bluuebunny/crossref_metadata_2025 huggingface dataset:
Phenotyping the right heart according to left ventricular geometry patterns in severe HFrEF
Authors: Casati M , Bursi F , Mondellini G.M , Santangelo G , Giustiniani A , Massironi L , Tarricone D.G.F , Carugo S , Guazzi M
Published: October 2021

Background

Right ventricular (RV) failure significantly impact on heart failure with reduced ejection fraction (HFrEF) prognosis. How and whether specific functional and geometrical phenotypes of the RV function adapt and combined with left ventricular (LV) geometry is unknown.

Purpose

To test the RV function across LV geometrical patterns looking at respective prognostic roles.

Methods

We retrospectively examined a population of patients homogenously diagnosed with chronic HFrEF (defined as LV ejection fraction (EF) less than 35%) and treated with optimal therapy (OT) and all implanted with ICD for primary prevention of sudden cardiac death. Patients were categorized by echocardiography according to remodeling pattern based on left ventricular mass index and relative wall thickness into four groups: normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH) and eccentric hypertrophy (EH). RV parameters were: tricuspid annulus plane systolic excursion (TAPSE), TAPSE/pulmonary artery pressures (PAPs), RV basal diameter and fractional area change (FAC). Outcome variable was all-cause mortality, assessed with multivariable Cox proportional hazard (PH) models.

Results

Among 193 patients (age 66±11 years, 81% men, 74% with ischemic etiology of HF and EF 28±5%) 21% had NG, 3% had CR, 8% had CH, and 68% had EH. Distribution of RV echo parameters across LV remodeling groups is shown in table 1. Over a median follow-up time of 4 (1.9 – 6.1) years, 65 deaths occurred. In multivariable Cox PH models adjusted for age, LVEF, ischemic etiology and LV geometry, TAPSE, TAPSE/PAPs, RV basal diameter and FAC strongly and independently predicted the outcome variable [HR 0.92 (95% C.I. 0.86–0.98), HR 0.08 (95% C.I. 0.01–0.57), HR 1.87 (95% C.I. 1.29–2.71), HR 0.97 (95% C.I. 0.95–1.00), respectively all p-value <0.05].

Conclusion

In a homogeneously defined population of severe HFrEF outpatients receiving OT, the majority showed EH remodeling pattern, which did not predict the primary outcome. LV geometry did not further stratify patients in this high risk group. Conversely, RV dysfunction proved to be a strong predictor of mortality, independently of age, LV function and etiology of HF, regardless LV morphology.

Funding Acknowledgement

Type of funding sources: None.
Hemoglobin, anemia, and clinical outcomes in vericiguat global study in subjects with heart failure with reduced ejection fraction (VICTORIA)
Authors: Ezekowitz J.A , Zheng Y , Cohen-Solal A , Melenovsky V , Escobedo J , Butler J , Hernandez A.F , Lam C.S.P , O'Connor C.M , Pieske B , Ponikowski P , Voors A.A , McMullan C , Roessig L , Armstrong P.W ,   the VICTORIA Study Group
Published: October 2021

Background

In the VICTORIA trial of patients with HFrEF after a worsening HF event, anemia occurred more often in patients treated with vericiguat (7.6%) compared with placebo (5.7%). We explored the association between vericiguat, baseline hemoglobin, and anemia and also whether hemoglobin was related to the benefit of vericiguat in HF.

Methods

Anemia was defined as a hemoglobin <13.0 g/dL in men and <12.0 g/dL in women (WHO anemia). Adverse events reported as new anemia were also evaluated (AE anemia). We evaluated the risk-adjusted relationship between baseline hemoglobin (as both quartiles and continuous variable), hematocrit, and hematinic indices with the primary outcome (composite of cardiovascular death or heart failure hospitalization). Time-updated hemoglobin relationship was also examined.

Results

Of 4812 patients with baseline hemoglobin data available, 1719 (35.7%) were WHO anemic; median hemoglobin was 13.4 g/dL (IQR 12.1 to 14.7 g/dL). In total, 1643 patients had WHO anemia at 16 weeks (of which 284 were new from baseline for vericiguat and 219 for placebo) and this occurred more often in the vericiguat group than the placebo group (P<.001). Subsequently, there was no further decline in hemoglobin over the 96 weeks of follow-up (Figure A). The ratio of hemoglobin/hematocrit remained constant and none of the hematinic indices including red cell density width, mean corpuscular volume, white blood cell or platelet counts changed over time. Overall, AE anemia occurred in 342 patients (7.1%) and was more frequent in those with a lower baseline hemoglobin (hemoglobin Q1: 184 [14.5%], Q2: 94 [7.9%], Q3: 40 [3.4%], Q4: 24 [2.1%]; p<.001). Whereas outcomes were associated, quartiles of baseline hemoglobin were not related to the treatment benefit of vericiguat (compared with placebo) for the primary outcome (Figure B). Additionally, analysis of the time-updated hemoglobin values revealed no association with the treatment effect of vericiguat (compared with placebo) on the primary outcome.

Conclusions

Anemia was present at baseline in over one-third of patients in the VICTORIA trial and was generally mild. Lower hemoglobin was associated with greater frequency of clinical events. Although vericiguat modestly lowered hemoglobin by 16 weeks, this effect did not further progress nor influence the association of benefit of vericiguat.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Merck & Co., Inc. and Bayer
Impact of parity on cardiac structure and function in apparently healthy pregnant women in Nigeria
Authors: Saidu H , Mohammed I.Y , Ishaq N.A , Balarabe S.A , Tukur J , Adedeji T.A , Makinde O.N , Adebayo R.A , Umar H , Isezuo S.A , Karaye K.M ,   PEACE REGISTRY INVESTIGATORS
Published: October 2021

Background

There are a few and conflicting data in the literature about parity and maternal cardiac function.

