Advanced Chronic Heart Failure Patients Research Articles

Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure.

Central Illustration : Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure Transcatheter devices for monitoring and treating advanced chronic heart failure patients. PA: pulmonary artery; LA: left atrium; AFR: atrial flow regulator; TASS: Transcatheter Atrial Shunt System; VNS: vagus nerve stimulation; BAT: baroreceptor activation therapy; RDN: renal sympathetic denervation; F: approval by the American regulatory agency (FDA); E: approval by the European regulatory agency (CE Mark). Innovations in devices during the last decade contributed to enhanced diagnosis and treatment of patients with cardiac insufficiency. These tools progressively adapted to minimally invasive strategies with rapid, widespread use. The present article focuses on actual and future directions of device-related diagnosis and treatment of chronic heart failure.

Systemic immune-inflammation index as a prognostic marker for advanced chronic heart failure with renal dysfunction.

We aim to investigate the correlation between high levels of the systemic immune-inflammation index (SII) and long-term mortality and major cardiovascular adverse events in advanced chronic heart failure patients with renal dysfunction. Seven hundred seventeen advanced chronic heart failure patients with renal dysfunction, who visited the First affiliated hospital of Zhengzhou University from September 2019 to December 2020, were included. All-cause mortalities (ACM) were selected as primary endpoints and major cardiovascular adverse events (MACEs) as the secondary endpoints. Based on the receiver operating characteristic (ROC) curve and the Youden index, the optimal cut-off values of SII for ACM and MACEs were 1228 and 1406. In the group where ACM were the primary endpoint, patients were categorized into the low-SII group (n=479) and the high-SII group (n=238). Patients in the group using MACEs as the secondary endpoint were also categorized into the low-SII groups (n=514) and the high-SII groups (n=203). Univariate and multivariate COX regression were used to screen the independent predictors for ACM and MACEs, revealing the relationship between SII levels and endpoints. According to the univariate COX analysis, SII was the risk factor (hazard ratio [HR]=2.144, 95% confidence interval [CI]: 1.565-2.938, P<0.001) for the ACM subgroup. It was also the risk factor (HR=1.625, CI: 1.261-2.905, P<0.001) for the MACEs subgroup. Multivariate COX regression analysis indicated that the occurrence of ACM and MACEs in high-level SII and low-level SII patients had statistical differences. The incidence of ACM increased by 70.3% (HR=1.703; 95% CI: 1.200-2.337; P=0.002) in patients of the high SII level group, the incidence of MACEs increased by 58.3% (HR=1.583, 95% CI: 1.213-2.065, P=0.001). Kaplan-Meier (K-M) survival analysis further suggested that patients with a high SII level had an increased risk of having ACM (log-rank P<0.001) and MACEs (log-rank P<0.001) within 30months. SII could be considered as a novel predictor of the occurrence of ACM and MACEs for patients with advanced chronic heart failure and renal dysfunction. This study suggested that SII is a novel independent predictor of mortality in advanced chronic heart failure patients with renal dysfunction, and it should be considered in current clinical management.

Clinical Effects of CD34+ Cell Therapy in Advanced Chronic Heart Failure Patients Listed for Heart Transplantation

