bluuebunny/crossref_metadata_2025 huggingface dataset:
Changes of RV-PC coupling during negative for myocardial ischemia dobutamine stress echocardiography
Authors: Koukos M , Giannoulis E , Solomou E , Poulidakis E , Dimitroglou I , Patsourakos D , Chatzigeorgiou V , Liakos C , Tsartsalis D , Kalompatsou A , Valatsou A , Aggeli C , Tsioufis K
Published: October 2022

Background

Coupling between RV contractile function and pulmonary circulation (PC) reflects the comprehensive performance of the RV by integrating afterload and contractility. RV-PC coupling is nowadays frequently expressed by the non-invasively measured ratios TAPSE/RVSP and RVFWLS/RVSP. It has been shown that it decreases slightly during exercise, whereas no known data exist on how dobutamine does affect it.

Purpose

The aim of this study was to evaluate the changes in RV-PC coupling and RV mechanics during the different stages of dobutamine stress echocardiography (DSE) in cases without known coronary artery disease (CAD) and negative for myocardial ischemia DSE.

Methods

Patients with a low-to-intermediate risk for CAD were referred for and underwent DSE. RV systolic function was evaluated with TAPSE, S' and RV Free Wall (RVFW) Strain. The non-invasively measured RV-PC coupling was evaluated by indexing TAPSE and RV free wall longitudinal strain to right ventricular systolic pressure (RVSP) during baseline echocardiogram, low dose (inotropic dobutamine effect) and peak dose (chronotropic effect) stages of DSE.

Results

Initially, a total of 53 patients underwent DSE. Eight patients had a positive for ischemia response and were excluded.

The remaining 45 patients {mean age 65±8.7, 28 (63%) male}, 24 (53%) had hypertension, 24 (53%) were smokers, 33 (74%) had dyslipidemia, 15 (34%) had family history of CAD and 7 (15%) had diabetes mellitus. TAPSE, S' and RVFW Strain increased from baseline to peak dose [23.55±2.91 vs 28.76±1.9 (p<0.001), 13.13±1.79 vs 23.83±4.87 (p<0.001) and 19.7±5.87 vs 23.46±5.42 (p=0.044) respectively].

TAPSE/RVSP showed a significant steady decrease between baseline and low dose (0.88±0.14 vs 0.79±0.19) and peak dose (0.88±0.14 vs 0.74±0.12) stages with a difference of 0.09 (p value 0.013) and 0.14 (p value 0.000) respectively. On the other hand, RVFW Strain/ RVSP exhibited a significant decrease (0.60±0.15, p value 0.000) only between baseline and peak dose.

There was no significant correlation of the change in TAPSE/RVSP with the change in E/E' or change in Systolic Blood Pressure.

Conclusions

RV-PC coupling decreases during negative for ischemia DSE independently of LV dynamic changes and therefore, future studies should be oriented to evaluate the incremental role of this novel index not only for the assessment and evaluation of myocardial ischemia and RV disease that affects RV coupling, but also as a prognostic marker for patients with no evident ischemia.

Funding Acknowledgement

Type of funding sources: None.
Dissociation between two-dimensional and three-dimensional echocardiography – clinical implications
Authors: Lyng Lindgren F , Bundgaard Ringgren K , Ascanius Jacobsen P , Tayal B , Hay Kragholm K , Holmark Andersen N , Zaremba T , Biering-Sorensen T , Mogelvang R , Schnohr P , Boje Jensen G , Sogaard P
Published: October 2022

Objectives

To investigate the agreement between two-dimensional (2DE) and three-dimensional echocardiography (3DE) in a general population, along with clinical impact of the differences.

Background

Left ventricular ejection fraction (LVEF) has prognostic value and is used to guide cardiac treatment. The preferred technique is two-dimensional (2D) echo, although three-dimensional (3D) echo is more accurate when compared to MRI. Our study evaluates the agreement between 2D and 3D LVEF and the potential clinical impact of disagreements.

Methods

Study population ware participants from the Copenhagen City Heart Study, who underwent 2DE and 3DE between 2011–2014. Means of difference (MD) were assessed in participant groups with a LVEF below 40%, 40–50%, and above 50%. Age-adjusted Cox proportional hazard ratios (HR) were calculated for all-cause mortality, major adverse cardiovascular event (MACE) and cardiac event of any kind.

Results

In total 2554 participants from the Copenhagen City Heart Study were included. Median age was 58.3 (IQR: 44.2–69.8) years and 1137 (44.5%) were male. Mean LVEF in 2D was 56.6% (95% CI: 56.4–56.9%) and 52.0% (95% CI: 51.7–52.4%) in 3D, p<0.05. MD increased the further LVEF deteriorated: −14.9% (95% CI: −16.0 to −13.9%) (LVEF <40%), −9.3% (95% CI: −9.8 to −8.9%) (LVEF 40–50%) and −1.2% (95% CI: −1.6 to −0.9%) (LVEF ≥50%). 2DE overestimated the LVEF relative to 3D in 1824 (71.4%) instances.

3D LVEF <40% was associated with a HR for all-cause mortality of 2.58 (95% CI: 1.55–4.31, p<0.05), MACE: 1.90 (95% CI: 1.22–2.98, p<0.05) and cardiovascular event: 1.61 (95% CI: 1.04–2.48, p<0.05).

HR for 2D LVEF <40% 0.84 (95% CI: 0.21–3.41, p=0.80) (all-cause), 3.12 (95% CI: 1.64–5.94, p<0.05) (MACE) and 2.68 (95% CI: 1.42–5.09, p<0.05) (cardiovascular event).

Conclusion

With declining LVEF, 2D echo is prone to significantly overestimate LVEF and a 3D LVEF less than 40% is associated with excess all-cause mortality but less with MACE and cardiovascular events when compared to 2D LVEF.

