bluuebunny/crossref_metadata_2025_split huggingface dataset:
P219 IS DISPROPORTIONALITY ENOUGH TO IDENTIFY CANDIDATES FOR PERCUTANEOUS MITRAL VALVE REPAIR? A CLINICAL CASE
Authors: Carassia C , Mennuni M , Degiovanni A , De Vecchi S , Erbetta R , Patti G 
Published: May 2022

Abstract
Functional mitral regurgitation (FMR) is defined as regurgitation with structurally normal leaflets secondary to the distortion of the LV in the context of dilated cardiopathy. The conflicting results emerged from the MITRA–FR and COAPT trials have raised a new interest in the individuation of “primary–like” components of MR. In this scenario, a binary classification in proportionate and disproportionate FMR has been proposed by Garland et al. When the MR is completely due to LV remodeling, they observed a linear relationship between ERO and LVEDV, defining a proportionate FMR; on the other side, when the ERO is superior to the expected one, the FMR is considered as disproportionate, and it may benefit from TEER on top of GMDT. However, the Garland’s model may not explain the full complexity of MV apparatus and FMR. We present the case of a 75–years–old woman diagnosed with dilated cardiopathy of ischemic origin, known since 2008. In 2021 she started receiving multiple hospitalizations for acute decompensation of HF with dyspnoea and symptoms of hypoperfusion, such as AKI on top of CKD and hypotension. The TOE showed a severe LV dysfunction and a moderate dilation of the left ventricle (EF 19%, LVEDVi 90 ml/m2), with a severe FMR secondary to annular dilation and retraction with tethering of the posterior leaflet (MR ERO 0,27 cm2, VC 0,67 cm, RV 45 ml). In order to improve symptoms she underwent TEER with implantation of one Edwards Pascal device at the level of A2–P2, with good results and a mild residual MR. Basing on the Garland’s model our patient would have been classified as proportionate FMR, with no benefit from TEER. However, removing MR component from the heart disease, she improved her stroke volume and her systolic function, allowing a better peripheral perfusion, as showed by an increase in renal function and in arterial pressure during follow–up, which allowed an introduction ad up–titration of Sacubitril/Valsartan, impossible before TEER. At the same time TEER decreased pulmonary pressures improving dyspnoea and functional status (she was NYHA II–III at the 6 month follow–up). In conclusion, the binary model of proportionality has the strength of being easy–to–use and of easily recognizing a primary–like MR that can benefit from TEER; however, proportionate FMR probably includes different pathophysiological mechanisms of disease, requiring an ultra stratification to better identify cases where TEER may increase survival.
P225 RESPIRATORY FAILURE AND BIOELECTRICAL PHASE ANGLE ARE INDEPENDENT PREDICTORS FOR LONG–TERM SURVIVAL IN ACUTE HEART FAILURE
Authors: Scicchitano P , Potenza A , Basile M , Piscopo A , Landriscina R , Sasanelli P , Trotta F , Sanasi M , Paolillo C , Ciccone M , Caldarola P , Massari F 
Published: May 2022

Abstract

Background
The assessment of long term mortality in acute decompensated heart failure (ADHF) is challenging. Respiratory failure and congestion play a fundamental role in risk stratification of ADHF patients. The aim of this study was to investigate the impact of arterial blood gases (ABG) and congestion on long–term mortality in patients with ADHF.

Methods and Results
We enrolled 252 patients with ADHF. Brain natriuretic peptide (BNP), blood urea nitrogen (BUN), phase angle as assessed by means of bioimpedance vector analysis (BIVA), and ABG analysis were collected at admission. The endpoint was all–cause mortality. At a median follow–up of 447 days, (IQR: 248–667), 72 patients died 1–840 days (median 106, IQR: 29–233) after discharge. Respiratory failure types I and II was observed in 78 (19%) and 53 (20%) patients, respectively. The ROC analyses revealed that the cut–off points for predicting death were: &gt;441 pg/mL for BNP, &gt;30 mg/dL for BUN, ≤ 69.7 mmHg for partial pressure in Oxygen (PaO2), and ≤4.9° for Phase Angle. Taken together, these four variables proved to be good predictors for long–term mortality in ADHF (AUC 0.78, 95% CI 0.72–0.78), thus explaining 60% of all deaths. A multiparametric score based on these variables was determined: each single–unit increase promoted a 2.2–fold augmentation of the risk for death (HR 2.2, 95% CI 1.8–2.8, P &lt; 0.0001).