Purpose Data on cell therapy in heart failure patients listed for heart transplantation (HTX) are lacking. We sought to investigate the clinical effects of CD34+ cell therapy in this patient cohort. Methods In a single-center retrospective study we analysed data of all patients listed for heart transplantation between 2007 and 2017. Pediatric patients ( Results At the time of HTX listing the two groups did not differ in age (56±7 years in Group A vs. 54±10 years in Group B, P=0.24), gender (male: 100% vs. 80%, P=0.12), heart failure etiology (ishemic; 44% vs. 39%; P=0.55), history of hypertension (61% vs. 59%; P=0.99), renal dysfunction (33% vs. 23%, P=0.46) or diabetes (26% vs 24%, P=0.80). Left ventricular ejection fraction (LVEF: 22±3% vs. 24±4%, P=0.15) and NT-proBNP levels (3524±3821 pg/mL vs. 4048±3482 pg/mL, P=0.64) were also not different between the two groups. Within 1 year after HTX listing patients in both groups did not differ in rates of HTX (48% in Group A vs. 50% in Group B, P=0.88), LVAD implantation (0% in Group A vs. 4% in Group B, P=0.25), or total mortality (3% vs. 10%; p=0.16). However, in Group A, 24% of patients were delisted due to clinical improvement; compared to only 9% of patients in Group B (P=0.005). At the time of HTX listing, the delisted patients displayed similar clinical characteristics than the remaining cohort (LVEF: 22±2% in the delisted vs. 23±4% in the remaining cohort, P=0.67; NT-proBNP: 2822±1198 pg/mL vs. 3983±3927, P=0.45, ishemic heart failure etiology: 43% vs. 39%, P=0.77, history of hypertension: 61% vs. 58%; P=0.82; renal dysfunction: 31% vs. 25%, P=0.44 or diabetes: 20% vs 27%, P=0.52). On multivariate analysis, cell therapy was an independent correlate of delisting (P=0.002). Conclusion CD34+ cell therapy appears to be associated with beneficial clinical outcomes and increased rates of delisting in advanced heart failure patients awaiting heart transplantation.

Abstract 15719: Levosimendan Improves Liver Function in Patients With Advanced Chronic Heart Failure

Introduction: Although there is evidence of beneficial effects of levosimendan on heart and renal function in patients with advanced chronic heart failure, the impact of levosimendan on liver function remains undefined. Hypothesis: We investigated the effects of levosimendan on liver function in patients with advanced chronic heart failure. Methods: We enrolled 299 patients with chronic heart failure (NYHA class 3) and left ventricular ejection fraction &lt;30%, aged between 18 and 80 years. 150 patients were randomized to receive levosimendan (0.1 mcg/kg/min infusion for 24 hours; LS Group), and 149 received no levosimendan (Controls). Liver function was evaluated at baseline and again at 3 months by measuring total bilirubin, direct bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (gGT) and lactate dehydrogenase (LDH). Results: At baseline, the groups did not differ in age (59±11 years in LS Group vs. 60±10 years in Controls; P=0.74), sex (male: 77% vs. 75%; P=0.36), heart failure etiology (ischemic: 45% vs. 47%; P=0.64), left ventricular ejection fraction (27±2% vs. 26±3%; P=0.97), and plasma NT-proBNP levels (4758±3912 pg/mL vs. 5111±4271 pg/mL; P=0.71). Liver function tests of both groups at the time of enrollment were comparable. At 3 months we found a significant improvement in liver function in LS Group, but not in Controls, with a decrease in total bilirubin (21.9±16.4 μmol/L to 18.5±13.1 μmol/L in LS Group vs. 22.1±17.1 μmol/L to 22.0±17.3 μmol/L in Controls; P&lt;0.001), direct bilirubin (8.6±6.4 μmol/L to 7.1±5.2 μmol/L vs. 8.7±6.6 μmol/L to 8.8±6.7 μmol/L; P&lt;0.001), AST (1.18±0.98 μkat/L to 0.42±0.40 μkat/L vs. 1.16±0.92 μkat/L to 1.15±0.87 μkat/L; P=0.03), ALT (0.73±0.71 μkat/L to 0.50±0.49 μkat/L vs. 0.75±0.77 μkat/L to 0.74±0.70 μkat/L; P=0.006), gGT (2.25±2.30 μkat/L to 1.87±1.94 μkat/L vs. 2.23±2.18 μkat/L to 2.22±2.16 μkat/L; P=0.003) and LDH (3.66±2.46 μkat/L to 3.36±1.96 μkat/L vs. 3.58±2.77 μkat/L to 3.62±2.82 μkat/L; P=0.006). Conclusions: Levosimendan appears to improve long-term liver function in advanced chronic heart failure patients. Thus, repetitive levosimendan infusions may potentially slow the progression of cardio-hepatic syndrome to cardiac cirrhosis.