Purpose

The purpose of this study was to assess the impact of parity on cardiac structure and function in apparently healthy pregnant women in Nigeria.

Methods

This was a cross-sectional study carried out in 4 tertiary centers in Kano, and 1 in Ile- Ife, Nigeria. 112 apparently healthy pregnant women were consecutively recruited between 28thand 38th weeks of gestation. Left ventricular (LV)systolic dysfunction was defined as LV ejection fraction of below 50%, and diastolic dysfunction was graded using mitral filling pattern and tissue velocities.

Results

LV systolic dysfunction and diastolic dysfunction were found in 6 (5.4%) subjects and 20 (17.9%) subjects respectively. Age (p= <0.0001), left atrial (LA)size (P= <0.0001), interventricular septal thickness at end diastole (IVSD) (p=0.005) and posterior wall thickness at end diastole (PWTD) (p=0.004) increased progressively with parity (Table 1). There was significant positive correlation between parity and age (r=0.475, p= <0.0001), LA size (r=0.332, p= <0.0001), IVSD (r=0.264, p=0.005) and PWD (r=0.343, p= <0.0001). LV systolic function was not significantly associated with parity.

Conclusion

Our findings suggests that parity causes significant myocardial remodeling in apparently healthy pregnant women that should be taken in to consideration while interpreting their echocardiograms.

Funding Acknowledgement

Type of funding sources: None.
Sex differences on new-onset heart failure in patients with known or suspected chronic coronary syndrome
Authors: Lorenzo Hernandez M , Nunez J , Minana G , Palau P , Lopez-Lereu M.P , Monmeneu J.V , Marcos V , Rios-Navarro C , Gavara J , Perez N , De Dios E , Nunez G , Nunez E , Chorro F.J , Bodi V
Published: October 2021

Background

The impact of sex in patients with chronic coronary syndrome (CCS) has been widely reported, but little is known about the influence of sex on the risk of new-onset HF in patients with CCS.

Objectives

We aimed to examine sex-related differences and new-onset heart failure (HF) risk in patients with known or suspected CCS undergoing vasodilator stress cardiac magnetic resonance (CMR).

Methods

We prospectively evaluated 5,899 consecutive HF-free patients submitted to stress CMR for known or suspected CCS. Ischemic burden (number of segments with stress-induced perfusion deficit) and left ventricular ejection fraction (LVEF) were assessed by CMR. The association between sex and new-onset HF (including outpatient diagnosis or acute HF hospitalization) was evaluated using a Cox proportional-hazards regression model adjusted for competing events (death, myocardial infarction, and non-CMR-related revascularization).

Results

A total of 2,289 (38.8%) patients were women, and 539 (9.1%) underwent CMR-related revascularization. During a median follow-up of 4.5 years, 610 (10.3%) patients died, 191 (3.2%) suffered a myocardial infarction, 420 (7.1%) underwent CMR-non-related revascularization, and 314 (5.3%) developed new-onset HF. Unadjusted new-onset HF rates were higher in women than in men (1.25 vs 0.83 per 100 person/years, p=0.002) (Figure 1). After comprehensive multivariate adjustment, women showed an increased risk of new-onset HF (HR=1.61, 95% CI: 1.21–2.13, p=0.001). Compared with men, the risk of new-onset HF was higher in women with LVEF >53%.

Conclusions

Compared with men, women with CCS are at a higher risk of new-onset HF. Further studies are needed to unravel the mechanisms behind these sex-related differences.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III and Fondo Europeo de Desarrollo Regional (FEDER) Figure 1
Heart failure in low risk patients with atrial fibrillation, nationwide registry case-control study based on 227811 patients
Authors: Basic C , Hansson P , Zverkova-Sandstrom T , Johansson B , Fu M , Mandalenakis Z
Published: October 2021

Background

Heart failure (HF) is common in patients with atrial fibrillation (AF), and also associated with worse outcome. Consequently, it is commonly included in risk prediction models for AF, used in daily clinical praxis. However, knowledge about the association between solely AF and incidental HF is limited.

Aim

This study aims to evaluate the short and long-term risks for onset of HF in patients with AF and low cardiovascular risk profile.

Methods

All patients with first recorded hospitalization for AF in the Swedish National Patient Register, were included from the 1St January 1987 to 31st December 2018. Each patient with AF was matched by age, sex and county with two controls from the Swedish Total Population Register. Patients <18 years, or with concomitant hypertension, diabetes mellitus, coronary and periphery artery disease, previous stroke or transitory ischemic attack, cardiomyopathy, pulmonary arterial hypertension, congenital heart disease, valvular heart disease and renal failure prior or at baseline were excluded.

Results

In total 227 811 patients and 452 712 controls met the inclusion and exclusion criteria and were included in the study. The incidence rate for incidental HF per 1000 person-year within one year after AF diagnosis was 6.2 (95% CI: 4.5–8.6) among patient 18–34, increased with increasing age and was 142.8 (95% CI: 139.4–146.3) among those >80 years. Within five years the incidence rate decreased in all age categories and was 2.4 (95% CI: 1.8–3.0) among the youngest and 94.0 (95% CI: 92.4–95.6) in the oldest age group. When compared to matched controls from the general population patients with AF had a hazard ratio (HR) and CI 95% to develop HF within one year at 103.9 (46.3–233.1), 34.9 (26.5–45.9), 17.5 (15.5–19.8), 10.3 (9.6–11.1) and 6.1 (5.8–6.4) among patients aged 18–34, 35–49, 50–59, 60–69, 70–79 and >80 years, respectively.