Funding Acknowledgement

Type of funding sources: None.
3D-Echocardiography in the assessment of lead-induced tricuspid regurgitation
Authors: Chango D X , Pelayo M E , Munin M A , Sanchez G A , Raggio I , Garro H , Arevalo M , Carbajales J , Ronderos R
Published: October 2022

Background

Lead-induced tricuspid regurgitation (LITR) is caused by several mechanisms that can be assessed by 3D-Echocardiography (3DE). Its prevalence was not studied to date in the Latin-American series.

Purpose

To determine prevalence and mechanisms of LITR in a series of patients with permanent cardiac devices by 3DE.

Methods

We perform a cross-sectional analysis of 101 patients with permanent cardiac devices as pacemakers or defibrillators. Transthoracic 3DE was obtained on all patients in RV-focused apical views to perform a complete tricuspid valve leaflets, subvalvular apparatus, lead placement and functional assessment to evaluate possible mechanisms of tricuspid regurgitation.

Results

Of a total of 101 patients, lead visualization was possible in 88%. In 59% lead was in commissural position and did not interfere with tricuspid leaflet mobility. Nevertheless, in 41% LITR was observed by several mechanisms. Leaflet impingement was the most prevalent cause in 30,7% causing valve leaflet interference and organic damage. Catheter adherence and/or entrapment to the leaflet or the tricuspid subvalvular apparatus was present in 10.3%. Two patients seem to have leaflet perforation by the catheter as the main mechanism; however, a further assessment was not possible. Patients with LITR had higher time since catheter implantation, lower left ventricular ejection fraction, more severity of tricuspid regurgitation, and right ventricular dilatation.

Conclusions

3DE enables to the identification of 41% of patients with LITR and leaflet impingement was the most prevalent mechanism. LITR patients had more time since cardiac device implantation. Some unfavorable catheter locations on the tricuspid valve can have some influence on the development of LITR over time.

Funding Acknowledgement

Type of funding sources: None.
Lower rate limit in cardiac resynchronization therapy defibrillators
Authors: Barradas M , Duarte F , Coutinho Dos Santos I , Resendes De Oliveira L , Serena C , Xavier Fontes A , Viveiros Monteiro A , Machado C , Dourado R , Santos E , Pelicano N , Pacheco M , Tavares A , Martins D
Published: October 2022

Background

There is few data about programmed lower rate limit (LRL) in real world heart failure (HF) patients with cardiac resynchronization therapy–defibrillators (CRT-Ds) and its influence in clinical outcomes. Heart rate score (HRS) is the percentage of all atrial-paced and sensed events in the single tallest 10 beats/min device histogram bin and may indicate impaired heart rate variability.

Purpose

We hypothesized that higher LRL programming is associated with worse clinical outcomes as arrhythmic events and HF decompensations in chronic HF patients with CRT-Ds.

Methods

LRL was evaluated and HRS was calculated from remote monitoring in 126 HF patients with CRT-D. Primary outcome was defined as HF hospitalizations and related admissions to the emergency department and secondary outcome as number of device therapies, sustained ventricular tachycardia (VT) and ventricular fibrillation (VF).

Results

Mean age was 69,03±10,39 years, 81 (64,3%) were males and mean follow-up was 53,72±46,13 months. Mean left ventricular ejection fraction was 30,31±8,33% and 29 (23,0%) were in NYHA III–IV. HF aetiology was idiopathic in 39 (43,3%), ischemic in 32 (25,4%) and alcoholic cardiomyopathy in 8 (6,3%). Thirty-seven (29,4%) patients had atrial fibrillation and 33 (26,2%) coronary disease. LRL ranged from to 40 to 80 bpm and mean LRL was 52,64±9,64 and mean HRS 49,60±23,17%. Programmed LRL was higher in women (p=0,014), patients with atrial fibrillation (AF) (p=0,012) and coronary disease (p=0,015). Higher LRL correlated with HF hospitalizations and related admissions to the emergency department (ED) (r=0,541, p=0,001), VT or VF episodes (r=0,337, p=0,005) and CRT-D number of therapies (r=0,342, p=0,004) and higher HRS (r=0,547, p<0,05).

Conclusion

Higher LRL programming was associated with higher HRS, HF decompensations with hospitalization or admission to the emergency department, VT or VF episodes and CRT-D therapies in a real world population. More studies are required but lower LRL may be preferred in HF patients.

Funding Acknowledgement

Type of funding sources: None.
Long-term outcome and mortality predictors in patients with extremely enlarged left ventricle end-diastolic diameter undergoing cardiac resynchronization therapy
Authors: Mazurek M , Jedrzejczyk-Patej E , Lenarczyk R , Sokal A , Kotalczyk A , Kowalska W , Gumprecht J , Kowalski O , Kalarus Z
Published: October 2022

Background

Data on efficacy of cardiac resynchronization therapy (CRT) and prognosis of CRT recipients with extremely enlarged left ventricular prior to device implantation are scarce.

Aim

To determine outcome and mortality predictors in patients with heart failure (HF) and extremely increased left ventricle end-diastolic diameter (LVEDD) treated with cardiac resynchronization therapy.

Methods

Study population consisted of 1059 consecutive patients with CRT implanted between 2002 and 2019 in a tertiary care university hospital, in a densely inhabited, urban region of Poland (949 subjects [89.6%] with CRT-D; 110 patients with CRT-P [10.4%]).

Results

The median LVEDD before CRT implantation was 68 mm (56–80). We divided all CRT patients into quartiles as per LVEDD: I <61 mm, II 61–67 mm, III 68–73 mm and IV ≥74 mm. During the median follow-up of 1661 days (10th and 90th percentile: 323–3995) mortality rates for quartiles I–IV were 41.2, 49.6, 55.9 and 68.1%, respectively (P<0.001). The LVEDD ≥74 mm (quartile IV) appeared to be an independent risk factor for death (HR 1.29, 95% CI 1.05–1.6, P=0.02). On multivariable analysis, severe mitral regurgitation (MR; HR 1.54, 95% CI 1.1–2.16, P=0.01) and advanced age (HR 1.02, 95% CI 1.01–1.03, P=0.02) were independent risk factors for death in quartile IV. During observation, mortality rate for quartile IV patients aged >65 years and with severe MR was 90%. Exclusion of subjects with severe MR and aged >65 from quartile IV resulted in similar mortality rate (53.1%) as for patients in lower quartiles.