The unsurpassed value of cardiopulmonary exercise testing in assessing the prognosis of heart failure

Abstract Introduction Cardiopulmonary exercise testing (CPET) has become an important clinical tool to predict outcome in patients with chronic heart failure (CHF) and help to select candidates for heart transplantation (HTx) or left ventricular assist devices (LVAD). Purpose To evaluate CPET measurements in advanced CHF patients that are being considered for HTx or LVAD and its association to early mortality regardless of the performed procedure. Methods Maximum intensity CPET was performed on a treadmil and ramp protocol in 65 patients with patients with CHF and reduced ejection fraction, NYHA functional classes III and IV between 2012 and 2018. Measurements derived from CPET were the following: peak V'O2, VO2 at the anaerobic threshold (AT), percentage of the VO2 of the anaerobic threshold in relation to the peak, the VE/VCO2 slope, maximum heart rate (HR), respiratory quotient (R), oxygen kinetics, circulatory power (CP), the recovery HR in the first minute and the oxygen uptake efficiency slope (OUES) and the relation (VE/VCO2 slope)/VO2 peak. Results Seventy-four percent were male. Mean age of 67±12 years. Amost half (47%) had ischemic etiology. There were no complications related to CPET. Ten patients were transplanted, six had an intracorporeal LVAD implanted and the reminder (49 patients) were kept in supervised physical rehabilitation program. There were 11 deaths, 2 in HTx, 2 in LVAD, 7 in the rehabilitation group. Mean follow-up among the survivors was 43 months ± 40.6 and it was 12.1±10.3 months in those who died. CPET derived measurements between survivors and non-survivors were as follows: V'O2 peak (mL kg–1 min–1): 12.6±4.6 and 8.6±2.7 (p=0.002); the VO2 AT (mL kg–1 min–1): 9.9±3.3 and 6.1±3.0 (p=0.002); VE/VCO2 slope: 34.2±12.1 and 68.1±68.7 (p=0.0003); R peak: 1.1±0.2 and 1.0±0.1 (p=0.009); t1/2, in seconds: 135.8±47.9 and 170.1±82.0 (p=0.03); HR at the first minute 16.6±13 and 7±5 (p=0.009); OUES (L min–1): 1.1±0.4 and 0.9±0.3 (p=0.04) and CP [(ml O2 kg–1 min–1) mmHg] 1.516.2±689. 3 and 960.6±363.6 (p=0.005). and the relation (VE/VCO2 slope)/V'O2 peak were 3.2±2.0 and 11.4±19.5 (p=0.001), respectively. Conclusion The predisposition to early death could be stratified by V'O2 peak, VO2 of the ventilatory threshold, VE/VCO2 slope, t1/2, recovery HR, OUES, CP, and by the relation (VE/VCO2 slope)/V'O2 peak. Funding Acknowledgement Type of funding source: Private hospital(s). Main funding source(s): own financing

Clinical Effects of CD34+ Cell Therapy in Advanced Chronic Heart Failure Patients Listed for Heart Transplantation