Conclusion

Despite low cardiovascular risk profile AF still carries high risk for developing incidental HF in particular during the first observation year with increasing tendency along with increasing age. Younger patients with AF and without other cardiovascular comorbidities had more than 100 times higher relative risk to develop HF within one year when compared to matched controls.

Funding Acknowledgement

Type of funding sources: None.
Applying the ESC 2016, the H2FPEF, and the HFA-PEFF diagnostic algorithms for heart failure with preserved ejection fraction to the general population – a comparative approach
Authors: Nikorowitsch J , Bei Der Kellen R , Kirchhof P , Magnussen C , Schnabel R , Blankenberg S , Wenzel J.P ,   HCHS Echo
Published: October 2021

Background

Heart failure with preserved ejection fraction (HFpEF) is common in patients presenting with dyspnoea. Nevertheless, diagnosing HFpEF remains challenging. Recently, different algorithms were developed to predict the likelihood of HFpEF.

Purpose

Our objective was to provide an in-depth comparison of the ESC 2016 algorithm, the H2FPEF- and the HFA-PEFF algorithm for diagnosing and characterising HFpEF in the general population.

Methods

The study included 5,613 participants of the population-based H. City Health Study (HCHS), aged 62±8.7 years (51.1% women), that were enrolled between 2016 and 2019. Exclusion criteria were other common causes of dyspnea. We calculated the prevalence and compared characteristics of HFpEF according to the different diagnostic algorithms applying the ESC 2016 heart failure guidelines and the cut-off values suggested by the authors of the HFA-PEFF and H2FPEF score for defining HFpEF.

Results

Unexplained dyspnea was present in 407 (7.3%) subjects. In those, the estimated prevalence of HFpEF was 20.4% (ESC 2016), 12.3% (H2FPEF), and 7.6% (HFA-PEFF). The majority of subjects was classified as HFpEF not excludable according to the HFA-PEFF (57.7%) and the H2FPEF (59.2%) score. For all algorithms, subjects diagnosed with HFpEF showed elevated age and body mass index as well as a higher prevalence of atrial fibrillation, diabetes, and arterial hypertension compared to those without HFpEF or HFpEF not excludable. The distribution of those comorbidities and risk factors varied between the differently diagnosed HFpEF groups with the highest burden in the HFpEF group defined by the H2FPEF score. The overlap of subjects diagnosed with HFpEF according to the different algorithms was very limited.

Conclusion

Unexplained dyspnoea is common in the middle-aged general population. The ESC 2016 algorithm, the H2FPEF-, and the HFA-PEFF score detect different, discordant sub-populations of probands with breathlessness. Further classification of the HFpEF syndrome is desirable.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Innovative medicine initiative Figure 1. Prevalence and concordance of the three HFpEF algorithms in subjects with unexplained dyspnea. Of the 407 subjects with unexplained dyspnea, the prevalence ranged from 20.4% (n=83, ESC 2016 guideline) to 12.3% (n=50, H2FPEF score) and 7.6% (n=31, HFA-PEFF score). The concordance was highest between the ESC 2016 guidelines and the HFA-PEFF score reflected by a kappa coefficient of 0.38 and a reclassification rate of 16%. RecR = reclassification rate.
Left ventricular contractile reserve, coronary flow reserve, and heart rate reserve during dipyridamole stress echocardiography predict survival in non-ischemic heart failure
Authors: Daros C , Ciampi Q , Cortigiani L , Gaibazzi N , Rigo F , Villari B , Antonini-Canterin F , Lorenzoni V , De Nes M , Carpeggiani C , Picano E ,   Stress Echo 2020 study group of the Italian Society of Echocardiography and Cardiovascular Imaging
Published: October 2021

Background

Left ventricular contractile reserve (LVCR), coronary flow velocity reserve (CFVR), and heart rate reserve (HRR) have recognized independent impact on outcome in heart failure (HF). They all can be simultaneously measured during dipyridamole stress echocardiography (DSE).

Aim

To assess the value of comprehensive DSE in patients with non-ischemic heart failure.

Methods

We evaluated 613 patients with HF, no history of coronary artery disease and no inducible regional wall motion abnormalities: 270 patients with preserved (≥50%) ejection fraction; 147 with mid-range (40–49%) ejection fraction; 196 with HF and reduced (<40%) ejection fraction. All underwent DSE (0.84 mg/kg in 6') in 5 accredited laboratories. We measured LVCR (abnormal value ≤1.1), CFVR in left anterior descending artery (abnormal value ≤2.0), and HRR (peak/rest heart rate, abnormal value ≤1.22). All patients were followed-up.

Results

Abnormal CFVR, LVCR and HRR occurred in 29%, 44% and 46% of patients, respectively. After a median follow-up time of 20 months (interquartile range 12–32 months), 41 patients died. Annual mortality rate was lowest in patients (n=200) with normal response, and >10-fold higher in patients (n=96) with 3 abnormal criteria: see figure. At multivariable analysis, a reduced HRR (Hazard Ratio = 3.402, 95% Confidence Intervals 1.530–7.565, p=0.003) was the strongest SE independent predictor of all-cause death.