Conclusions

Mortality rates in CRT recipients with extremely enlarged LVEDD is significantly higher compared to those with LVEDD <74 mm. CRT offer to HF patients with LVEDD ≥74 mm (and in particular those with accompanying severe MR and aged >65 years) should be very carefully assessed and other HF therapies (i.e. left ventricular assist devices) should be considered, as more than 90% of those die within 4 years since CRT implantation.

Funding Acknowledgement

Type of funding sources: None.
The impact of frailty index on long-term outcome in CRT patients
Authors: Kuthi L , Schwertner W , Veres B , Merkel E , Behon A , Masszi R , Kovacs A , Osztheimer I , Molnar L , Zima E , Geller L , Kosztin A , Merkely B
Published: October 2022

Background

Frailty is a complex clinical syndrome associated with ageing and comorbidities resulting from multiple organ impairment by losing homeostatic reserves and increased vulnerability to physiological decompensation. Frailty can be measured by quantifying the “vulnerability status” by the range of comorbidities.

Purpose

We assessed the long-term all-cause mortality based on Frailty Index (FI) among patients who underwent Cardiac Resynchronization Therapy (CRT) implantation.

Methods

We calculated patients' FI individually using 30 clinical parameters from our retrospective single centre large-scale registry. The applied clinical features incorporated patients' medical history, anthropometric-, laboratory and echocardiographic parameters. Based on previous studies, patients with FI ≤0.210 were classified as non-frail, and patients above that value were considered frail. Frail patients were divided into two different subgroups (F1; F2) by a FI increment of 0.100 based on the Rockwood method. Primary endpoint was all-cause mortality, log-rank and Cox multivariate analysis were performed.

Results

Among 1010 included patients, 58 (6%) were considered as Non-frail, while 245 (24%) and 707 (70%) participants were categorized to F1- and F2 groups. Patients in F2 group were older [non-frail 62 years (IQR 57–68) vs. F1 66 years (IQR 57–73) vs. F2 70 years (IQR 63–76); p<0.001], had worse laboratory parameters as higher creatinine, uric acid, lower sodium or hemoglobin levels (p<0.001) and more comorbidities than patients of Non-frail or F1 groups. During the median follow-up time of 4.4 (2.3–6.9) years, 17 (29%) patients in the Non-frail group, 103 (42%) in Frail group 1 and 479 (68%) in the Frail group 2 reached the primary endpoint. Non-frail patients showed the best outcome, and patients in the Frail group 1 demonstrated a 46% (HR 0.46, 95% CI 0.39–0.55; p<0.001) lower all-cause mortality risk compared to Frail group 2. In the total cohort, mortality predictors were also assessed, NYHA functional class, serum sodium, creatinine and TAPSE were identified as independent predictors of all-cause mortality.

Conclusion

By calculating individual frailty index among CRT patients, distinct groups could be identified, of which mortality differed significantly. Those with the highest Frailty index demonstrated the worse outcome compared to lower index or non-frail patients. Frailty index can help selecting the most vulnerable patients, requiring a strict follow-up.

Funding Acknowledgement

Type of funding sources: None.
Artificial intelligence-based body composition predicts postoperative complications and mortality in advanced heart failure patients receiving long-term mechanical circulatory support
Authors: Just-Lauer I A , Schoenrath F , Roehrich L , Auer T A , Fehrenbach U , Potapov E J , Solowjowa N , Balzer F , Geisel D , Braun J , Boening G
Published: October 2022

Background

Obesity is an independent cardiovascular risk factor and is associated with higher postoperative infection rates in patients after cardiac surgery. However, in heart failure, obesity has been described as beneficial in terms of survival (“obesity paradox”); whereas sarcopenia is associated with poor prognosis. An increasing number of advanced heart failure patients requires surgical treatment in terms of left ventricular assist device (LVAD) implantation. The postoperative in-hospital survival has improved in recent years but is still relatively high (11.1%). The impact of body composition on outcome in this population remains unclear.

Purpose

The aim of this investigation was to examine the preoperative computed tomography (CT) body composition based on artificial intelligence (AI) analysis as a predictor of the postoperative outcome in advanced heart failure patients, who underwent LVAD implantation.

Methods

Preoperative CT scans of 137 patients who received LVAD implantations between 2015 and 2020 were retrospectively analyzed using an AI-powered automated software tool based on a convolutional neural network, U-net, developed for image segmentation (Visage version 7.1., Visage Imaging GmbH, Berlin, Germany; Figure 1). Assessment of body composition included visceral and subcutaneous adipose tissue areas (VAT, SAT), psoas and total abdominal muscle areas (PMA, TAMA) and sarcopenia (defined as lumbal skeletal muscle index ≤38.5 cm2/m2 in women and ≤54.4 cm2/m2 in men). The body composition parameters were correlated with postoperative major complication rates and survival.

Results

The mean age of patients was 58.21±11.9 years; 122 (89.1%) were male. Most patients had severe heart failure requiring inotropes (INTERMACS profile I-III, 71.9%) secondary to coronary artery diseases or dilated cardiomyopathy (96.4%). 44 (32.1%) patients were obese (BMI ≥30 kg/m2), 96 (70.1%) were sarcopene and 19 (13.9%) were sarcopene obese. Adipose tissue was associated with a significantly higher risk of overall postoperative complications (SAT 158.22 cm2 [63.09, 256.78 cm2] vs. 124.04 cm2 [42.86, 187.68 cm2], p=0.049) and in-hospital mortality (VAT 168.11 cm2 [134.19, 285.27 cm2] vs. 135.42 cm2 [49.44, 227.91 cm2], p=0.033; SAT 227.28 cm2 [139.38, 304.35 cm2] vs. 173.81 cm2 [97.65, 254.16 cm2], p=0.009). Sarcopenia did not influence the postoperative outcome and survival within 1 year post LVAD implantation.

