS subjects (7.9±0.07 mm vs. 5.4±1.2 mm, P<0.001) and correlated with RV Tei index (r=0.614, P<0.001; fig.1.B), Et/e't (r=0.432, P<0.001). Multivariate regression analysis showed that systolic blood pressure, plasma glucose level, EFT and RV EDWT were independently associated with RV global and diastolic dysfunction in patients with MetS (P<0.05 for all parameters).

Conclusions

Our findings support that MetS is associated with diastolic and global dysfunction of RV. In subjects with MetS increased EFT and RV hypertrophy are independently associated with RV diastolic and global function.

Funding Acknowledgement

Type of funding source: None
Non-fatal cardiovascular events preceding sudden cardiac death in patients with an acute myocardial infarction complicated by heart failure: insights from the High-Risk-Myocardial-Infarction database
Authors: Hui S , Sharma A , Docherty K , McMurray J.J.V , Pitt B , Dickstein K , Pfeffer M.A , Girerd N , Rossignol P , Ferreira J.P , Zannad F
Published: November 2020

Background

Sudden cardiac death (SCD) is responsible for 20–40% of mortality following acute myocardial infarction (AMI). The risk of SCD is even higher among patients with AMI complicated by heart failure (HF) (either clinically apparent HF or left ventricular dysfunction). The temporal relationship between an AMI complicated by HF and subsequent SCD and the association of non-fatal cardiovascular (CV) events following AMI with SCD has yet to be described.

Purpose

Among patients with AMI complicated by HF, we evaluated the probability and temporal association of subsequent non-fatal cardiovascular (CV) events (HF hospitalization, recurrent MI, or stroke) and SCD.

Methods

The High-Risk Myocardial Infarction (HRMI) database contains 28,771 patients with signs of HF or reduced LV ejection fraction (<40%) after AMI. Among patients with an AMI complicated by HF, we used adjudicated cause of death from the HRMI Database to identify: 1) the temporal distribution of SCD among patients following an index AMI; 2) the probability of having SCD following a non-fatal CV event following the index AMI.

Results

Median follow-up was 1.9 years. Mean age was 65.0±11.5 years and 70% were male. The incidence of CV death was 7.9 per 100 patient-year [py] and for SCD was 3.1 per 100py (40% of CV deaths). SCD rates were highest in the early period (<90 days) after AMI and decreased over time. Recurrent MI preceded 9.6% of SCD after a median time of 145 days; HF hospitalization preceded 17.0% of SCD after a median 144 days; and stroke preceded 2.7% of SCD after a median of 138 days (vs. non-sudden CV death: MI 46.6% at 1 days, HF hospitalization: 30.9% at 67 days, stroke 12.9% at 9 days). The incidence of SCD preceded by HF hospitalization was significantly higher than SCD without preceding HF hospitalization.

Conclusion

Among patients with AMI complicated by HF, SCD predominantly occurred in the early “high-risk” period after AMI; SCD rates decreased afterwards. Patients with non-fatal HF hospitalizations during follow-up may have a higher subsequent SCD risk. Preventing HF onset after MI may help decreasing SCD.

Proportion of sudden cardiac death

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Lucien Award, McGill University
Prognostic value of the cardiorespiratory optimal point during submaximal exercise testing
Authors: Dias Ferreira Reis J.P , Goncalves A , Bras P , Ferreira V , Viegas J , Rio P , Moreira R , Pereira Silva T , Timoteo A , Soares R , Cruz Ferreira R
Published: November 2020

Background

Peak oxygen consumption (pVO2) is a key parameter in assessing the prognosis of heart failure with reduced ejection fraction (HFrEF) patients (pts). However, it is a less reliable parameter when the cardiopulmonary exercise test (CPET) is not maximal. It is crucial to identify the submaximal exercise variables with the best prognostic power (PP), in order to improve the management of pts that cannot attain a maximal CPET.

