Advanced NYHA Functional Class Research Articles

Systemic Vascular Resistance and Myocardial Work Analysis in Hypertrophic Cardiomyopathy and Transthyretin Cardiac Amyloidosis with Preserved Left Ventricular Ejection Fraction.

Background: The pathophysiological impact of systemic vascular resistance (SVR) and pressure-strain loop-derived global myocardial work index (GWI) in hypertrophic cardiomyopathy (HCM) and transthyretin cardiac amyloidosis (ATTR) has been randomly investigated. Methods: Both SVR and GWI were assessed in outpatients consecutively referred at two Italian cardiology departments for heart failure with preserved left ventricular ejection fraction (LVEF), affected by either nonobstructive HCM or wild-type ATTR. Based on relevant cross-tabulations, the patients were gathered into 4 functional classes according to cut-off values of 1440 dyne/s/cm-5 for SVR, and 1576 mm Hg% for GWI, as suggested by previous studies. Results: A total of 60 patients, 30 in each group, aged 61 ± 16 years, with 78% males, were studied. HCM patients were younger than those with ATTR and in a better clinical condition (23% HCM vs. 77% ATTR were NYHA class II-III, p < 0.001). Overall, 51 patients (85%) showed a high SVR, 21/30 HCM (70%), and 30 ATTR (100%) (p < 0.005). Both SVR and GWI (expressions of ventricular-arterial coupling) were impaired in 43% of HCM patients (showing greater LV concentric hypertrophy) and 93% of ATTR patients (in advanced NYHA functional class) (p < 0.001). Conclusions: A substantial percentage of present study population showed impaired SVR and/or GWI, despite preserved LVEF. The proposed classification may shed further light on the pathophysiological and clinical characteristics of such hypertrophic phenotypes.

COVID-19–Related Thrombotic and Bleeding Events in Adults With Congenital Heart Disease

BackgroundAltered coagulation is a striking feature of COVID-19. Adult patients with congenital heart disease (ACHD) are prone to thromboembolic (TE) and bleeding complications. ObjectivesThe purpose of this study was to investigate the prevalence and risk factors for COVID-19 TE/bleeding complications in ACHD patients. MethodsCOVID-19-positive ACHD patients were included between May 2020 and November 2021. TE events included ischemic cerebrovascular accident, systemic and pulmonary embolism, deep venous thrombosis, myocardial infarction, and intracardiac thrombosis. Major bleeding included cases with hemoglobin drop >2 g/dl, involvement of critical sites, or fatal bleeding. Severe infection was defined as need for intensive care unit, endotracheal intubation, renal replacement therapy, extracorporeal membrane oxygenation, or death. Patients with TE/bleeding were compared to those without events. Factors associated with TE/bleeding were determined using logistic regression. ResultsOf 1,988 patients (age 32 [IQR: 25-42] years, 47% male, 59 ACHD centers), 30 (1.5%) had significant TE/bleeding: 12 TE events, 12 major bleeds, and 6 with both TE and bleeding. Patients with TE/bleeding had higher in-hospital mortality compared to the remainder cohort (33% vs 1.7%; P < 0.0001) and were in more advanced physiological stage (P = 0.032) and NYHA functional class (P = 0.01), had lower baseline oxygen saturation (P = 0.0001), and more frequently had a history of atrial arrhythmia (P < 0.0001), previous hospitalization for heart failure (P < 0.0007), and were more likely hospitalized for COVID-19 (P < 0.0001). By multivariable logistic regression, prior anticoagulation (OR: 4.92; 95% CI: 2-11.76; P = 0.0003), cardiac injury (OR: 5.34; 95% CI: 1.98-14.76; P = 0.0009), and severe COVID-19 (OR: 17.39; 95% CI: 6.67-45.32; P < 0.0001) were independently associated with increased risk of TE/bleeding complications. ConclusionsACHD patients with TE/bleeding during COVID-19 infection have a higher in-hospital mortality from the illness. Risk of coagulation disorders is related to severe COVID-19, cardiac injury during infection, and use of anticoagulants.