Conclusion

Abnormal LVCR, CFVR and HRR can be frequently observed during vasodilator SE in HF patients. They target different pathophysiological vulnerabilities (myocardial function, coronary microcirculation and cardiac autonomic system) and are useful for outcome prediction.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Consiglio nazionale delle ricerche - Institute of Clinical Physiology Figure 1
Beta-blocker could show the prognostic impact in heart failure patients even on the regular hemodialysis
Authors: Kishihara M , Kentaro J , Takuma T , Takuro A , Shota S , Ayano Y , Shonosuke W , Yuichiro M , Nobuhisa H
Published: October 2021

Background

β-blockers are recommended as standard medications for patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). However, this favorable prognostic effect of β-blockers has not been fully validated in patients receiving regular hemodialysis. Indeed, prior clinical trials have generally excluded such very high-risk population for adverse cardiovascular events. Main reasons for that are the limited number of regular hemodialysis patients in the Western nations, and too high rates of clinical events.

Purpose

This study aimed to clarify the prognostic benefit of β-blocker in patients on regular hemodialysis who were hospitalized due to HF.

Methods

This observational study included 1,930 consecutive patients who were hospitalized for worsening of HF and discharged alive from 2013 to 2019. Of them, 151 patients who underwent regular hemodialysis were ultimately analyzed. They were divided into 2 groups depending on the prescription of β-blocker at the discharge; β-blocker group (n=115) and No-β-blocker group (n=36). The primary endpoint of this study was a composite of death from any cause and rehospitalization due to HF.

Results

During the observation period with 501 days of median follow-up (IQR: 197–954 days), the primary endpoint was occurred in 45 patients (39%) who were receiving β-blockers, while in 24 patients (67%) who were not. Kaplan-Meier analysis showed a significantly lower rate of the primary endpoint in patients in the β-blocker group (Log-rank, p<0.001, Figure). After the adjustment for age, sex, LVEF, systolic blood pressure, heart rate and atrial fibrillation, the administration of β-blocker was still an independent predictor for the primary endpoint in patients who underwent regular hemodialysis (hazard ratio; 0.46, 95% confidence interval; 0.26–0.82). Further analysis each for the population with reduced LVEF (<45%) and preserved LVEF (>45%) showed that the main result of the current study was consistent with that in the reduced LVEF group (Log-rank, p=0.005), but was diminished in the preserved LVEF group (p=0.13).

Conclusion

The prescription of β-blocker at discharge in HF patients with regular hemodialysis was associated with lower risk of adverse cardiovascular events, mainly in the patients with reduced LVEF. From the findings of our study, we should consider the administration of β-blockers in HF patients, even they are on the regular hemodialysis.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Absence of exercise capacity improvement after in-hospital short-term cardiac rehabilitation is associated with long-term clinical outcome in heart failure patients
Authors: Fukushima T , Fukui J , Maemura K
Published: October 2021

Background

Previous studies suggest Cardiac rehabilitation (CR) improve exercise capacity and decline mortality in heart failure (HF) patients. However, some studies show there are HF patients who do not improve exercise capacity by CR and these patients have a higher risk of adverse events in long-term clinical outcome. We investigated whether absence of exercise capacity improvement after in-hospital short-term CR also has adverse effect in long-term clinical outcome.

Methods

In this retrospective study, 130 HF patients who underwent two weeks in-hospital CR after received standardized HF treatment between July 2014 and August 2020 were included. Improvement in exercise capacity was assessed by change in peak oxygen consumption (delta-Peak VO2) measured at 1st and 14th day of CR by cardiopulmonary test. The median delta-PeakVO2 was 1.3 ml·kg-1·min-1. Patients were classified as responder if they demonstrated delta-PeakVO2 ≥1.3 ml·kg-1·min-1 and as non-responder if they demonstrated delta-PeakVO2 <1.3ml·kg-1·min-1. MeanΩ follow-up was 1236 days. The primary outcome was all-cause death.

Result

63 patients (48.4%) were classified as non-responder. Non-responders were older (75.5±10.6 vs 70.8±11.0, P=0.01) and lower estimated glomerular filtration rate (eGFR) (49.7±19.4 vs 57.9±19.2) and lower albumin (3.5±0.5 vs 3.7±0.3 g/dL, P=0.04) than responders. Transtricuspid pressure gradient (TRPG) measured by transthoracic echocardiography was also higher in non-responders (28.5±10.9 vs 22.7±6.3). Predictor of non-responders were TRPG (OR = 1.1, 95% CI 1.02–1.26) and albumin (OR =0.04, 95% CI: 0.003–0.40). In multivariate analysis including delta-PeakVO2 <1.3 ml·kg-1·min-1 (non-responder), age >75, male gender, PeakVO2 at 1st day of CR, body mass index (BMI), left ventricular ejection fraction measured by transthoracic echocardiography, medication of β-blockers showed that delta-PeakVO2 <1.3 ml·kg-1·min-1 (HR =2.8, 95% CI 1.0–7.5), age>75 (HR11.2, 95% CI 2.1–60.1), BMI (HR =0.8, 95% CI 0.6–0.96) were associated with all-cause death.

Conclusion

The absence of exercise capacity improvement after in-hospital short-term CR was the risk of all-cause death. Especially, the HF patients with higher TRPG and lower albumin have a higher probability of becoming a non-responder.

Funding Acknowledgement

Type of funding sources: None.
Improvement of exercise tests and reduction of heart failure biomarkers in short term follow up after comprehensive rehabilitation program of patients with implanted LVAD
Authors: Chwyczko T , Smolis-Bak E , Zalucka L , Segiet-Swiecicka A , Piotrowicz E , Was J , Niedolistek M , Kowalik I , Furmanek M , Sobieszczanska-Malek M , Zielinski T , Szymanski J , Kusmierczyk M , Piotrowicz R , Dabrowski R ,   RH-ROT
Published: October 2021

Background

There is increasing recognition of the importance of rehabilitating patients after LVAD implantation. The novel method of comprehensive rehabilitation starting directly after LVAD implantation was designed for our LVAD patients population.