Conclusions

Preoperative AI-based CT body composition identifies patients with poor prognosis after LVAD implantation. Adipose tissue areas predict in-hospital mortality, thus, obesity as a perioperative risk factor outweighs the protective effect known in heart failure patients when undergoing LVAD implantation.

Funding Acknowledgement

Type of funding sources: None.
Right ventricular myocardial work in patients undergoing left ventricular assist device implant
Authors: Mandoli G E , Landra F , Pica A , Marrese F , Gallone G , Sciaccaluga C , Cavigli L , D'Ascenzi F , Focardi M , Maccherini M , Bernazzali S , Valente S , Cameli M
Published: October 2022

Background

Right ventricular failure (RVF) complicates 10 to 40% of left ventricular assist device (LVAD) implants, with necessity of high dose inotropic/vasodilatory drugs and right ventricular assist devices in severe cases. Prevention of RVF starts with appropriate patient selection for LVAD implant through extensive clinical, echocardiographic and hemodynamic evaluation.

Purpose

This study aimed to evaluate the performance of a novel non-invasive echocardiographic method for estimation of right ventricular myocardial work to predict RVF and death after LVAD implant.

Methods

Consecutive patients from May 2017 to February 2022 undergoing LVAD implant were retrospectively reviewed. Patients without a useful echocardiographic exam and/or a right heart catheterization prior to LVAD implant were excluded. Myocardial work analysis by Speckle Tracking Echocardiography (STE) was performed in these patients. The primary endpoints were RVF and death.

Results

The study included 23 patients (mean age 64±8 years, 91% men). Median follow-up time was 304 days (IQR: 23–1017). GWI significantly correlated with invasively-derived right ventricular stroke work index (RVSWI, r=0.538; p=0.008) and pulmonary arterial compliance (PAC, r=−0.522; p=0.013). Patients who experienced RVF (26.1%) had lower GWI (p=0.047) and GWE (p=0.001) and higher GWW (p=0.001). Patients who experienced death at 30 days after LVAD implant (26.1%) had lower GWE (p=0.005) and higher GWW (p=0.006). Performance for prediction of RVF after LVAD implant was greatest for GWE (AUC 0.92), followed by GWW (AUC 0.88) and GWI (AUC 0.78). A cut-off of 77% for GWE have a 100% sensibility and 82% specificity for prediction of RVF. At long term follow-up, death occurred in 4 patients (29%) in the GWE>77% group and in 6 patients (67%) in the GWE<77% group (hazard ratio for death, 0.24; 95% CI, 0.07 to 0.89, p=0.032).

Conclusions

Right ventricular myocardial work is a strong predictor of RVF after LVAD implant and death at long-term follow up. Its calculation should be implemented in the evaluation for LVAD candidacy.

Funding Acknowledgement

Type of funding sources: None.
Impact of preoperative hemodynamic optimization on right ventricular failure after left ventricular assist device implantation
Authors: Briasoulis A , Alvarez P , Panos A , Ruiz Duque E
Published: October 2022

Background

Preoperative hemodynamic parameters are linked to higher rates of right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation. It is unclear if preoperative hemodynamic optimization decreases the incidence of RVF after LVAD.

Methods

Single-center retrospective analysis of consecutive LVAD recipients between 2015 and 2020. Pre-operative right heart catheterization and a strategy of hemodynamic optimization were performed in all patients. Pre-operative right ventricular dysfunction (RVD) was defined by a CVP ≥16 mmHg and pulmonary artery pulsatility index (PAPi) <1.85. The optimization goal was defined as CVP <16 mmHg, PAPi ≥1.85, and Cardiac Index of ≥2.0. The main outcome was RVF (inotropes >14 days, discharge on home inotropes, or right ventricular mechanical support device).

Results

128 LVAD recipients (age 58 years, 74% male, 68% had non-ischemic cardiomyopathy, 45% were on home inotropes, HeartMate 2 in 61%, HeartMate 3 in 31%, and HVAD in 9%) were analyzed. Pre-operative RV dysfunction was present in 48% and these patients were younger, with higher rates of home inotropes, and intra-aortic balloon pump (IABP) pre-LVAD. Postoperative RVF occurred in 60% of patients with RV dysfunction and 40% of the patients without pre-operative RV dysfunction (p<0.002). 40% of patients with RV dysfunction achieved RV optimization goals (32% required IABP). Among those, 53% developed RVF-Post LVAD. RVF was numerically but not significantly higher among those with RV dysfunction who achieved hemodynamic goals (66% vs. 34%, p=0.37) vs. those that did not. Patients with RVF-post LVAD had 10% (n=5) in-hospital mortality.

Conclusion

Pre-LVAD RV dysfunction based on hemodynamic markers is associated with RVF after LVAD implantation. In patients with RV dysfunction, a strategy of pre-LVAD “optimization” to achieve RV hemodynamic optimization goals did not affect the incidence of post-operative RVF.

Funding Acknowledgement

Type of funding sources: None.
Characteristics and outcomes of left ventricular assist device recipients transplanted before and after the new donor heart allocation system
Authors: Briasoulis A , Inampudi C , Kourek C , Asleh R , Doulamis I
Published: October 2022

Background

Concerns about the impact of the new donor heart allocation system on post-transplant outcomes have emerged after its implementation. We sought to evaluate the characteristics and outcomes of left ventricular assist device (LVAD) recipients transplanted before and after the implantation of the new policy on October 18, 2018.

Methods

Data on bridge to transplantation adult LVAD patients January 2015 and October 2021, with durable LVAD as a (BTT), was queried from the United Network of Organ Sharing (UNOS) registry. The main outcomes were 30-day all-cause mortality, 30-day fatal graft failure, 1-year all-cause mortality, treated acute rejection at one year and renal replacement therapy (RRT) for acute renal failure.