Characterization and natural history of phenotypes in hereditary transthyretin amyloidosis

Abstract Background Hereditary systemic amyloidosis (ATTRv), caused by mutations in the transthyretin (TTR) gene, is a rare systemic disease with autosomal dominant transmission, incomplete penetrance, and variable expressivity. Purpose The purpose of this study was to describe the population of individuals with pathogenic mutations for TTR, comparing the genotype and clinical-instrumental characteristics of patients based on phenotype. Subsequently, the disease course was investigated in terms of the onset of new clinical manifestations, survival, and hospitalizations for heart failure. Methods Clinical and instrumental data from 325 consecutive patients carrying a pathogenic mutation of the TTR gene (asymptomatic carriers, n=106; cardiac phenotype, n=49; neurological phenotype, n=49; mixed phenotype, n=121) were analyzed at Our Center between 1979 and August 2022. Results A total of 23 different mutations were found, with Ile68Leu (41.8%), Val30Met (19%), and Glu89Gln (10%) being the most represented. Dominant mutations were found in patients with cardiac and neurological phenotypes, respectively Ile68Leu and Val30Met, while patients with mixed phenotype had marked genotypic variability. Patients with cardiac amyloidosis (CA) were predominantly male and had a more advanced NYHA functional class at presentation, while subjects with neurological involvement showed greater motor disabilities. There was also a significant difference in the age of disease diagnosis between the three groups: cardiac phenotype 73.2 years (IQR 66.5 – 78.1), mixed phenotype 58.4 years (IQR 47- 66.3), neurological phenotype 44 years (IQR 33.5 – 62.9). At the end of a median follow-up of 51 months (IQR 24 – 90 months), data from 290 subjects were analyzed, of whom 111 (38.3%) died and 123 (42.4%) had a major clinical event, including death or hospitalization for heart failure. Subjects without signs of disease had a prognosis similar to that of the healthy population, while patients with CA, with or without neurological manifestations, had a worse overall and event-free survival compared to those with isolated neurological phenotype. On multivariate analysis, age at diagnosis, NYHA functional class, and an mPND score ³ 2 were independently associated with adverse clinical events. Conclusions This study confirms the important clinical heterogeneity of patients with ATTRv, where three main phenotypes can be identified, characterized by specific clinical, demographic, and instrumental features. Although in some cases it is possible to identify a genotype-phenotype correlation, the extreme variability of clinical presentation is evident even among patients sharing the same mutation. In the study cohort, patients with CA had a worse prognosis. However, this finding should be interpreted with caution because it is influenced by disease-modifying therapy, which was performed unevenly among the three phenotypes.Univariate and multivariateKaplan-Meier curves

Pregnancy in Patients with Moderate and Highly Complex Congenital Heart Disease.

Although not completely devoid of risk, pregnancy can be managed in virtually all patients affected by even the most complex forms of congenital heart disease. It is not however advisable in patients with any form of pulmonary arterial hypertension. Pregnancy is even manageable in patients with univentricular heart converted to Fontan circulation. A personalised risk stratification should be performed, and patients affected by advanced NYHA functional class appropriately warned of the potential risks. In this setting, metabolomics might represent a novel tool for use in conducting personalised risk stratification. All pregnancies, particularly those at higher risk, should be managed in a tertiary care centre capable of providing the necessary assistance to both the mother and infant. With a few rare exceptions, vaginal delivery is to be preferred over caesarean section due to the lower degree of maternal and foetal complications. The desire for motherhood, at times extreme in women with congenital heart disease, may often be accomplished, thus providing a ray of hope in the lives of these patients.

Clinical significance of the albumin-bilirubin score in patients with heart failure undergoing cardiac resynchronization therapy.