Purpose

The aim of this study was to evaluate and compare the PP of several exercise parameters in submaximal CPET for risk stratification in pts with HFrEF.

Methods

Prospective evaluation of adult pts with HFrEF submitted to CPET in a tertiary center. A submaximal CPET was defined by a respiratory exchange ratio (RER) ≤1.10. Pts were followed up for at least 1 year for the primary endpoint of cardiac death and urgent heart transplantation/ ventricular assist device implantation. Several CPET parameters were analyzed as potential predictors of the combined endpoint and their PP (area under the curve - AUC) was compared to that of pVO2, using the Hanley and McNeil test.

Results

CPET was performed in 487 HF pts, of which 317 (66%) performed a submaximal CPET. Pts averaged 57±12 years of age, 77% were male, 45.7% had ischemic cardiomyopathy, with a mean LVEF of 30.4±7.6%, a mean heart failure survival score of 8.6±1.1. The mean pVO2 was 17.1±5.5 ml/kg/min and the mean RER 1.01±0.08. During a mean follow-up (FU) time of 11±1 months, 18 pts (6%) met the primary endpoint. Cardiorespiratory optimal point (OP - VE/VO2) had the highest AUC value (0.915, p=0.001), followed by the partial pressure of end-tidal CO2 at the anaerobic threshold - PETCO2L (0.814, p<0.001). pVO2 presented an AUC of 0.730 (p=0.001). OP≥31 and PETCO2L ≤37mmHg had a sensitivity of 100 and 76.9% and a specificity of 71.1 and 67%, respectively, for the primary outcome. OP presented a significantly higher PP than pVO2 (p=0.048), whether PETCO2L didn't achieve any statistical significance (p=0.164). Pts with anOP≥31 presented a significantly lower survival free of HT during FU (log rank p=0.002).

Conclusion

OP had the highest PP for HF events of all parameters analyzed for a submaximal CPET. This parameter can help stratify the HF pts physiologically unable to reach a peak level of exercise.

Funding Acknowledgement

Type of funding source: None
HLM, a TNM-like classification for heart failure, compared with other nosologies at 12 months follow-up
Authors: Severino P , Pucci M , Mariani M.V , D'Amato A , Infusino F , Birtolo L.I , Morano G , D'Ascenzo F , Maestrini V , Mancone M , Fedele F
Published: November 2020

Background

Heart failure (HF) is the pandemic of the third millennium with the highest mortality among general population, while lung cancer is the second most common cause of death. As cancer, HF can affect close organs, as lungs, or can reach peripheral organs (kidney, liver, brain), leading to multi-organ dysfunction, like cancer metastasis.

Purpose

We proposed a new staging system named HLM, analogous to TNM classification used in oncology, which refers to heart damage (H), lung involvement (L), and malfunction (M) of peripheral organs. The aim of this study is a comparison between HLM and NYHA, ACC/AHA and MAGGIC scores to assess the most accurate prognosis of HF patients in terms of rehospitalization for acute HF (AHF) or major adverse cardiac and cerebrovascular events (MACCE), and cardiac death.

Methods

We performed a single-center observational study of HF patients. All parameters for heart, lungs and peripheral organs function were examined. Each patient was classified according to HLM, NYHA, ACC/AHA and MAGGIC score at the entrance and at the discharge. Rehospitalization for MACCE or AHF and cardiac death were checked at 12 months follow up.

Results

We enrolled 2054 patients: 68.5% males, 31.3% females, mean age 70.18±7.48 years. Among them, overall survival curves regarding rehospitalization for MACCE, AHF and cardiac death at 12 months, show that HLM classification is as valid as the others (p<0.001). In particular, the area under the ROC curve (AUC) is greater for HLM than NYHA, ACC/AHA and MAGGIC score in terms rehospitalisation for MACCE (HLM=0.687; NYHA=0.642; ACC/AHA=0.604; MAGGIC=0.657) or AHF (HLM=0.662; NYHA=0.652; ACC/AHA=0.604; MAGGIC=0.662) and cardiac death (HLM=0.783; NYHA=0.712; ACC/AHA=0.623; MAGGIC=0.737).