Conclusions
A multiparametric approach based on measurements of BNP, BUN, PaO2, and phase angle is a reliable approach for long–term prediction of mortality risk in patients with ADHF.
P226 LONGITUDINAL EVALUATION OF CONGESTION AND RENAL FUNCTION IN ADVANCED HEART FAILURE PATIENTS TREATED WITH A LEFT VENTRICULAR ASSIST DEVICE
Authors: Zucchetti O , Iacovoni A , Vittori C , Abete R , Terzi A , Campo G , Senni M 
Published: May 2022

Abstract

Introduction
In patients affected by advanced heart failure (advHF) long term mechanical support with left ventricular assist devices (LVADs) is a established therapeutic option. Congestion and renal function in pts treated with a LVAD require expert management.

Aim
Describe the longitudinal trend of congestion and renal function during a 12th follow–up in advHF pts treated with a LVAD, examine the correlation between congestion and renal function, study predictors of sustained improvement of congestion and renal function.

Methods
retrospective single–centre analysis of 39 pts treated with a LVAD and followed in ASST–PG23 Hospital for at least 12 months. Biochemical, echocardiographic and clinical parameters were collected at specific time points from baseline to 12 months after hospitalization during which a LVAD was implanted. Congestion was studied with BNP, bilirubin, haematocrit and daily diuretics dosage. Renal function was studied with absolute changes of eGFR (Cockcroft–Gault). Primary endpoint was sustained improvement of congestion and renal function, derived after comparing baseline pre–LVAD and 12th month parameters.

Results
congestion improved early after LVAD implantation, with steep and high reduction of BNP, bilirubin and daily diuretics dosage. The improvement was higher in those pts with a baseline BNP&gt;median. Bilirubin, haematocrit and daily diuretics dosage showed statistically significant correlations with BNP. Sustained improvement of congestion was present in 59% pts, in particular in those with higher baseline BNP (p = 0.04 after χ²–test). Renal function showed an early steep improvement from baseline pre–LVAD to discharge, more significant in those pts with baseline CKD; during the following months renal function did not show significant changes. Sustained improvement of renal function was present in 54% pts, in particular in those with baseline CKD (p = 0.002 after χ²–test). No significant correlations were found after comparing the trend of congestion and renal function. At multivariable logistic regression, no significant predictors were found for sustained improvement of congestion or renal function.

Conclusions
A multiparametric evaluation of congestion in pts with a LVAD is feasible. The benefit derived from LVAD support appears to be higher in those pts with a baseline higher risk, both in term of congestion and renal function. No significant correlation between the trend of congestion and renal function was found.
P227 DOES NITROPRUSSIDE TEST BEHAVE AD AN INCREMENTAL PROGNOSTIC FACTOR IN SELECTION OF PATIENTS CANDIDATE TO LVAD IMPLANTATION?
Authors: Cusenza V , Pidello S , Frea S , De Ferrari GM 
Published: May 2022

Abstract

Background
Left ventricular assist device in the last two decades has been used to improve survival and quality of life of patients suffering from heart failure, regardless presence of concomitant pulmonary hypertension. Most patients showed improvement in pulmonary pressure. Current clinical practice lacks a reliable method for prediction of reverse remodelling and prognosis.

Aim
of this study is to investigate the possible role of nitroprusside test as prognostic factor in candidates to LVAD implantation.

Methods
We conducted a monocentric prospective observational study analysing 31 consecutive patients implanted with LVAD between July 2013 and October 2021 that underwent right heart catheterization and nitroprusside test before implantation. Basal and nitroprusside–obtained hemodynamic parameters were subsequently correlated with the primary outcome, defined as the composite of death and episodes of right ventricular failure.

Results
Mean age of study population was 58,6 ± 7,97 years, 12,9% were female. Most prevalent INTERMACS class was 3 and mean EF was 18 ± 4,92 %. Mean follow–up was 31,3 ± 20,4 months, during which 11 death and 14 episodes of RVF occurred. At basal hemodynamic assessment, patients with pulmonary vascular resistance above 3 WU had a significant higher rate of events (50% vs 9%, Likelihood ratio 5.7, p = 0.029). No hemodynamic parameter measured after nitroprusside infusion was found to predict survival or episode of RVF.