Aim of the study

The study aimed to determine, if novel rehabilitation program improves functional and biochemical parameters in patients after recent LVAD implantation.

Study group

37 recent LVAD (22 Heart Mate III, 15 HeartWare) recipients (19–67, mean 58.7 years, 35 men) participated in specially designed rehabilitation program. The program included 4–5 weeks of sationary rehabilitation: supervised endurance training on cycloergometer (5 times per week), resistance training, general fitness exercises with elements of equivalent and coordination exercises (every day). It was followed by individual exercises performed at home. At the beginning and at the end of rehabilitation program the patients performed 6 minute walking test (6MWT), cardiopulmonary exercise test (CPET). Following prognostic biomarkers of heart failure: NT-proBNP, galectin-3 and ST2 were also measured.

Results

See table 1. Increase of 6MWT distance, higher maximal 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 rehabilitation.

Conclusions

Comprehensive novel rehabilitation in LVAD recipients is safe and results in significant improvement of functional tests and biomarkers of heart failure.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Center for Research and Development: National grant - STRATEGMED II,
Right ventricular reverse remodeling assessed by echocardiography as a new goal-oriented treatment strategy in PAH patients
Authors: Fauvel C , Raitiere O , Si-Belkacem N , Viacroze C , Artaud-Macari E , Schleifer D , Dominique S , Bauer F
Published: October 2021

Background

While in heart failure with reduced ejection fraction, left ventricular reverse remodeling assessed by transthoracic echocardiography (TTE) is associated with better prognosis, right ventricular reverse remodeling (RVRR) was less investigated in pulmonary arterial hypertension (PAH)

Purpose

We aimed to investigate whether RVVR assessed by echocardiography could help to stratify PAH patient's prognosis.

Methods

Between 2002 and 2019, all consecutive PAH patients were included, treated and followed in a single PAH center in accordance with the current ESC/ERS guidelines. In addition to regular risk stratification parameters, we measured several echocardiographic RV systolic function and size parameters, including tricuspid annular plane systolic excursion (TAPSE, mm) or RV-end diastolic area (cm2) from apical-4 chamber view both at baseline, 1-year of follow-up as well as their change. Primary composite outcome was three-year transplant-free survival and death from all cause from the 1-year evaluation. Conditional inference trees were used to determine which TTE parameters and cutoffs values were associated with primary outcome from hierarchy of multiple covariates in multivariable Cox regression analysis. Kaplan-Meier curves were then drawn and compared with log-rank test.

Results

126 incident PAH patients were included (63% female, mean age 59±18 yo), mainly due to connectivite-tissue disease and idiopathic PAH (26% and 22% respectively). At baseline, mean pulmonary arterial pressure was 42 (33, 52) mmHg. At 1-y follow-up under pulmonary vasodilation therapy, NYHA (p<0.01), NTproBNP (p<0.01), mean pulmonary arterial pressure (p<0.01) and cardiac index (p<0.01) were significantly improved compared to baseline. Conditional inference trees showed that 1-year TAPSE gain >1 mm and 1-year RV end-diastolic area decreased >2 cm2 were associated with 3-year transplant-free survival in multivariable Cox regression analysis (HR=0.23, 95% CI [0.08–0.61] p=0,0035, HR=0.34, 95% CI [0.12–0.94], p=0.038). Simple score from 0 (absence of RVRR), 1 (partial RVRR) and 2 (complete RVRR), describing the number of TTE parameters reach at 1-year was then investigated. Patients with complete RVRR depicted better transplant-free survival than partial or absence of RVRR, log-rank p<0.001 (figure).

Conclusion

Complete reverse remodeling from right ventricular size and function could represent a new goal-oriented treatment strategy in PAH patients.

Funding Acknowledgement

Type of funding sources: None. RVRR survival curves
10-year survival in patients undergoing cardiac resynchronization therapy
Authors: Mazurek M , Jedrzejczyk-Patej E , Sokal A , Gumprecht J , Kotalczyk A , Szulik M , Pruszkowska P , Kowalski O , Lenarczyk R , Kalarus Z
Published: October 2021

Background

Advanced heart failure with reduced ejection fraction (HFrEF) is associated with poor prognosis. Cardiac resynchronization therapy (CRT) is an effective method of treatment for advanced HFrEF to reduce HF hospitalizations and mortality. Nonetheless, very long-term observation of HF patients undergoing CRT implantation is scarce.

Aim

To assess very long-term survival (≥10 years) and predictors of shorter survival (death within 10 years from CRT implantation).

Methods

We screened a large dataset of CRT population from a tertiary care university hospital comprising consecutive HF patients implanted with CRT from 2002 through 2019 to select those who were alive ≥10 years and those who died within 10 years since device implantation. We analyzed various patients' baseline, clinical and procedural characteristics and sought for predictors of mortality within 10 years from CRT implantation.

Results

Of 1059 CRT patients, 143 (13.5%) were alive ≥10 years since CRT implantation. On multivariable regression analysis the independent predictors for all-cause death up to 10 years from CRT implantation were as follows: age, HR 1.02, 95% CI 1.01–1.31; male sex, 1.27, 95% CI 1.01–1.60; primary prevention of sudden cardiac death (SCD), HR 0.72, 95% CI 0.58–0.89; ischemic cardiomyopathy, HR 1.41, 95% CI 1.76–1.70; NYHA class at implantation, HR 1.38, 95% CI 1.17–1.62; baseline left ventricle ejection fraction (EF), HR 0.97, 95% CI 0.96–0.98; severe mitral regurgitation, HR 1.38; 95% CI 1.08–1.75; baseline NT-proBNP concentration, HR 1.00, 95% CI 1.00–1.00; and creatinine level, HR 1.00, 95% CI 1.00–1.01.