Conclusion(s)

According to our results, HLM classification has greater prognostic power compared to other nosologies in terms of rehospitalization for MACCE, AHF and cardiac death for HF patients, thanks to a more accurate evaluation of the systemic impact of heart failure. Such a multivariable, holistic approach should be used in HF patients, rather than a “cardiocentric” approach, in order to address the pathophysiological mechanisms underlining heart abnormalities, improving clinical management and costs.

Funding Acknowledgement

Type of funding source: None
Evidence of occult right ventricular dysfunction in morbidly obese patients
Authors: Samuel Kulifay S.L.K , Dominic Lattanzio D.S.L , Brandon Mikolich B.M.M , Ronald Mikolich J.R.M
Published: November 2020

Background

Abnormalities of right ventricular (RV) strain have been shown to occur prior to impairment of global right ventricular function, measured by global RV ejection fraction (RVEF) in patients with increased RV afterload, such as pulmonary hypertension. Obesity is a form of increased afterload involving both the right and left cardiac circulations, raising suspicion that impaired RV strain may be an early indicator of myocardial dysfunction.

Purpose

This study was designed to assess impairment of RV strain in obese patients with normal right ventricular ejection fraction (RVEF) using cardiac MRI Fast SENC (strain encoded) pulse sequences.

Methods

An institutional cardiac imaging database was queried for all patients with body mass index (BMI) greater than 35 kg/m2 who underwent measurement of RV global longitudinal strain (GLS), RV global circumferential strain (GCS) and 37 segmental strain measurements using cardiac MRI Fast-SENC pulse sequences. Global RVEF was computed for all patients using a standard cardiac MRI method using non-automated hand drawn RV endocardial borders. Global and regional strain measurements were compared to a cohort of healthy volunteers who also underwent CMR Fast-SENC imaging. Abnormal myocardial strain was defined as a value greater than −17%.

Results

Of the 356 patients in the database, 48 had a BMI greater than 35 kg/m2. Mean RV GLS and GCS for the study cohort were −16.6 and −15.8 respectively. For healthy volunteers RV GLS and GCS were −20.8 and −19.0 respectively. Comparison of mean RV GLS and GCS of both groups were statistically significant ANOVA p<0.001. The number of normal RV segmental strain values was significantly decreased in obese patients when compared to the normal cohort, ANOVA p<0.001 (Figure 1). Furthermore, the prevalence of abnormal RV GCS in morbidly obese patients with normal RVEF greater than or equal to 40% was 84% (21 of 25 patients).

Conclusions

These findings suggest that morbidly many obese patients have occult RV dysfunction despite a normal RVEF. This occult RV dysfunction not only affects RV global GLS and GCS, but also the percentage of normal segmental strain values. Detection of occult RV dysfunction is of clinical significance in that it may provide an opportunity for treatment before development of symptomatic right heart failure.

Figure 1

Funding Acknowledgement

Type of funding source: None
Effects of tafamidis on exercise capacity, cardiac function and myocardial amyloid deposition in patients with transthyretin amyloid cardiomyopathy
Authors: Rettl R , Mann C , Dachs T , Duca F , Binder C , Dusik F , Seirer B , Badr Eslam R , Hengstenberg C , Bonderman D
Published: November 2020

Background

Transthyretin amyloid cardiomyopathy (ATTR-CA) is caused by deposition of amyloid fibrils in the myocardium. Tafamidis is a kinetic stabilizer of TTR that prevents tetramer dissociation and amyloidogenesis.

Methods

Thirty-eight patients with diagnosis of ATTR-CA were treated with tafamidis (20mg or 61mg) for a period of six months. In our explorative analysis we aimed to evaluate the effects of tafamdis by changes from baseline of the serum NT-proBNP concentration, 6MWD, as well as cardiac structure and function, compared to untreated amyloidosis patients.