Conclusion
In this exploratory study we have shown that nitroprusside infusion does not add further prognostic information when compared with basal hemodynamic parameters.
P231 PULMONARY ARTERY WEDGE PRESSURE VS LEFT VENTRICULAR END–DIASTOLIC PRESSURE DURING EXERCISE IN PATIENTS WITH UNEXPLAINED DYSPNEA
Authors: Caravita S , Baratto C , Gallone G , Faini A , Céline D , Sganzerla P , Perego G , Muraru D , Iacovoni A , Senni M , Badano L , Vachiéry J , Parati G 
Published: May 2022

Abstract

Background
Left ventricular end–diastolic pressure (LVEDP) approximates LV stiffness. Pulmonary artery wedge pressure (PAWP) reflects the hemodynamic load imposed by the left heart on the pulmonary circulation, with the interposition of the left atrium (LA). PAWP is frequently seen as a surrogate measure for LVEDP, but the two measures may not coincide. The imprecision of PAWP estimates for LVEDP and the disagreement between the two measures have been widely described for cardiac catheterization at rest. PAWP measurement during exercise has been advocated to discriminate heart failure with preserved ejection fraction (HFpEF) from non–cardiac dyspnea (NCD), with an end–expiratory pathologic threshold ≥25 mmHg. However, a formal comparison of PAWP vs LVEDP during exercise has never been performed. Aim. We sought to compare LVEDP and PAWP during exercise.

Methods
We retrospectively analyzed consecutive patients with unexplained dyspnea and a normal LV ejection fraction, who performed right and left heart catheterization at rest and during exercise.

Results
Forty–six consecutive patients were included in the analysis (80% with a peak PAWP ≥25 mmHg). We found a good correlation between both end–diastolic and mean PAWP on one side, and LVEDP on the other side (R2&gt;0.55). End–expiratory, end–diastolic (mid–A) peak PAWP had no bias as compared with LVEDP, while mean PAWP slightly overestimated LVEDP by 1–2 mmHg. However, confidence intervals were quite large (Figure 1), suggesting imprecision of PAWP estimates for LVEDP. A disagreement between PAWP and LVEDP, using a threshold of ≥ 25 mmHg for both variables at peak exercise, was found in 11% of patients. In 4%, PAWP was ≥25 but LVEDP &lt;25 mmHg, due to the appearance of tall V waves in the PAWP position (increased LA stiffness), increasing PAWP above LVEDP. In 7%, LVEDP was ≥25 but PAWP &lt;25 mmHg. Those patients would have not been diagnosed as HFpEF based on peak PAWP alone. However, they had a PAWP increase during exercise relative to cardiac output changes (PAWP/CO slope) &gt;2 mmHg/L/min, as an alternative parameter confirming HFpEF.

Conclusions
PAWP estimates for LVEDP during exercise bear a good correlation and a minimal bias, albeit being burdened by a relevant imprecision. In patients with unexplained exertional dyspnea and peak PAWP &lt;25 mmHg, additional measures (including LVEDP or PAWP/CO slope) may be indicated in order to maximize the diagnostic yield of exercise cardiac catheterization.
P232 EXERTIONAL BREATHLESSNESS IN HYPERTROPHIC CARDIOMYOPATHY: OBSTRUCTION–INDEPENDENT SYMPTOMS IN A “PARADOXICAL” RESPONSE TO EXERCISE
Authors: Baratto C , Caravita S , Crotti L , Villella F , Rella V , Cecchi F , Badano L , Parati G , Perego G 
Published: May 2022