Data on cell therapy in heart failure patients listed for heart transplantation (HTX) are lacking. We sought to investigate the clinical effects of CD34+ cell therapy in this patient cohort. In a single-center retrospective study we analysed data of all patients listed for heart transplantation between 2007 and 2017. Pediatric patients (<18 years), patients with congenital heart disease, mechanical circulatory support, and patients awaiting multi-organ transplantation were excluded. Of 372 patients included, 33 patients (Group A) received CD34+ cell therapy, and 339 (Group B) received optimal medical management. Patients were followed for 1 year; the primary end-point was the rate of delisting from HTX elective waiting list. At the time of HTX listing the two groups did not differ in age (56±7 years in Group A vs. 54±10 years in Group B, P=0.24), gender (male: 100% vs. 80%, P=0.12), heart failure etiology (ishemic; 44% vs. 39%; P=0.55), history of hypertension (61% vs. 59%; P=0.99), renal dysfunction (33% vs. 23%, P=0.46) or diabetes (26% vs 24%, P=0.80). Left ventricular ejection fraction (LVEF: 22±3% vs. 24±4%, P=0.15) and NT-proBNP levels (3524±3821 pg/mL vs. 4048±3482 pg/mL, P=0.64) were also not different between the two groups. Within 1 year after HTX listing patients in both groups did not differ in rates of HTX (48% in Group A vs. 50% in Group B, P=0.88), LVAD implantation (0% in Group A vs. 4% in Group B, P=0.25), or total mortality (3% vs. 10%; p=0.16). However, in Group A, 24% of patients were delisted due to clinical improvement; compared to only 9% of patients in Group B (P=0.005). At the time of HTX listing, the delisted patients displayed similar clinical characteristics than the remaining cohort (LVEF: 22±2% in the delisted vs. 23±4% in the remaining cohort, P=0.67; NT-proBNP: 2822±1198 pg/mL vs. 3983±3927, P=0.45, ishemic heart failure etiology: 43% vs. 39%, P=0.77, history of hypertension: 61% vs. 58%; P=0.82; renal dysfunction: 31% vs. 25%, P=0.44 or diabetes: 20% vs 27%, P=0.52). On multivariate analysis, cell therapy was an independent correlate of delisting (P=0.002). CD 34+ cell therapy appears to be associated with beneficial clinical outcomes and increased rates of delisting in advanced heart failure patients awaiting heart transplantation.

P2628Predicting cardiac recovery before durable left ventricular assist device implantation in advanced heart failure patients

Abstract Background Predicting cardiac recovery (CR) in advanced heart failure (HF) patients before left ventricular assist device (LVAD) implantation remains challenging. This study sought to investigate whether CR after LVAD unloading can be predicted by cardiac functional and structural parameters together with clinical characteristics. Methods From 2008 to 2016, consecutive advanced chronic HF patients (N=347) supported with durable continuous-flow LVADs were prospectively evaluated. Patients with acute HF etiologies or without adequate post-LVAD follow up (&lt;3 months) were excluded. A great variety of clinical characteristics were evaluated in the remaining 285 subjects. LVAD patients were phenotyped while on support, as CR Responders or Non Responders, based on published predefined echocardiographic criteria. Multivariable logistic regression was used to form the model and the Utah Cardiac Recovery (UCAR) score was created from the regression beta coefficients of the final model. Results CR occurred in 13.7% of patients. Univariate analysis showed that responders were more likely to be young, female, non-ischemic cardiomyopathy, with shorter HF symptoms duration and no prior cardiac surgery. They had lower blood urea nitrogen and were more likely to be on temporary mechanical support before LVAD. The multivariable UCAR model (AUC=0.755; p&lt;0.001) predicted CR using 3 clinical parameters – Figure. Conclusion Univariate and multivariable predictors of CR include both modifiable and non-modifiable patient characteristics that are known prior to LVAD implantation. The UCAR score can serve as a practical tool for targeted patient selection to implement protocols that facilitate CR in the advanced HF patient subpopulation that is most likely to respond.

The Combination of Left Ventricular Assist Device and Laparoscopic Sleeve Gastrectomy May Promote Myocardial Recovery in Obese Advanced Chronic Heart Failure Patients