Conclusions

In a real-life patient population with CRT only 13.5% survived over 10 years since device implantation. Independent predictors for death within 10 years since CRT implantation were older age, male sex, secondary prevention of SCD, ischemic and more advanced heart failure along with renal impairment.

Funding Acknowledgement

Type of funding sources: None.
The effect of prolonged Intraaortic ballon pump (IABP) support on right ventricular function in end-stage heart failure
Authors: Bonios M.J , Armenis I , Kogerakis N , Thodou A , Fragkoulis S , Gkouziouta A , Leontiadis E , Vartela V , Georgiadou P , Zarkalis D , Tsiapras D , Koliopoulou A , Chamogeorgakis T , Drakos S.G , Adamopoulos S
Published: October 2021

Introduction

Right Ventricular (RV) function has prognostic implications in end-stage heart failure (ESHF) patients. RV failure following Left Ventricular Assist Device (LVAD) implantation increases morbidity and mortality. Achieving optimal RV function before LVAD implantation is of paramount importance.

Purpose

Purpose was to investigate the effect of Intra-aortic Balloon Pump (IABP) on RV function optimization in patients with bi-ventricular ESHF.

Methods

ESHF patients with poor RV function, presenting with acutely decompensated heart failure resistant to inotropes/vasopressors, thus requiring IABP for stabilization, were prospectively enrolled. Serum biochemistry, echocardiography and invasive hemodynamics were applied and eligibility for LVAD according to RV function was determined on the basis of pre-specified criteria (Right atrium Pressure (RAP) <12mmHg, Pulmonary Artery Pulsatility index (PAPi) >1.85, RAP/Pulmonary Capillary Wedge Pressure (PCWP) <0.67, RV strain <−14%). LV and RV tissue was harvested during LVAD or bi-ventricular mechanical circulatory implantation or at the time of heart transplantation. Fibrosis of the myocardial tissue was quantified.

Results

Sixteen patients aged 38±14 years were enrolled. Duration of IABP support was 62±50 (3–180) days. Three patients deteriorated requiring additional mechanical circulatory support. Two patients were stabilized without RV function improvement. In the remaining 11 patients, RV improved and fulfilled LVAD eligibility criteria (IABP responders); RA and RA/PCWP decreased from 18±6 to 10±4mmHg (p=0.0001) and from 0.60±0.19 to 0.42±0.11 (p=0.011) respectively. PAPi and RV strain improved from 1.46±0.65 to 3.20±0.58 (p=0.0001) and from −12.9±3.4% to −18.7±1.7% (p=0.0001) respectively. Significantly lower baseline NTproBNP and total bilirubin values were observed in the responders group. Six patients finally received LVAD and none suffered RV failure post-operatively (the remaining 5 were successfully transplanted). RV fibrosis correlated with post-IABP NTproBNP (r=0.91, p=0.001), total bilirubin (r=0.79, p=0.011), RAP (r=0.78, p=0.014), PAPi (r=−0.69, p=0.040), RAP/PCWP (r=0.74, p=0.022) and LV fibrosis (r=0.77, p=0.016), but not with baseline (pre-IABP) parameters.

Conclusions

Prolonged IABP support contributes to partial RV function recovery in patients with ESHF and bi-ventricular failure, thus leading to eligibility for LVAD implantation. RV fibrosis may predict RV response to IABP and post-IABP eligibility for LVAD.

Funding Acknowledgement

Type of funding sources: None.
Third generation continuous flow left ventricular assist devices; a comparative outcome analysis by device type
Authors: Mihalj M , Heinisch P.P , Schober P , Dobner S , Fuerholz M , Martinelli M , Hugi-Mayr B , De By T.M.M.H , Mohacsi P , Schefold J.C , Luedi M.M , Kadner A , Carrel T , Hunziker L , Reineke D ,   LVAD Unit University Hospital Bern
Published: October 2021

Background

Continuous-flow left ventricular assist devices (CF-LVADs) have become a standard of care in end-stage heart failure (HF). Device-related complications remain high. Limited data exists comparing outcomes of the HeartMate 3 (HM3) and the HeartWare HVAD (HW). We aimed to analyze HM3 and HW devices implanted over the past 10 years with a focus on long-term clinical outcomes of respective patients.

Methods

Investigator-initiated comparative, retrospective observational analysis of all patients who underwent primary implantation of a centrifugal CF-LVAD at our tertiary care academic center between January 2010 and December 2020. Data derived from a prospective registry, and included all patients receiving a HM3 or HW device. Primary endpoint was overall (all-cause) mortality and heart transplantation. Secondary endpoints included device-related major adverse cardiac and cerebrovascular events (MACCE), as well right heart failure (RHF), gastrointestinal (GI) bleeding, driveline infections, and surgical re-interventions.

Results

Out of 106 primary CF-LVAD implantations, 36 (34%) received HM3 and 70 (66%) received HW. Median follow-up time was 1.48 years [interquartile range 0.67, 2.41] and did not differ between devices (p=0.739). HM3 was more often implanted in men (91.7% vs. 72.9%, p=0.024), patients were older (median 61 years [54, 66.5] vs. 52.5 years [43, 60], p<0.001), had a higher body mass index (BMI) (median 26.7 kg/m2 [23.4, 29.0] vs. 24.3 kg/m2 [20.7, 27.4], p=0.013), had more comorbidities and were more likely targeted for destination therapy (DT) (36.1% vs. 14.3%, p=0.010). Death occurred in 33.3% of HM3 patients, compared to 22.9% of HW patients, p=0.247 (probability of survival at 2 years 54.7% vs. 74.1%, p=0.296). After adjustment for confounders, we observed a significant 6-fold risk increase in device malfunctions for HW (hazard ratio (HR) 6.49, 95% CI [1.89, 22.32], p=0.003), but no significant differences between devices in pump thrombosis (p=0.173) or overall survival (p=0.801).