Abstract
A 66–y.o. man with hypertrophic cardiomyopathy presented with residual exertional dyspnea NYHA III a few years after surgical myectomy, mitral valve repair and ICD implantation. Echocardiography showed residual mild septal hypertrophy and mitral regurgitation (MR), and a variable obstruction of left ventricular outflow tract (LVOT), witnessed by a pressure gradient ranging from 15 to 50–70 mmHg (Figure 1). Exercise echocardiography did not suggest exercise–induced LVOT obstruction (LVOTO) or functional MR. We thus performed a thorough invasive hemodynamic evaluation at rest and during exercise. LVOTO was present at rest, with a maximum pressure gradient of 90–100 mmHg and typical “spike–and–dome” configuration of the aortic pulse contour (Figure 2), with LV end–diastolic pressure (LVEDP) at the upper limit of normal (15 mmHg) and normal pulmonary hemodynamics. During exercise, we observed a paradoxical reduction of the LVOTO (30–40 mmHg at peak, Figure 2). Pulmonary hypertension developed during exercise, due to LV diastolic dysfunction, witnessed by a marked increase in pulmonary artery wedge pressure and LVEDP (up to 25 mmHg and 30 mmHg at peak, respectively). Cardiac output (CO) reserve was at the lower limits of normal, mainly due to chronotropic incompetence, responsible for a mildly reduced exercise capacity (peak oxygen consumption was 20 mL/Kg/min, 75% of predicted). Thus, cardiac catheterization confirmed the presence of a relevant LVOTO at rest, that was not directly related to exertional symptoms. These latter were mainly attributable to LV diastolic dysfunction and reduced CO reserve. These findings helped us driving treatment decision in a tailored way: beta–blockers were not uptitrated, because of their negative inotropic effect, and high–risk septal reduction therapies were excluded, since exertional symptoms were unrelated to LVOTO. However, an attempt to reduce LVOTO was done by DDD sequential pacing through the ICD. Pacing could induce mechanical dyssynchrony and reduce LVOTO by increasing the end–systolic LVOT diameter. The simultaneous echocardiographic monitoring highlighted an acute reduction of LVOT gradient from 50–70 mmHg to 20–30 mmHg (Figure 3).
This case suggests that, in well–selected cases, patients’ management based on pathophysiological reasoning may help to define the etiopathogenetic mechanism underlying symptoms, and to drive treatment decision in a patient–centered way.
P237 INFLUENCE OF HEART RATE ON LEFT AND RIGHT VENTRICULAR LONGITUDINAL STRAIN IN PATIENTS WITH CHRONIC HEART FAILURE
Authors: Di Terlizzi V , Barone R , Manuppelli V , Correale M , Casavecchia G , Goffredo G , Pellegrino P , Puteo A , Ieva R , Di Biase M , Brunetti N , Iacoviello M 
Published: May 2022

Abstract

Background
Myocardial deformation evaluated by two–dimensional speckle tracking echocardiography (STE) is a useful tool to evaluate both left and right ventricular function. However, there are no conclusive data about the relationship between strain measures and heart rate (HR).

Aim of the Study
To analyse changes in left (LV) and right ventricular (RV) longitudinal strain associated with variations of HR in patients with and without chronic heart failure (CHF). Methods. We enrolled 45 patients. Of the 38 patients diagnosed with CHF, 21 were carrying an ICD (Group 1), and 17 an ICD with CRT (Group 2). Group 3 included 7 participants without CHF with sinus node dysfunction that were carrying a pacemaker. The frequency of atrial stimulation was increased to 90 beats/min and an echocardiogram was performed at each increase of 10 beats/min. Global LV and RV longitudinal strain (LVGLS and RVGLS, respectively) and RV free wall longitudinal strain (RVfwLS) were calculated at each HR, together with other echocardiographic parameters. Worsening or improvement of strain measures was defined as a relative change from baseline of 10%.

Results
The reproducibility of strain measurements was assessed in all the images obtained at the different HRs for 19 of the study participants. A high degree of reproducibility was observed for LVGLS (ICC = 0.96; 95% CI, 0.93 – 0.97) as well as for RVGLS (ICC = 0.91; 95%CI, 0.86 – 0.94) and RVfwLS (ICC = 0.91; 95%CI, 0.85 – 0.94). When analysed as continuous variables, significant reductions in LVGLS were detected at higher HRs, whereas improvements in both RVGLS and RVfwLS were observed (left panels of the figure). Patients with worsening of LVGLS (76% overall) were more likely to present lower baseline LV function and maximum relative changes of LVGLS correlated significantly with the E/e’ ratios (r = –0.56; p &lt; 0.001). Only few patients (18% for RVGLS and 16% for RVfwLS) exhibited HR–related worsening of RV strain measures, which was associated with lower levels of baseline RV function and higher pulmonary systolic pressures. Finally, 21 (47%) and 25 (56%) of the participants responded with improvements in RVGLS and RVfwLS, respectively. Right panels of the figure show the trend of left and right measures in the different groups.

Conclusions
Our findings revealed heterogeneous RV and LV responses to increases in HR. These findings might ultimately be used to optimize cardiac functionality at rest in patients diagnosed with CHF.
P239 TOLERABILITY OF SACUBITRIL/VALSARTAN TREATMENT IN OLDER PATIENTS WITH HEART FAILURE WITH REDUCED EJECTION FRACTION: PRELIMINARY DATA FROM THE REAL–WORLD AGING–HF REGISTRY
Authors: Herbst A , Orso F , Camartini V , Virciglio S , D‘Errico G , Salucci C , Verga F , Fattirolli F , Marchionni N , Di Bari M , Ungar A , Baldasseroni S 
Published: May 2022

Abstract

Background
Although older patients with heart failure (HF) with reduced ejection fraction enrolled in PARADIGM–HF showed a good tolerance to sacubitril/valsartan (Sa/Va), more real–word data are needed to define their tolerability in this population. Aim: To describe the Sa/Va tolerability and titration in older HFrEF patients followed by our HF outpatient.