Despite emerging recognition of interactions between heart failure (HF) and liver dysfunction, the impact of cardiac hepatopathy on patients with HF undergoing cardiac resynchronization therapy (CRT) has not been fully elucidated. Albumin-bilirubin (ALBI) score is a new assessment of liver function. The relationship between liver dysfunction severity based on ALBI score and clinical outcomes of patients with HF receiving CRT is unclear. Clinical records of 274 patients who underwent CRT device implantation between March 2003 and October 2020 were retrospectively investigated. ALBI score was calculated based on serum albumin and total bilirubin levels obtained before CRT device implantation. Patients were divided into three groups based on ALBI score: first tertile (ALBI ≤ - 2.62, n = 91)), second tertile (- 2.62 < ALBI < - 2.13, n = 92), and third tertile (ALBI ≥ - 2.13, n = 91). The study endpoint was all-cause mortality. The third tertile group had more advanced NYHA functional class, lower hemoglobin levels, and higher total bilirubin, aspartate aminotransferase, γ-glutamyl transferase, and N-terminal Pro-B-type natriuretic peptide levels (all p < 0.05). The third tertile group also had a higher prevalence of moderate or severe tricuspid regurgitation and higher tricuspid regurgitation pressure gradient (all p < 0.05). CRT response rates were significantly lower in the third tertile group. During a median (interquartile range) follow-up of 30 (9-60) months, 104 (37.9%) patients died. The third tertile group had significantly higher rates of all-cause mortality (log-rank p < 0.001). Higher ALBI score was significantly associated with all-cause mortality, even after adjusting for clinically relevant factors, a conventional validated risk score, and echocardiographic parameters related to right HF (all p < 0.01). Higher ALBI score before CRT device implantation is associated with HF severity, hepatic congestion and impairment due to right HF, lower CRT response, and higher all-cause mortality in CRT recipients.

Incidence and Characterization of Concealed Cardiac Amyloidosis Among Unselected Elderly Patients Undergoing Post-mortem Examination.

Background: The prevalence of cardiac amyloidosis (CA) is unknown.Aims and Methods: We sought to (a) determine the prevalence of CA in unselected patients ≥75 years undergoing autopsy, (b) characterize cardiological profiles of CA and non-CA patients by providing clinical-histological correlations, and (c) compare their cardiological profiles. After dedicated staining, the localization (interstitial or vascular) and the distribution (non-diffuse or diffuse) of amyloid deposition were analyzed. Cardiological data at last evaluation were retrospectively assessed for the presence of CA red-flags.Results: CA (50% light chains, 50% transthyretin) was found in 43% (n = 24/56) of the autopsied hearts. Atria were involved in 96% of cases. Amyloid localized both at the perivascular and interstitial levels (95.5 and 85%, respectively) with a slightly predominant non-diffuse distribution (58% of cases). Compared to the other patients, CA patients had a more frequent history of heart failure (HF) (79 vs. 47%, p = 0.014), advanced NYHA functional class (III-IV 25 vs. 6%, p = 0.047), atrial fibrillation (68 vs. 36%, p = 0.019), discrepancy between QRS voltage and left ventricular (LV) thickness (70 vs. 12%, p < 0.001), thicker LV walls (15 vs. 11 mm, p < 0.001), enlarged left atrium (49 vs. 42 mm, p = 0.019) and restrictive filling pattern (56 vs. 19%, p = 0.020). The presence of right ventricular amyloidosis seemed to identify hearts with a higher amyloid burden. Among the CA patients, >30% had ≥3 echocardiographic red-flags of disease.Conclusion: CA can be found in 43% of autopsied hearts from patients ≥75 years old, especially in patients with HF, LV hypertrophy and atrial fibrillation.

B-PO05-185 CLINICAL SIGNIFICANCE OF THE CONTROLLING NUTRITIONAL STATUS (CONUT) SCORE IN PATIENTS UNDERGOING CARDIAC RESYNCHRONIZATION THERAPY