Results

The analysis showed a significant reduction in the serum NT-proBNP concentration in tafamidis-treated patients compared to untreated patients (median difference, −1042.5 pg/mL, p=0.015). Tafamidis also improved the walking distance at month six, while reduction in untreated patients was observed (mean difference, +29.27 m, p=0.175). Echocardiographic findings revealed a decrease in LV size (mean, −1.56 mm) as well as improvements regarding the LA size (mean difference, −2.51 mm) and the GLS (mean difference, 0.80%) in tafamidis-treated patients. T1 mapping in cardiac MRI showed a decrease in ECV (mean, −1.79%) in patients receiving tafamidis, while an increase in ECV in untreated patients was observed (mean, +0.41%).

Conclusion

Treatment with tafamidis for a period of six months in patients with ATTR-CA results in a significant improvement in NT-proBNP levels and may have positive effects on exercise capacity, cardiac function and myocardial amyloid deposition compared to untreated amyloidosis patients.

Picture 1. Change from baseline.

Funding Acknowledgement

Type of funding source: None
The combination of angiotensin receptor-neprilysin inhibitor and sodium-glucose cotransporter-2 inhibitors in heart failure with reduced ejection fraction patients comorbid with diabetes mellitus
Authors: Hsiao F.C , Lin C.P , Chang P.C , Wang C.L , Chu P.H
Published: November 2020

Background

Angiotensin receptor-neprilysin inhibitor (ARNI) and dapagliflozin were two new drugs that were proved to reduce clinical events in patients with HFrEF. However, evidence about the combination use of these two drugs in patients with both HFrEF and DM is lacking. The purpose of present study is to elucidate the clinical benefit of combining ARNI and sodium-glucose cotransporter-2 inhibitors (SGLT2i) in this population.

Methods

Patients who have HFrEF and received ARNI, or ACEi, or ARB plus any antidiabetic agents (ADA) were identified from original medical records of 8 major branches of Chang Gung Memorial Hospital. Patients were divided into four groups: 1. ARNI + SGLT2i; 2. ACEi/ARB + SGLT2i; 3. ARNI + other ADA; 4. ACEi/ARB + other ADA. Primary clinical event is the composite of CV death or readmission for heart failure at 1-year (time to event outcome). Primary renal event is the composite of decrease of eGFR more than 50% or progression to ESRD at 1-year follow up (binary outcome).

Results

2628 patients were identified. Among them, 170, 288, 391, and 1772 patients were divided into group 1 to 4, respectively. After multivariable adjustment, patients in group 1 had significantly lower incidence of primary clinical event (adjusted hazard ratio [aHR] 0.63, 95% CI 0.45–0.89) and primary renal event (adjusted odds ratio 0.32, 95% CI 0.14–0.74) than patients in group 4. Patients in group 1 had borderline lower incidence of primary clinical event (aHR 0.71, 95% CI 0.49–1.02) than patients in group 3. Patients in group 1 and group 2 had no difference in the incidence of primary clinical events (aHR 0.98, 95% CI 0.66–1.46) Surprisingly, patients in group 2 had significantly lower incidence of primary clinical event (aHR 0.72, 95% CI 0.54–0.97) than patients in group 3.

Conclusion

In patients with both HFrEF and DM, a combination of ARNI + SGLT2i significantly improved clinical and renal outcomes, comparing to a combination of ACEi/ARB + other ADA. In patients who already received ARNI, SGLT2i marginally improved clinical outcome. In addition, a combination of ACEi/ARB + SGLT2i significantly improved clinical outcome, comparing to a combination of ARNI + other ADA.

Funding Acknowledgement

Type of funding source: None
Discharge heart rate and beta-blockers treatments in hospitalized heart failure patients with coexisted atrial fibrillation
Authors: Xing F , Bai X , Li J
Published: November 2020

Background

Beta-blockers are widely used to improve clinical outcomes in heart failure (HF) patients. However, the effects of beta-blockers on clinical outcomes in those who have coexisted atrial fibrillation (AF) remains uncertain.