Purpose Laparoscopic sleeve gastrectomy (LSG) has been associated with efficient and durable weight loss in obese patients with advanced heart failure (AHF) who undergo LVAD support. However, the effects of this combinatory approach on myocardial recovery remain undefined. Thus, we sought to evaluate the potential association between the combination therapy (LVAD support and LSG) and myocardial recovery in this patient cohort. Methods We retrospectively analyzed patients who underwent simultaneous LVAD implantation and LSG at our center from January 2013-August 2017. Demographic, biochemical, LVAD-related and transplant data were reviewed. Data from patients' outpatient follow-up appointments were gathered for 12 months. Echos were performed at baseline and 12 months. Myocardial recovery was defined as an improvement of LVEF ≥ 10%. Results 20 patients were included in this study. The average patient age was 47±13 years; 11 (56%) of the patients were male and the average BMI was 44±5 kg/m2. Ischemic heart disease was the underlying cause of heart failure in 7 (35%) of the patients. Three (15%) patients received a HeartWare device and 17 (85%) patients received a HeartMate II LVAD. The average pre-implant INTERMACS score was 2.7±0.6. Regarding the cardioprotective therapy, 9 (45%) of patients received ACEI/ARB, 11 (54%) beta blockers and 6 (27%) MRA. The average baseline LVEF was 21±5%; LVEF significantly improved to 32±14% at 12 months (p=0.001). Myocardial recovery was observed in 6 (30%) of the patients; two of these patients' LVEF improved to over 40% and had their LVAD explanted. Interestingly, the average HbA1c also significantly decreased at 12-month follow-up timepoint (6.6±1.5% vs. 5.1±0.5%, p=0.007). There were no deaths during the 12-month follow-up period. Conclusion The combined LVAD and LSG approach may represent a safe and feasible novel treatment strategy to promote myocardial recovery in obese patients with AHF. Although underlying mechanisms remain to be identified, a decrease in insulin resistance, as previously reported, achieved through a combined approach, may represent a significant contributing factor to myocardial recovery in this patient cohort.

Predicting Cardiac Recovery before Durable Left Ventricular Assist Device Implantation in Advanced Heart Failure Patients

Purpose Predicting cardiac recovery (CR) in advanced heart failure (HF) patients before left ventricular assist device (LVAD) implantation remains challenging. This study sought to investigate whether CR after LVAD unloading can be predicted by cardiac functional and structural parameters together with clinical characteristics. Methods From 2008 to 2016, consecutive advanced chronic HF patients (N=347) supported with durable continuous-flow LVADs were prospectively evaluated. Patients with acute HF etiologies or without adequate post-LVAD follow up ( Results CR occurred in 13.7% of patients. Univariate analysis showed that responders were more likely to be young, female, non-ischemic cardiomyopathy, with shorter HF symptoms duration and no prior heart surgery. They had lower blood urea nitrogen and were less likely to be on temporary mechanical support before LVAD. The multivariable UCAR model (AUC=0.755; p Conclusion Univariate and multivariable predictors of CR include both modifiable and non-modifiable patient characteristics that are known prior to LVAD implantation. The UCAR score can serve as a practical tool for targeted patient selection to implement protocols that facilitate CR in the advanced HF patient subpopulation that is most likely to respond.

Strategies to address the shortcomings of commonly used advanced chronic heart failure descriptors to improve recruitment in palliative care research: A parallel mixed-methods feasibility study

Background: Recruitment challenges contribute to the paucity of palliative care research with advanced chronic heart failure patients. Aim: To describe the challenges and outline strategies of recruiting advanced chronic heart failure patients. Design: A feasibility study using a pre–post uncontrolled design. Setting: Advanced chronic heart failure patients were recruited at two nurse-led chronic heart failure disease management clinics in Ireland Results: Of 372 patients screened, 81 were approached, 38 were recruited (46.9% conversion to consent) and 25 completed the intervention. To identify the desired population, a modified version of the European Society of Cardiology definition was used together with modified New York Heart Association inclusion criteria to address inter-study site New York Heart Association classification subjectivity. These modifications substantially increased median monthly numbers of eligible patients approached (from 8 to 20) and median monthly numbers recruited (from 4 to 9). Analysis using a mortality risk calculator demonstrated that recruited patients had a median 1-year mortality risk of 22.7 and confirmed that the modified eligibility criteria successfully identified the population of interest. A statistically significant difference in New York Heart Association classification was found in recruited patients between study sites, but no statistically significant difference was found in selected clinical parameters between these patients. Conclusion: Clinically relevant modifications to the European Society of Cardiology definition and strategies to address New York Heart Association subjectivity may help to improve advanced chronic heart failure patient recruitment in clinical settings, thereby helping to address the paucity of palliative care research this population.