Results

In our study, 7096 patients met the inclusion criteria including 2,435 in the new allocation system. The transplanted patients in the new allocation system era had older donor age, longer ischemic time and higher proportion of newer generation LVADs. Adjusted 30-day all-cause mortality was significantly lower for LVAD recipients in the new allocation system era (sub-hazard ratio [SHR] 0.36, 95% Confidence intervals [CI] 0.27–0.48, p<0.001) without differences in the risk of fatal graft failure and one-year mortality. Significantly lower adjusted 30-day mortality with HVAD and HM3 devices than HM2 in the new allocation system era was found, without differences in one-year mortality. Acute allograft rejection requiring treatment was significantly lower (Odds Ratio 0.78, 95% CI 0.65–0.94, p=0.01) whereas a trend towards higher risk of renal failure requiring RRT was identified.

Conclusions

Despite changing donor characteristics and longer ischemic times, post-transplant outcomes in LVAD recipients have not worsened with the implementation of the new allocation system and this finding is related to the use of newer generation continuous flow LVADs.

Funding Acknowledgement

Type of funding sources: None.
Characteristics, predictors and outcomes of early mTOR inhibitor use after heart transplantation: insights from the UNOS database
Authors: Briasoulis A , Doulamis I , Kampaktsis P
Published: October 2022

Background

The clinical characteristics of mammalian target of rapamycin (mTOR) inhibitors use in heart transplant (HT) recipients and their outcomes have not been well described.

Methods

We compared patients that received mTOR inhibitors within the first 2 years after HT to patients that did not by inquiring the United Network for Organ Sharing database between 2010 and 2018. The primary endpoint was all-cause mortality with re-transplantation as a competing event. Rejection, malignancy, hospitalization for infection and renal transplantation were secondary endpoints.

Results

There were 1,619 (9%) and 15,686 (81%) mTORi+ and mTORi− patients respectively. Body mass index, induction, cardiac allograft vasculopathy, calculated panel reactive antibody and less days in 1A status were independently associated with mTORi+ status. Over a follow up of 10.4 years there was no difference in all cause mortality after adjusting for donor and recipient characteristics (adjusted subdistribution hazard ratio 1.03 [0.90–1.19], p=0.66) (Figure 2). mTORi+ was independently associated with increased risk for rejection (odds ratio 1.43 [1.11–1.83], p=0.005) but not for infection, malignancy or renal transplantation.

Conclusion

mTOR inhibitors are used in <10% patients in the first 2 years after HT and are non-inferior to contemporary immunosuppression regimens in terms of all-cause mortality, infection, malignancy or renal transplantation. They are associated with risk for rejection.

Funding Acknowledgement

Type of funding sources: None.
Predictors of early renal dysfunction after heart transplantation: a report from the International Consortium on Primary Graft Dysfunction
Authors: Guzman Bofarull J , Han J , Moayedi Y , Truby L K , Foroutan F , Miller R , Potena L , Zuckermann A , Chih S , Farr M , Hall S , Ross H J , Khush K , Farrero M
Published: October 2022

Background

Renal dysfunction is a common complication after heart transplantation (HT). Renal replacement therapy (RRT) after HT has been associated with increased risk of death. Long-term renal dysfunction is associated mainly to immunosuppressive therapy but is also strongly related to post-transplant renal failure. Predictors of early renal dysfunction after HT have not been clearly identified.

Purpose

We aimed to define predictors of early renal dysfunction after HT.

Methods

Our consortium includes 10 centers in the US, Canada and Europe. We collected data on all consecutive single-organ HT recipients from 2010 to 2020. The primary outcome was early renal dysfunction (ERD), defined as a composite of need for RRT or creatinine ≥2.5 mg/dL 24 hours after HT. We assessed the incidence of early renal dysfunction and performed univariate and multivariate analyses to identify the recipient and transplant characteristics associated with its development.

Results

We included 2,764 HT recipients: 282 (10.2%) presented early renal dysfunction and 2482 (89.8%) did not. Recipients who presented postoperative renal dysfunction were more frequently male, Caucasian, with previous sternotomy, higher baseline creatinine, longer ischemic time and worse donor LVEF. They were also more likely to be under RRT, intravenous inotropes or ECMO support and there was more incidence of severe primary graft dysfunction (PGD) (Table 1). Multi-variable logistic regression demonstrated that the strongest predictors for post-transplant renal dysfunction were development of severe PGD (OR 5.26, 2.88–9.62, p<0,001) and RRT prior to HT (OR 5.80, 2.93–11.5, p<0.001). Other predictors were male sex, previous sternotomy, long ischemic time and need for inotropes prior to HT.

Conclusions

Early renal dysfunction is a common complication after HT with an incidence around 10% in a large and contemporary cohort. The presence of PGD and need for RRT pre-transplant were the strongest predictors for its development. Interestingly, emergent transplantation or need for MCS were not independently associated with ERD. Further studies are needed to identify patients at high risk of early and late kidney dysfunction that may benefit from combined transplantation.

Funding Acknowledgement

Type of funding sources: None.
Novel clinical data on cardiac contractility modulation in NYHA II patients – Results from the MAINTAINED Observational Study
Authors: Fastner C , Yuecel G , Hetjens S , Rudic B , Schmiel G , Toepel M , Liebe V , Kruska M , Borggrefe M , Burkhoff D , Akin I , Duerschmied D , Kuschyk J
Published: October 2022

Background

Cardiac contractility modulation (CCM) is an FDA-approved device therapy for patients with medication refractory systolic heart failure and normal QRS width. Pivotal trials have been performed primarily in patients with advanced heart failure (NYHA class III or ambulatory IV). As observed in clinical practice, CCM might also be beneficial in patients with low-grade but persistent heart failure that limits daily activity (NYHA class II).