Purpose

We investigated the associations between beta-blockers and clinical outcomes according to discharge heart rate.

Methods

The study cohort included 1631 HF patients hospitalized primarily with AF, which was from the China PEACE Prospective Heart Failure Study. Clinical outcome was 1-year combined all-cause mortality and HF hospitalization after discharge. The associations between beta-blockers and clinical outcome were assessed using Cox proportional hazard and standardization mortality weighting regression models, with stratified discharge heart rate group predefined by restricted cubic spline.

Results

The median age was 68 (IQR: 60- 77) years, 41.9% were women, discharge heart rate was (median (IQR)) 75 (69- 84) beats per minute (bpm), and 60.2% received beta-blockers at discharge. According to the result of restricted cubic spline plot, these patients were divided into 3 groups: lowest <65 bpm, middle 65–86 bpm and highest ≥87 bpm (Fig.1). In the Cox proportional hazard analysis, a significant interaction between discharge heart rate and beta-blocker use was observed (P<0.001 for interaction). Stratified analysis showed beta-blocker prescription at discharge was associated with reduced risk for clinical outcomes in patients with high heart rates (hazard ratio 0.336, 95% CI: 0.144–0.786, p=0.012) but not in those with lowest and middle heart rates (hazard ratio: 1.32; 95% CI, 0.95–1.63; hazard ratio: 1.02; 95% CI, 0.68–1.55, respectively).

Conclusion

The associations between beta-blockers and clinical outcomes may be significantly influenced by baseline heart rate. Hospitalized HF patients with AF benefit the most from beta-blockers use if they had high heart rate (≥87 bpm) at discharge.

Figure 1

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): This work was supported by the National Key Research and Development Program (2017YFC1310803) from the Ministry of Science and Technology of China; the CAMS Innovation Fund for Medical Science (2017-I2M-B&R-02); the 111 Project from the Ministry of Education of China (B16005).
Novel rehabilitation program after left ventricular assist device (LVAD) implantation improves functional tests and reduces levels of prognostic heart failure biomarkers
Authors: Chwyczko T , Zalucka L , Smolis-Bak E , Kowalik I , Noszczak E , Bogucki M , Piotrowicz E , Sobieszczanska-Malek M , Zielinski T , Szymanski J , Was J , Kusmierczyk M , Dabrowski R , Szwed H , Piotrowicz R
Published: November 2020

Background

Rehabilitation after LVAD implantation is increasingly used. We developed the novel method of comprehensive rehabilitation starting directly after LVAD implantation.

Study group

21 recent LVAD (15 Heart Mate III, 6 HeartWare) recipients (56.2±11.7 yrs, 100% men) were included to 5-week rehabilitation program, which included supervised endurance training on cycloergometer (5 times per week), resistance training, general fitness exercises with elements of equivalent and coordination exercises (every day). 6-minute walking test (6MWT), cardiopulmonary exercise test (CPET) and prognostic biomarkers: NT-proBNP, Galectin-3 and ST2 were investigated at the beginning and at the end of rehabilitation program.

Results

See Table 1.

At the end of rehabilitation program, significant increase in 6MWT distance, maximum workload, peak VO2 and upward shift of anaerobic threshold in CPET were observed in all patients. Significant reductions of NTproBNP, ST2 and galectin-3 levels were observed. There were no major adverse events during rehabilitaton.