Circulating miR-30d Predicts Survival in Patients with Acute Heart Failure

Background/Aims: Identification of novel biomarkers to identify acute heart failure (AHF) patients at high risk of mortality is an area of unmet clinical need. Recently, we reported that the baseline level of circulating miR-30d was associated with left ventricular remodeling in response to cardiac resynchronization therapy in advanced chronic heart failure patients. However, the role of circulating miR-30d as a prognostic marker of survival in patients with AHF has not been explored. Methods: Patients clinically diagnosed with AHF were enrolled and followed up for 1 year. Quantitative reverse transcription polymerase chain reactions were used to determine serum miR-30d levels. The univariate logistic regression analysis and multivariate logistic regression analysis were used to determine the predictors for all-cause mortality in AHF patients. Kaplan–Meier survival analysis was used to analyze the role of miR-30d in prediction of survival. Results: A total of 96 AHF patients were enrolled and followed up for 1 year. Serum miR-30d was significantly lower in AHF patients who expired in the one year follow-up period compared to those who survived. Univariate logistic regression analysis yielded 18 variables that were associated with all-cause mortality in AHF patients, while the multivariate logistic regression analysis identified 4 variables including heart rate, hemoglobin, serum sodium, and serum miR-30d level associated with mortality. ROC curve analysis showed that hemoglobin, heart rate and serum sodium displayed poor prognostic value for AHF (AUCs not higher than 0.700) compared to miR-30d level (AUC = 0.806). Kaplan–Meier survival analysis confirmed that patients with higher serum miR-30d levels had significantly lower mortality (P=0.001). Conclusion: In conclusion, this study shows evidence for the predictive value of circulating miR-30d as 1-year all-cause mortality in AHF patients. Large multicentre studies are further needed to validate our findings and accelerate the transition to clinical utilization.

Improvement in Exercise Capacity by Exercise Training is associated with Favorable Clinical Outcome in Advanced Chronic Heart Failure Patients

Improvement in Exercise Capacity by Exercise Training is associated with Favorable Clinical Outcome in Advanced Chronic Heart Failure Patients

Predictive value of apoptotic microparticles to mononuclear progenitor cells ratio in advanced chronic heart failure patients

BackgroundAcutely decompensated chronic heart failure (ADHF) is considered a life-threatening event. Despite contemporary treatment strategies of ADHF, frequent recurrent hospitalizations due to other cardiovascular reasons after discharge of patients from hospital occur. The objective of the study was to examine the prognostic value of circulating endothelial-derived apoptotic microparticles (EMPs) to mononuclear progenitor cells (MPCs) ratio for post-discharge patients with clinical stabilization after ischemic ADHF. MethodsWe consecutively enrolled 136 patients (62 male) with coronary artery disease (CAD) admitted with a primary diagnosis of ADHF. All patients gave written informed consent for participation in the study. At baseline, all enrolled patients were hemodynamically stable and they had New York Heart Association (NYHA) III/IV classes of ischemic chronic heart failure (CHF). Observation period started at discharge from the hospital and was up to 3 years. Flow cytometry analysis for quantifying the number of EMPs and angiogenic MPCs was used. ResultsCalculated EMP to MPC ratios in survivor and dead patient cohort were 8.4 (95% CI=7.6–9.2) and 78.9 (95% CI=53.0–116.6), respectively (p=0.001). MPCs, EMPs, NYHA class, N-terminal pro-brain natriuretic peptide (NT-proBNP) and increased NT-proBNP>30% within 24–84h of admission period remained statistically significant for all-cause mortality, CHF-related death, and CHF-related rehospitalization, whereas left ventricular ejection fraction and high-sensitivity C-reactive protein for all variables did not. We found that the addition of EPMs to MPCs ratio to the ABC model (NT-pro-BNP, increased NT-pro-BNP>30%) improved the relative integrated discrimination indices by 19.6% for all-cause mortality, by 21.7% for CHF-related death, and by 19.5% for CHF-related rehospitalization. ConclusionWe demonstrated that EMP to MPC ratio is considered an important indicator of an imbalance between angiogenic and apoptotic responses with possible relation to cardiovascular outcomes in post-discharge patients with clinical stabilization after ischemic ADHF.