Purpose

To facilitate an individualized indication in these patients, we evaluated the long-term effects of CCM in patients with baseline NYHA class II versus baseline NYHA class III or ambulatory IV from our large clinical registry (MAINTAINED Observational Study).

Methods

CCM effectiveness was measured by changes in functional parameters (i.e., NYHA class, left ventricular ejection fraction (LVEF), tricuspid annular plane systolic excursion (TAPSE), NT-proBNP levels, and KDIGO CKD stage). In addition, mortality within 3 years was compared with the prediction of the Meta-Analysis Global Group in Chronic (MAGGIC) heart failure survival risk score.

Results

172 patients were included (10% with NYHA class II). Patients with NYHA class III/IV showed a significant improvement in NYHA class over 5 years of CCM (II: 0.1±0.6; p=0.96 vs. III/IV: −0.6±0.6; p<0.0001). In contrast, LVEF improved significantly in each group (II: 4.7±8.3; p=0.0072 vs. III/IV: 7.0±10.7%; p<0.0001; p=0.67 for the comparison of changes between both groups). TAPSE improved significantly only in NYHA class III/IV patients (II: 2.2±1.6; p=0.20 vs. III/IV: 1.8±5.2 mm; p=0.0397). NYHA class II patients had significantly lower NT-proBNP levels at baseline (858 [175/6887] vs. 2632 [17/28830] ng/L; p=0.0044), which was offset under therapy (399 [323/1497] vs. 901 [13/18155] ng/L; p=0.48). KDIGO CKD stage did not experience significant improvement in any group. Actual 3-year mortality was 17 and 26% vs. a predicted mortality of 31 and 42%, respectively (p=0.0038 for NYHA III/IV).

Conclusions

In clinical practice, CCM was infrequently performed in NYHA class II patients. No significant improvement in NYHA class/dyspnea was observed in these patients over 5 years. Because of the improvement in LVEF, sustainable positive effects on long-term cardiac reverse remodeling might be expected in young patients. Patients with advanced heart failure showed improvements in NYHA class, LVEF, and TAPSE also in clinical practice.

Funding Acknowledgement

Type of funding sources: None.
3D atrial strain for prediction of atrial fibrillation recurrence
Authors: Krizanovic-Grgic I , Anwer S , Steffel J , Hofer D , Saguner A M , Spengler C M , Breitenstein A , Tanner F C
Published: October 2022

Introduction

Atrial fibrillation (AF) is one of the most common supraventricular arrhythmias. Treatment options apart from medication include interventional catheter-guided pulmonary vein isolation (PVI). However, there is limited knowledge about factors predicting arrhythmia recurrence after PVI.

Aim

To study the association of 3-dimensional (3D) left atrial (LA) strain (LAS) and 3D electro-anatomical voltage mapping (EAVM) with early recurrence of AF after PVI.

Methods

In this prospective single center study, 93 patients undergoing PVI were enrolled between December 2018 and October 2021. All patients underwent an echocardiographic examination within two weeks before PVI using the Canon Aplio i900 system to analyse LAS from 3D LA volume. A 3D EAVM was obtained using high-density mapping catheters during PVI. The CARTO 3 system (Version V6-V7) was used for determining LA scar area by low voltage mapping (local amplitude <0.5 mV) indicated as percentage (EAVM-%). Follow-up time points were set at 2, 3, 6 and 12 months to investigate recurrence of AF, with exclusion of events occurring during the first two months (blanking phase).

Results

During follow-up, 12 out of 93 patients experienced recurrence of AF (12.9%; AF-Group). Baseline characteristics did not differ between AF-Group and Non-AF-Group. In contrast, LAS was significantly impaired in the AF-Group (median −4.6, IQR [−5.6 to −3.6]) when compared to the Non-AF-Group (−6.2 [−8.3 to −4.5]; p=0.009). The EAVM-% did not differ between the groups (AF-Group: 5.0 [1.5 to 21.5]; Non-AF-Group: 4.4 [1.5 to 15.9]; p=0.710). No significant correlations were found between LAS and EAVM-% (r=0.03, p=0.812). A cut-off value of −5.89% for LAS had a sensitivity of 100% and a specificity of 57% for AF recurrence (AUC=70%; p<0.001). Kaplan Meier curves for event-free survival were generated based on the LAS cut-off demonstrating excellent differentiation of those with and without AF recurrence (p<0.001; see figure). Furthermore, LAS was associated with an increased risk of early AF recurrence (HR 1.40, IQR [1.02–1.92], p=0.040), while EAVM-% was not (HR 0.99 [0.95–1.04], p=0.787).

Conclusion

3D LAS was associated with an increased risk of early AF recurrence after PVI, while EAVM-% was not. 3D LAS might be used for identifying patients who would benefit from PVI.

Funding Acknowledgement

Type of funding sources: None.
Benefits of interventional telemonitoring in patients with chronic heart failure
Authors: Matta A , Itier R , Fournier P , Massot-Rubio M , Rene M , Lecourt L , Galinier M , Roncalli J
Published: October 2022

Background

The aim of this study was to assess the effect of interventional specialized Telemonitoring (ITM) compared to standard telemonitoring (STM) and standard of care (SC) on preventing all causes of death, cardiovascular mortality and unplanned hospitalization in heart failure (HF) patients.

Methods and results

414 HF-patients derived from two French cohorts (OSICAT and ETAPES) were included in this study, and subsequently randomized into three groups ITM-group (n=220), STM-group (n=99) and SC-group (n=95). The telemonitoring was performed by the specialized HF-cardiology staff at a university hospital. During the mean follow-up period of 344 days, there were significantly fewer primary endpoints like unplanned hospitalization (13.6% vs 34.3% vs 36.8%, p<0.05), all-cause of death (4.5% vs 20.2% vs 16.8%, p<0.05) and cardiovascular mortality (3.2% vs 15.2% vs 8.4%, p<0.05) in the ITM-group. The multivariate logistic regression revealed a significant negative association between the ITM and unplanned hospitalization (OR=0.293 95% CI [0.160–0.535], p<0.05) and all-cause of death (OR=0.243 95% CI [0.099–0.596], p=0.002), respectively. Kaplan Meier and log rank test showed significant difference in median event-free survival in favor of ITM-group.