Methods
HFrEF patients aged ≥65 years and treated with Sa/Va from November 2016 to June 2021 were enrolled, assessing Sa/Va tolerability at six months and its clinical and hemodynamic effects.

Results
We enrolled 101 patients with a mean age of 78 years (⁓20% female). The aetiology was ischemic in 59% of cases while the mean ejection fraction was 31%. Sa/Va was prescribed at the starting dose (24/26mg) and intermediate dose (49/51mg) in 91% and 9% of cases, respectively. After six months, 9 of the 100 patients still alive had discontinued treatment with Sa/Va (4 for symptomatic hypotension, 3 for suspected allergic reaction and 2 for worsening renal function). Of the 91 patients still on therapy, only 17 had reached the target dose (97/103mg) while 28 were at the intermediate dose (Figure 1). Symptomatic hypotension (62%), hyperkalaemia (15%) and worsening of renal function (4%) were the main causes of maintaining Sa/Va therapy at the starting dose; note, in 15% of cases a specific cause of non–titration was not identified. Comparing HF treatment between starting dose vs higher–dose patients, after six months in low–dose patients there was a slight improvement in mineralcorticosteroid receptor antagonist (MRA) prescription and in combination therapy (Sa/Va, beta–blocker and MRA) while in patients at higher–doses there was a significant decrease (Figure 2). In patients still receiving Sa/Va, significant clinical improvement was observed while renal function, K+ levels and systolic blood pressure remained stable (Figure 3).

Conclusions
After six months of treatment, Sa/Va was well tolerated in most of our older patients and used in combination with a beta–blocker and an MRA in a high percentage of cases, although a reduction in MRA prescription is observed in patients taking higher dosages of Sa/Va. In addition, there was a marked improvement in the clinical variables.
P250 PROTOCOL FOR TELEHEALTH EVALUATION AND FOLLOW–UP OF PATIENTS WITH CHRONIC HEART FAILURE DURING THE COVID–19 PANDEMIC
Authors: D‘Errico G , Herbst A , Orso F , Baldasseroni S , Fattirolli F , Virciglio S , Camartini V , Di Bari M , Marchionni N , Ungar A , Salucci C , Verga F 
Published: May 2022

Abstract

Background
After the lockdown imposed by the COVID19 pandemic, physicians had to limite ambulatory visits to exceptional cases to reduce interpersonal contact. We structured a telephone follow–up developing a standardized 23 item questionnaire to administrate to our HF outpatient clinic and from whom we obtained the Covid–19–HFscore.

Methods
The patients were identified by a numeric code, date of birth and gender. The questionnaire was designed for rapid administration during telephone interview (on average 6 minutes) and was administered directly by physicians to patients and/or to their caregiver. It was built to reproduce our usual clinical evaluation.

Results
As shown in Figure 1, we investigated seven domains: 1) social and functional condition 2) mood 3) adherence to pharmacological and non–pharmacological recommendations (blood pressure, heart rate, weight monitoring and fluid intake control) 4) clinical and hemodynamic status 5) recording of laboratory tests 6) current pharmacological treatment 7) recent evaluation by family physician or need to contact emergency services followed or not by hospitalisation. General and pharmacological recommendations as well as the following telephone contact were finally recorded. To determine the timing of the next telephonic evaluation, we decided to weight questions regarding clinical and hemodynamic status, adherence to pharmacological and non–pharmacological recommendations, therapeutic changes and need for hospitalisation by scoring the answers (from 1 to 3) to build a score. The sum of individual scores represented the novel TeleHFCovid19–score, ranging from 0 to 29. Based on such score, three groups of patients were identified by arbitrary cut–off levels: the green (score &lt;4), the yellow (score 4–8) and the red (score ≥9) group, for which next telephonic evaluation was planned respectively after four, two and one week respectively. Alternatively, the red group could receive recommendation for urgent hospital evaluation.

Conclusion
During this emergency situation this questionnaire could be a useful clinical tool to help physicians maintaining a regular FU of their patients and identifying patients at greatest risk of imminent instability. Furthermore, this instrument could also represent a useful resource in the management of low–risk HF patients.