Acute effects of adaptive servo-ventilation on hemodynamics in advanced chronic heart failure patients

Acute effects of adaptive servo-ventilation on hemodynamics in advanced chronic heart failure patients

Milrinone in Advanced Heart Failure

Advanced chronic heart failure (ACHF) patients often require inotropes before transplantation or ventricular assist device implantation. Milrinone, an inotrope and vasodilator, may accumulate in cardiorenal syndrome with serious adverse effects. We investigated the potential for therapeutic drug monitoring of milrinone levels using High Performance Liquid Chromatography Mass Spectrometry (HPLC-MS). 22 ACHF patients (15 males, 49±9 years) received milrinone 50 µg/kg intravenously (i.v.) during heart catheterization. Milrinone levels were 216±71 ng/ml (within the reported therapeutic range: 100-300 ng/ml), followed by improvements in cardiac index, pulmonary artery and wedge pressures (p < 0.005). 18 ACHF patients (17 males, 50±12 years, 13 had renal dysfunction) received continuous i.v. milrinone (5-26 days) at 0.1-0.2 µg/kg/min, titrated according to plasma milrinone levels. No adverse events occurred. Therapeutic levels were achieved with doses of 0.2±0.06 µg/Kg/min, below those recommended in Summary of Product Characteristics. Milrinone therapy can be noninvasively monitored by HPLC-MS, while avoiding toxicity in ACHF.

Dimensions of Religiousness and Spirituality as Predictors of Well-Being in Advanced Chronic Heart Failure Patients

We examined relationships between seven dimensions of religion/spirituality (RS) (forgiveness, daily spiritual experiences, belief in afterlife, religious identity, religious support, public practices, and positive RS coping) and three dimensions of well-being (physical, mental, and existential) in a sample of 111 patients with advanced chronic heart failure. Participants completed questionnaires at baseline and 3 months later. Results showed that fairly high levels of RS were reported on all seven dimensions. Furthermore, RS dimensions were differentially related to well-being. No aspect of RS was related to physical well-being, and only a few aspects were related to mental well-being. Forgiveness was related to less subsequent depression, while belief in afterlife was related to poorer mental health. All aspects of RS were related to at least one aspect of existential well-being. In particularly, daily spiritual experiences were linked with higher existential well-being and predicted less subsequent spiritual strain. These results are consistent with the view that in advanced disease, RS may not affect physical well-being but may have potent influences on other aspects of well-being, particularly existential aspects.

631 Increased Red Cell Distribution Width Predicts Poor Stem Cell Mobilization in Advanced Chronic Heart Failure Patients

631 Increased Red Cell Distribution Width Predicts Poor Stem Cell Mobilization in Advanced Chronic Heart Failure Patients

Comparison of inverse Gaussian distribution with survival analysis in advanced chronic heart failure patients