Conclusions

Using ITM to follow-up HF-patients results in reducing the rate of unplanned hospitalization and all cause of death.

Funding Acknowledgement

Type of funding sources: None.
A multidisciplinary program based on early care in a day hospital after heart failure hospitalizations. Reduction of 30-day readmissions in patients discharged from cardiology departments
Authors: Vaqueriza Cubillo D , Dominguez Munoa M , Beltran Herrera C , Gomez Mariscal E , Suberviola Sanchez-Caballero V , Martinez Losas P , Cortes Beringola A , Nogales Romo M T , Giganto Arroyo M L , Cano Moracho J M , Gomez Alvarez Z , Cortina Camarero C , Briongos Figuero S , Estevez Paniagua A , Munoz Aguilera R
Published: October 2022

Introduction and objectives

Readmission rates at 30 days after admission for heart failure (HF) are high. Patients admitted in Cardiology are usually younger and with lower comorbidity than the total population with HF. Our department leads a multidisciplinary program for the management of HF (MHFP), based on early post-discharge follow-up in a day hospital, for clinical-analytical assessment, optimization and titration of pharmacological treatment, structured education, promotion of self-care and intravenous treatment if appropriate. The objective of this study is to assess the impact of the MHFP on all cause 30-day readmission rate in our patients (MHFP group), compared with the rest of the Cardiology units in our region (control group).

Methods

All discharges with HF main diagnosis in our region were analyzed through anonymized consultation of the Minimum Basic Data Set (a public administrative data base) in the period 2009–2015. The first admission of each patient in the period was identified as index admission, excluding patients who died at that admission and selecting only discharges by Cardiology. Epidemiological characteristics, comorbidities and hospital length of stay were compared in the two groups. The outcome variable was the time to first readmission for any cause in the first 30 days after discharge from index admission. Quantitative variables were compared using Student's t and categorical variables with χ2. For the multivariate analysis, Cox method was used.

Results

We included 15,440 patients, 474 in the MHFP group and 14,966 in the control group. The epidemiological characteristics and main comorbidities were compared, and the results are shown in the table. Readmission rate was significantly lower in the MHFP group (9.9 vs 14.2%, HR 0.72, 95% CI: 0.54–0.96 in multivariate analysis). The variables independently associated with an increase in 30-day readmissions were the age-adjusted Charlson index and chronic kidney disease.

Conclusions

Over a period of 6 years, in patients with HF, discharged by Cardiology, a MHFP significantly reduced all cause 30-day readmissions.

Funding Acknowledgement

Type of funding sources: None.
A novel algorithm for rapid sequence optimization of guideline directed medical therapy for heart failure with reduced ejection fraction
Authors: Pandey A , Bonsignore A , Pandey A , Bonvanie I , Verma S
Published: October 2022

Introduction

Current guidelines for management of Heart Failure with Reduced Ejection Fraction (HFrEF) recommend Beta-blockers, Angiotensin Receptor Neprilysin Inhibitors (ARNI), Mineralocorticoid Receptor Antagonists (MRA) and SGLT2 inhibitors. However, guideline-directed medical therapies (GDMT) remain underutilized. The 2018 CHAMP-HF registry of HFrEF patients demonstrated that only 1% of patients were treated with target doses of Beta-blockers, MRA and ACE-inhibitors (ACE-I) and Angiotensin Receptor Blocker (ARB) or ARNI. Historically, HFrEF therapies were initiated and up-titrated sequentially. Recent expert commentary has suggested a more aggressive approach of initiating all 4 classes of therapy at low doses after which patients should be up-titrated to target dose

Purpose

This study tested a novel, virtual HFrEF optimization program with the goal of achieving GDMT using a novel “rapid sequence” algorithm.

Methods

We conducted a single center study at a regional cardiovascular centre using a prospective pre-post design. NYHA class II/III HFrEF patients referred from both inpatient and outpatient settings were enrolled in a virtual 3-month HFrEF optimization program. All participants underwent an initial consult with a program nurse and cardiologist. After this, all patients were seen remotely by a nurse every two weeks for adjustment of HFrEF medications. At week 1, patients started on ARNI and SGLT2i. After week 3, Beta-Blocker was initiated. After week 5, MRA was initiated. Following this, medications were up-titrated every two weeks, based on clinical judgement of the overseeing cardiologist. Vital signs and bloodwork were obtained after all medication adjustments. In addition, all patients were seen once weekly by a kinesiologist for lifestyle optimization and counselling.

Results

From April 2020 to January 2021, 297 NYHA class II/III HFrEF patients enrolled in the virtual HFrEF optimization program. Mean age was 69 and 63% were male. Mean ejection fraction was 28% and 54% had ischemic cardiomyopathy. At intake, the proportion of patients prescribed maximally-tolerated dosage was 64% for Beta-Blockers, 7% for MRA, 1% for ARNI and 1% for SGLT2i. At 3-month follow-up, maximally-tolerated dose was prescribed in 84% of patients for beta-blockers (p<0.01), 58% for MRA (p<0.01), 77% for SGLT2i (p<0.01) and 96% for ARNI (p<0.01). 39% of patients achieved maximal doses of all 4 classes of medications at follow-up. No medication-related adverse events were reported and 18 patients were hospitalized for HF exacerbation during study follow-up.

Conclusions

This study demonstrates that a program using aggressive GDMT initiation can safely and effectively improve uptake of therapy in HFrEF patients. Future research should examine HFrEF “rapid sequence” optimization on patient outcomes in a randomized setting.