Conclusions

Comprehensive novel rehabilitation in LVAD recipients is safe and results in significant improvement of 6-minutes walking test distance and cardiopulmonary exercise test results. Moreover, this novel rehabilitation program reduces levels of prognostic biomarkers of heart failure: NT-proBNP, Galectin-3 and ST2.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Center for Research and Development - STRATEGMED II project
Quantitative analysis of dyssynchrony assessed by multidetector computed tomography can predict clinical outcome after cardiac resynchronization therapy
Authors: Onishi T , Koyama Y , Inoue K , Okamura A , Iwamoto M , Tanaka K , Nagai H , Hirao Y , Oka T , Tanaka N , Watanabe S , Sumiyoshi A , Okada M , Iwakura K , Fujii K
Published: November 2020

Background

The degree of mechanical dyssynchrony has been suggested as a predictor for long-term survival after cardiac resynchronization therapy (CRT). There have been little reports of dyssynchrony assessment with the use of cardiac computed tomography (CCT).

Methods

We studied 35 heart failure (HF) patients (average age 67±10 years) referred for CRT with NYHA III-IV heart failure, left ventricular (LV) ejection fraction (EF) 20±10% (all ≤35%), and QRS duration 156±22 ms (all ≥120ms). Electrocardiogram-gated contrast-enhanced 256-slice multidetector CT was performed before CRT. Based on CCT, the LV endocardial boundaries from short-axis images reconstructed at 5% increments of cardiac cycle were automatically detected, and the time from R-wave to maximal wall motion was calculated for each of the 16 standardized segments for all slices using software “Myocardial Contraction Map”. The standard deviation modified by mean heart rate (%SD) was respectively calculated as the global parameter of dyssynchrony. LVEF was also measured using MDCT. The predefined primary end-point was the first HF hospitalization or death over 2 years.

Results

%SD was feasible in all patients, respectably. There were 16 events over 2 years; 11 HF hospitalizations and 5 deaths. Patients with %SD ≥22% (optimal cutoff for outcome by ROC curve analysis) had a better clinical outcome than patients with %SD <22% (p=0.01, Figure).

Conclusion

Patients who had %SD ≥22% assessed by MDCT had a particularly favorable event-free survival following CRT, and this appears to be an important prognostic marker.

Funding Acknowledgement

Type of funding source: None
Higher pulsatile index in carotid arteries is associated with adverse outcomes in patients treated by left ventricular assist device
Authors: Tucanova Z , Wohlfahrt P , Ivak P , Netuka I , Pitha J
Published: November 2020

Introduction

Better understanding of vascular changes in patients after implantation of left ventricular assist devices (LVAD) is important to understand and prevent complications of this therapy. Currently, there is substantial lack of data regarding the impact of changes in carotid territory on clinical events in this population. Our aim was to analyze the association between carotid flow patterns and atherosclerotic changes with serious clinical events after LVAD implantation in a prospective single-center study.

Methods

Eighty five patients were included (Heart mate II, n=34; Heart mate 3, n=51; mean age 55±15 years; 13 women). Pulsatile and resistance indexes were calculated and atherosclerotic changes (Belcaro score) were assessed using triplex ultrasound at the 3rd and 6th month after LVAD implantation. Basic clinical and laboratory data were also included into the analyses. The median follow-up time was 982 days [IQR 472–1431].

Results

Pulsatile and resistance index significantly increased between 3rd and 6th month (p=0.036 and p=0.012, respectively). Belcaro score did not change significantly. During the follow-up, 17 patients died, 4 due to stroke. Another 4 patients suffered from non-fatal stroke. Pulsatile index measured at 3rd month was associated with an increased risk of composite outcome of stroke, GIT hemorrhage and all-cause mortality (HR 10.6, 95% CI 2.0–55.2, p=0.005) only in the group of HeartMate 3 patients, while not in patients with HeartMate II (HR 0.96, 95% CI 0.07–12.4, p=0.97), p for interaction between groups 0.04. Association between pulsatile index and the risk of adverse events in patients with HeartMate 3 remained significant after adjustments for age, cause of heart failure and INTERMACS score.

Conclusion

Among patients after LVAD implantation, assessment of carotid flow patterns, pulsatile index in particular, may identify individuals at increased risk of serious clinical complications. Future studies are needed to understand mechanisms leading to increase flow pulsatility in this population.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Ministry of Health of the Czech Republic