Conclusions

Comparing long-term outcomes between HeartMate 3 and HeartWare HVAD for LVAD support from a prospective registry, HeartWare HVAD patients had a significantly higher risk of device malfunctions. No significant differences were evident between devices in overall survival, and in respect to most clinical outcomes.

Funding Acknowledgement

Type of funding sources: None. KM Plot primary and secondary outcomesRisk analysis on all outcomes
Using group concept mapping software to develop a conceptual framework of left ventricular assist device recipients' experiences
Authors: Slade A.L , O'Hara M.E , Quinn D , Marley L , Griffith S , Haque M.S , Calvert M.J , Lim S , Lane D.A
Published: October 2021

Background

Advanced Heart failure (AHF) carries a high mortality rate. Heart transplantation is one therapeutic option, but low donation rates limits its availability. A left ventricular assist device (LVAD) is an alternative therapy which helps relieve symptoms, while improving prognosis and quality of life. However, lack of donors also means that the LVAD becomes a destination therapy by default.(1) Living with an LVAD requires significant psychological, social and physical adaptation for the recipients' and their families.(2) Patient reported outcome measures (PROMs) are one way of capturing these concerns and ongoing problems. Discussions with a patient and public involvement group found a range of issues not currently captured by available PROMS.

Aim

To develop a conceptual framework which reflects the experiences of LVAD recipients' and evaluate their importance for inclusion in PROMs using a research web platform.

Method

Participants were recruited from a regional transplant centre which covers a wide geographical area in the UK. Ethical approval was obtained and participants were recruited through routine LVAD clinics. Group concept mapping (GCM) is a semi-quantitative mixed methods approach that can be used to capture and quantify recipients' experiences.(3) Groupwisdom concept mapping software was used as the electronic data collection platform.(4) GCM consists of 3 stages: statement generation, thematic statement sorting, and rating statements for importance, relevance and frequency of impact. Multidimensional scaling and hierarchical cluster analysis produces visual representations of recipients' experiences as a points and cluster map, and scoring of statements produces relative importance of items across the clusters.

Results

18 LVAD recipients consented to take part. 101 items and 9 clusters were generated. Clusters represented: Activities; Partner/family dependency; Travel; Mental well-being; LVAD challenges; Equipment and clothing; Physical and cognitive limitations; Restrictions, and LVAD positives. LVAD Positives and LVAD restrictions were rated high for frequency, relevance and importance. Physical and cognitive limitations was rated high for importance and frequency. Equipment was rated high for relevance and frequency, and Challenges was rated high for relevance.

Conclusion

GCM and the online software is a useful tool for developing a conceptual framework and mapping key areas of importance for LVAD recipients, especially, when prioritising important patient reported outcome domains for use in clinical practice, future research and design evolution. Using an electronic platform allowed us to reach participants dispersed over a wide geographical area.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): British Heart FoundationNational Institute for Health Research Cluster Rating Map for Importance
Prospective evaluation of donor-derived cell-free DNA as a potential biomarker for cardiac allograft vasculopathy
Authors: Jimenez-Blanco Bravo M , Perez Gomez L , Arellano Serrano C , Hernandez Perez F.J , Gomez Bueno M , Torres Sanabria M , Segovia Cubero J
Published: October 2021

Background

Cardiac allograft vasculopathy (CAV) remains a major cause of morbidity and mortality among long-term heart transplant (HT) recipients. There is clearly an unmet need for a noninvasive biomarker of CAV that could obviate the need to perform surveillance coronary angiograms in these patients.

Purpose

Our aim was to evaluate the performance of Donor-derived Cell Free DNA (dd-cfDNA) as a biomarker of CAV.

Methods

We prospectively measured dd-cfDNA levels in all consecutive asymptomatic patients undergoing surveillance coronary angiography >1 year after HT at a single center, between Jan 2019 and Jan 2021. Endpoints included the association between dd-cfDNA levels and the presence CAV, according to ISHLT 2010 classification. Patients with history of acute cellular rejection ≥1R or antibody mediated rejection in the previous 6 months were excluded.

Results

We included 94 HT recipients, median age 57 years (IQR 50–67), 67% men, a median of 10.9 years after transplant. Coronary angiogram revealed CAV0, CAV1, CAV2 and CAV3 in 61%, 19%, 14% and 6% of patients, respectively. Median dd-cfDNA values for each CAV group were: CAV0 0.92% (IQR 0.46–2.0), CAV1 1.4% (0.38–2.8), CAV2 0.17% (0.07–0.52) and CAV3 0.24% (0.057–0.87); p=0.0535. Figure 1 summarizes baseline characteristics of the cohort and results.

Comparison of dd-cfDNA levels in patients with CAV0 and CAV1–2-3 did not show significant differences (0.92%, IQR 0.46–2.0 vs 0.46%, IQR 0.075–1.5, p=0.059) (Figure 2A), nor did the comparison between patients with stable CAV (no new coronary lesions since previous angiogram, n=77) and progressive CAV (patients with new coronary stenoses, n=17); median dd-cfDNA values were 0.735% (IQR 0.195–2.0) vs 0.9% (IQR 0.12–1.8), p=0.76 (Figure 2B). A subanalysis according to time after HT was also found non-significant: less than 5 years (p=0.95), 5 to 10 years (p=0.14) and more than 10 years after HT (p=0.16) (Figure 2C). The AUC ROC curve for the diagnosis of CAV revealed the lack of ability to predict the presence of any degree of CAV (AUC ROC = 0.38).