[1] Chan SH, Liu PY, Lin LJ, et al. Predictors of in-hospital mortality in patients with acute aortic dissection. Int J Cardiol 2005;105(3):267–73. [2] Imamura H, Sekiguchi Y, Iwashita T, et al. Painless acute aortic dissection — diagnostic, prognostic and clinical implications. Circ J 2010;75(1):59–66. [3] Trimarchi S, Eagle KA, Nienaber CA, et al. Role of age in acute type A aortic dissection outcome: report from the International Registry of Acute Aortic Dissection (IRAD). J Thorac Cardiovasc Surg 2010;140(4):784–9. [4] Goda M, Imoto K, Suzuki S, et al. Risk analysis for hospital mortality in patients with acute type a aortic dissection. Ann Thorac Surg 2010;90(4):1246–50. [5] Coats AJS, Shewan LG. Statement on Authorship and Publishing Ethics in the International Journal of Cardiology. Int J Cardiol 2011;153:239–40. [6] Su YJ, Chang WH, Chang KS, Tsai CH. Aortic dissection in the elderly. J Emerg Med 2008;35(2):135–8. [7] Hu G, Jin B, Zheng H, et al. Analysis of 287 patients with aortic dissection: general characteristics, outcomes and risk factors in a single center. J Huazhong Univ Sci Technolog Med Sci 2011;31(1):107–13. [8] Zizza A, Pano M, Zaccaria S, Villani M, Guido M. Aortic dissection study group. Outcome of acute type A aortic dissection: single-center experience from 1998 to 2007. J Prev Med Hyg 2009;50(3):152–8. [9] Immer FF. Is there a place for D-dimers in acute type A aortic dissection? Heart 2006;92(6):727–8. [10] Gaul C, Dietrich W, Erbguth FJ. Neurological symptoms in aortic dissection: a challenge for neurologists. Cerebrovasc Dis 2008;26(1):1–8. [11] Nallamothu BK, Mehta RH, Saint S, et al. Syncope in acute aortic dissection: diagnostic, prognostic, and clinical implications. Am J Med 2002;113(6):468–71.

Is there a role for subcutaneous furosemide in the community and hospice management of end-stage heart failure?

Patients with advanced chronic heart failure (CHF) can experience ‘revolving door’ admissions, often for parenteral diuretics, when time at home is precious. Home intravenous diuretic services are patchy. This retrospective review describes 43 consecutive episodes of continuous subcutaneous infusion of furosemide (CSCI-F) in 32 advanced CHF patients; 28 episodes aiming to correct fluid balance and prevent hospital admission and 15 aiming to prevent symptoms in the dying. Overall, 26/28 (93%) avoided hospital admission. Weight loss occurred in 20/28 (70%): a median loss of 5.6 kg [interquartile range (IQR) 0.1–8.9]). The daily dose of furosemide ranged from 40 to 250 mg. The median number of days on CSCI-F was 10.5 (range 2–48; IQR 6–13.8). Site reactions occurred in 10/43 (23%); all of which were mild except two, one of which required oral antibiotics. Symptoms were controlled in all 15 dying patients. CSCI-F for patients with advanced CHF is effective in terms of weight loss and prevention of hospital admission with the heart failure nurse specialist playing a key overall management role in selection and monitoring. As the majority of community and hospice nurses have access to and are familiar with CSCI pumps, this practice should be nationally transferable. The role in the dying patient requires further assessment.

Rationale and design of the multicentre randomized trial investigating the efficacy and safety of pulsed infusions of levosimendan in outpatients with advanced heart failure (LevoRep study)

Advanced chronic heart failure (CHF) is a clinical syndrome with high morbidity and mortality that often requires inotropic support for the alleviation of symptoms and congestion. There are no definite evidence-based data on the safety and efficacy of intermittent infusions of inotropic agents in this severe clinical condition. The purpose of the LevoRep study is to clarify whether pulsed infusions of the new inotropic agent levosimendan administered in an outpatient setting can safely improve exercise capacity, quality-of-life (QoL), and outcome in advanced CHF patients. The LevoRep study is a prospective, randomized, double-blind, placebo-controlled, two-armed, parallel-group, multicentre trial. The study is designed to investigate the effects of pulsed infusions of levosimendan (6 h administration at 0.2 microg/kg/min every 2 weeks) on the composite endpoint (primary endpoint) comprising changes in functional capacity and QoL (20% or greater improvement in the 6 min walk test and 15% or higher score on the Kansas City Cardiomyopathy Questionnaire) at the end of the 24 week study period. In addition, short-term (8 weeks from randomization) and long-term (24 weeks from randomization) event-free survival (secondary endpoint) will be assessed. The LevoRep study aims to include 120 outpatients with advanced CHF. LevoRep is the first prospective randomized trial to assess the effects of pulsed infusions of an inotrope on hard endpoints as well as on the safety in patients with advanced CHF on an outpatient basis. The results are expected to promote the development of evidence-based recommendations for the ambulatory management of patients with end-stage heart failure.