Funding Acknowledgement

Type of funding sources: None.
Introduction of a new scoring tool to identify clinically stable heart failure patients
Authors: Gingele A , Brandts L , Brunner-La Rocca H P , Knackstedt C , Boyne J
Published: October 2022

Introduction

Heart failure (HF) poses a burden on specialist care, making referral of clinically stable HF patients to primary care a desirable goal. However, a structured approach to guide patient referral is lacking.

Methods

The Maastricht Instability Score–Heart Failure (MIS-HF) questionnaire was developed to objectively stratify the clinical status of HF patients: patients with a low MIS-HF (0–2 points, indicating a stable clinical condition) were considered for treatment in primary care, whereas high scores (>2 points) indicated the need for specialised care. The MIS-HF was evaluated in 637 consecutive HF patients presenting between 2015 and 2018 at Maastricht University Medical Centre.

Results

Of the 637 patients, 329 (52%) had a low score and 205 of these 329 (62%) patients were referred to primary care. The remaining 124 (38%) patients remained in secondary care. Of the 308 (48%) patients with a high score (>2 points), 265 (86%) remained in secondary care and 41 (14%) were referred to primary care. The primary composite endpoint (mortality, cardiac hospital admissions) occurred more frequently in patients with a high compared to those with a low MIS-HF after 1 year of follow-up [29.2% vs 10.9%; odds ratio (OR) 3.36, 95% confidence interval (CI) 2.20–5.14]. No significant difference in the composite endpoint (9.8% vs 12.9%; OR 0.73, 95% CI 0.36–1.47) was found between patients with a low MIS-HF treated in primary versus secondary care.

Conclusion

The MIS-HF questionnaire may improve referral policies, as it helps to identify HF patients that can safely be referred to primary care.

Funding Acknowledgement

Type of funding sources: None.
Association of baseline and longitudinal changes in cardiometabolic health with risk of heart failure among adults with type 2 diabetes: an analysis from the Look AHEAD trial
Authors: Pandey A P , Patel K V P , Khan M S K , Bahnson J L B , Garcia K R G , Clark J M C , Balasubramanyam A B , Bertoni A G B , Vaduganathan M V , Farkouh M E F , Januzzi Jr J L J , Verma S V , Espeland M E
Published: October 2022

Background

Type 2 diabetes (T2D) is characterized by co-morbid cardiometabolic abnormalities and elevated heart failure (HF) risk.

Purpose

The purpose of this study was to evaluate the associations of baseline and longitudinal changes in cardiometabolic health with risk of HF among adults with T2D.

Methods

Adults with T2D enrolled in the Look AHEAD (Action for Health in Diabetes) trial without prevalent HF were included. Adjusted Cox models were used to create a cardiometabolic health score incorporating target levels of parameters weighted based on relative risk for HF. The associations of baseline, 1- and 4-year changes in the cardiometabolic health score with risk of overall HF, HF with preserved ejection fraction (HFpEF; EF≥50%), and HF with reduced EF (HFrEF; EF<50%) were assessed using adjusted Cox models.

Results

Of the 5,080 participants included, there were 257 incident HF events during 12.4-year follow-up. The cardiometabolic health score included 2-points each for target levels of waist circumference, glomerular filtration rate, urine albumin-to-creatinine ratio and 1-point each for blood pressure and hemoglobin A1c at target (Table 1). Higher baseline cardiometabolic health score was significantly associated with lower risk of overall HF (adjusted hazard ratio [aHR] per 1-unit higher score, 0.72 [95% CI, 0.66–0.79]) with similar associations observed for HFpEF and HFrEF (Table 2). Improvement in cardiometabolic health over 1- and 4-years was significantly associated with lower risk of overall HF (aHR per 1-unit increase in score at 1- and 4-years, 0.82 [95% CI, 0.73–0.92] and 0.80 [95% CI, 0.70–0.91], respectively).

Conclusions

Among adults with T2D, achieving target levels of more cardiometabolic health parameters at baseline and sustained improvements were associated with lower HF risk.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Diabetes and Digestive and Kidney Diseases
1-year hospital readmissions due to cardiovascular causes after a heart failure episode in elderly patients in Spain
Authors: Esteban Fernandez A , Anguita M , Bonilla J L , Anguita M , Ruesgas R , Molina M , Garcia M , Bernal J L , Del Prado N , Fernandez Perez C , Marin F , Perez Villacastin J , Gomez Doblas J J , Fernandez Rozas I , Elola F J
Published: October 2022

Background

The prevalence of heart failure (HF) increases with age, one of the leading causes of hospitalization and death in the elderly. However, there are little data about the long-term readmission rate of elderly patients after an episode of HF admission in Spain.

Purpose

Study 1-year hospital readmissions due to cardiovascular causes in patients ≥75 years discharged to a hospital due to HF in Spain.

Methods

We performed a retrospective analysis of the Minumum basic dataset of Spain, including all episodes of HF discharged from public hospitals in Spain between 2016 and 2019. The codification was made with ICD-10. We selected patients ≥75 years with HF as the principal diagnosis. We analyzed predictors of readmissions 365 days after the index episode of HF hospitalization with Poisson regression.

Results

236,463 index episodes of HF in>75 years were included. 59.1% were female, and the mean age was 85 (SD 5.6) years. 35.0% had HF-pef, 4.3% HF-ref, and 60.7% had unknown LVEF HF.

39.6% of patients had at least one readmission (mean 1.7 readmissions by year for these patients), with no differences in sex or age. Patients with non-cardiovascular comorbidities (renal failure, chronic lung disorders, and severe hematological disorders) as well as coronary atherosclerosis and diabetes were more likely to be readmitted (Table 1).

Conclusions

After a hospital discharge for HF in patients ≥75 years, the crude ratio of readmission due to cardiovascular causes at 1-year was 39.6%. Readmissions were more likely in patients with non-cardiovascular comorbidities, predominantly renal, hematological, and chronic respiratory disorders, and those with diabetes and coronary atherosclerosis.

Funding Acknowledgement

Type of funding sources: None.