Conclusion

In our experience, dd-cfDNA did not perform as a useful biomarker to avoid surveillance coronary angiograms for CAV diagnosis.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Sociedad Madrileña de Trasplantes
Impact of induction therapy on outcomes after heart transplantation
Authors: Briasoulis A , Doulamis I , Kampaktsis P , Alvarez P
Published: October 2021

Introduction

Approximately 50% of heart transplant (HT) programs currently employ a strategy of induction therapy (IT) with either interleukin-2 receptor antagonists (IL2RA) or polyclonal anti-thymocyte antibodies (ATG) during the early postoperative period. However, the overall utility of such therapy is uncertain and data comparing induction protocols are limited.

Methods

Adult HT recipients were identified in the United Network for Organ Sharing (UNOS) registry between 1990 and 2020. Patients were grouped according to administration of induction in the post-operative period after HT. Accounting for re-transplantation, Fine and Gray's test compared cumulative incidences of all-cause mortality between groups. Univariate and multivariate analysis were performed using the competing risk model. The risk of treated rejection and hospitalization for infection or rejection was analyzed with multivariable logistic regression.

Results

A total of 63,849 HT recipients were included in the study and among those 59% did not receive induction, 16.6% received ATG, 19.1% IL2RA, 0.7% alemtuzumab, and 4.6% OKT3. Since 2000 IL2RA is the most frequently used form of induction therapy whereas OK3 is not used in the past decade. In multivariable logistic regression models, use of ATG is associated with lower risk of treated rejection at one year after HT (relative risk ratio 0.55, 95% CI 0.47–0.63, p<0.001) compared with no induction whereas IL2RA had similar risk of treated rejection. Similarly, the risk of rejection requiring hospitalization was significantly lower with ATG than no induction. No significant differences in rates of infection requiring hospitalization were noted between groups. Moreover, no differences in rates of post-transplant lymphoproliferative disease and any malignancy were noted between those receiving induction versus no induction. Adjusted all-cause mortality was significantly lower among those treated with ATG than patients that did not receive induction therapy (sub-hazard ratio 0.72, 95% CI 0.63–0.82, p<0.001) (Figure).

Conclusion

Induction therapy with IL2RA is the most used approach. ATG is associated with lower risk of treated rejection and all-cause mortality than no induction and IL2RA.

Funding Acknowledgement

Type of funding sources: None.
Prognostic significance of non-sustained ventricular tachycardia on stored electrograms of heart failure patients with cardiovascular implantable electronic devices
Authors: Barradas Da Silva M , Duarte F , Oliveira L , Serena C , Fontes A , Monteiro A , Machado C , Dourado R , Santos E , Pelicano N , Pacheco M , Tavares A , Martins D
Published: October 2021

Background

Non-sustained ventricular tachycardia (NSVT) is commonly found in patients with structural heart disease and was historically obtained from registers of external ambulatory monitoring. The advent of Cardiac implantable electronic devices (CIEDs) has made it possible to detect asymptomatic NSVT in Heart Failure (HF) patients more frequently, but its true impact in real world is uncertain, and often does not lead to a change in clinical intervention.

Purpose

To determine the prognostic significance of NSVT detection on stored electrograms of CIEDs in HF patients with systolic left ventricle dysfunction.

Methods

We retrospectively enrolled 132 consecutive HF patients (mean age 67,5±11,1 years, males 72,0%) with systolic left ventricle dysfunction and CIEDs (biventricular pacemakers with or without cardiac defibrillators). Patients were evaluated through CIEDs interrogation and clinical evaluations and divided into NSVT positive (Group 1) and negative groups (Group 2). Mean follow-up period was 62,8±7,1 months.

Results

NSVT was detected in 51 (38,6%) patients. 70 (53,0%) had implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D), 37 (28,0%) transvenous implantable cardioverter defibrillator (ICD), 13 (9,8%) CRT pacemaker (CRT-P) and 12 (9,1%) subcutaneous ICD (S-ICD). Medium left ventricular ejection fraction (LVEF) was 31,1±7,9%, 20,6% were in NYHA III-IV and 47,0% were ischemic (49% Group 1 and 45,7% Group 2, p=0,708). Dyslipidemia was more prevalent in Group 2 (p=0,042). In total 11 (8,3%) patients died, 2 (1,5%) from sudden cardiac death and 5 (3,8%) from cardiovascular death. NSVT was associated with CIEDs treatments (hazard ratio [HR]2,52; 95% confidence interval [CI]1,2–5,1; p=0,001), ventricular fibrillation (VF) (HR: 3,71, 95% CI: 1,19–11,58; p=0,018), sustained ventricular tachycardia (VT) (HR: 9,06, 95% CI: 2,82–29,12; p<0,05) and composite outcome of VT, VF, HF re-admissions and related admissions to emergency department (ED) and death by all causes (HR: 2,52; 95% CI: 1,20–5,10; p=0,011). NSVT at 1 year was associated with HF readmissions at 1 year (p=0,004).

Conclusions

On extended monitoring possible with CIEDs, NSVT in HF patients was associated with a worse prognosis and may serve as a predictor of significant arrhythmic events, HF hospitalizations and mortality. These findings enhances the importance of remote monitoring and optimization of therapeutic modalities in these patients along with a close supervision.

Funding Acknowledgement

Type of funding sources: None.