The Controlling Nutritional Status (CONUT) score is an index of nutritional status. Malnutrition has recently been reported to be a common condition that is associated with adverse prognosis in patients with heart failure (HF). However, the relationship between nutritional status and clinical outcomes in patients with HF undergoing cardiac resynchronization therapy (CRT) is unclear. We investigated the prognostic value of the CONUT score in CRT recipients. Clinical records were retrospectively evaluated for 263 patients who underwent CRT implantation between March 2003 and August 2020. Blood samples were collected before CRT implantation. Nutritional status was assessed using the CONUT score. Patients were divided into three groups by CONUT score: normal group (CONUT score 0-1, n=56), mild malnutrition group (CONUT score 2-4, n=132), and moderate or severe malnutrition group (CONUT score ≥5, n=75). The primary endpoint was all-cause mortality. The moderate or severe malnutrition group had significantly advanced NYHA functional class, higher N-terminal pro-brain natriuretic peptide (NT pro-BNP) levels, and higher Clinical Frailty Scale scores (all p<0.05). During a median follow-up of 31 months (interquartile range, 10-67), 103 patients (39.1%) died. Kaplan-Meier analysis revealed that mortality was significantly higher in the moderate or severe malnutrition group (log-rank p<0.001). Even after adjustment for a conventional risk score (VALID-CRT risk score), CONUT score (as a continuous variable) remained associated with mortality (p<0.05). Nutritional status as assessed by the CONUT score is significantly associated with the severity of HF and frailty, and subsequent mortality in patients with HF undergoing CRT.

Prognostic value of ambulatory blood pressure values in elderly patients with heart failure. Results of the DICUMAP study

IntroductionAmbulatory blood pressure monitoring (ABPM) has demonstrated value in the prognostic assessment of hypertensive patients with heart failure (HF) with or without other cardiovascular diseases. The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis. Methods and resultsProspective multicenter study that included clinically stable outpatients with HF. All patients underwent ABPM. A total of 154 patients from 17 centers were included. Their mean age was 76.8 years (± 8.3) and 55.2% were female. In total, 23.7% had HF with a reduced ejection fraction (HFrEF), 68.2% were in NYHA functional class II, and 19.5% were in NYHA functional class III. At one year of follow up, there were 13 (8.4%) deaths, of which 10 were attributed to HF. Twenty-nine patients required hospitalization, of which 19 were due to HF. The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up (25% vs. 5%; p=.024). According to a Cox regression analysis, more advanced NYHA functional class (hazard ratio 3.51; 95% CI 1.70–7.26; p=.001; for NYHA class III vs. II) and a higher proportional nocturnal reduction in diastolic BP (hazard ratio 0.961; 95%CI 0.926−0.997; p=.032 per 1% diastolic BP reduction) were independently associated with death or readmission at one year. ConclusionIn older patients with chronic HF, a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF.

Utilidad pronóstica de las cifras ambulatorias de presión arterial en pacientes de edad avanzada con insuficiencia cardíaca. Resultados del estudio DICUMAP

IntroductionAmbulatory blood pressure monitoring (ABPM) has demonstrated value in the prognostic assessment of hypertensive patients with heart failure (HF) with or without other cardiovascular diseases. The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis. Methods and resultsProspective multicenter study that included clinically stable outpatients with HF. All patients underwent ABPM. A total of 154 patients from 17 centers were included. Their mean age was 76.8 years (±8.3) and 55.2% were female. In total, 23.7% had HF with a reduced ejection fraction (HFrEF), 68.2% were in NYHA functional class II, and 19.5% were in NYHA functional class III. At one year of follow up, there were 13 (8.4%) deaths, of which 10 were attributed to HF. Twenty-nine patients required hospitalization, of which 19 were due to HF. The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up (25% vs. 5%; p=.024). According to a Cox regression analysis, more advanced NYHA functional class (hazard ratio 3.51; 95%CI 1.70-7.26; p=.001; for NYHA class III vs. II) and a higher proportional nocturnal reduction in diastolic BP (hazard ratio 0.961; 95%CI 0.926-0.997; p=.032 per 1% diastolic BP reduction) were independently associated with death or readmission at one year. ConclusionIn older patients with chronic HF, a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF.

Growth Differentiation Factor 15 in Severe Aortic Valve Stenosis: Relationship with Left Ventricular Remodeling and Frailty.

Background: Frailty is an important outcome predictor in patients with aortic stenosis who are candidates for transcatheter or surgical aortic valve replacement (AVR). Growth/differentiation factor 15 (GDF15) is a cytokine playing a role in the pathophysiology of ventricular remodeling. We assessed its potential role as an independent soluble biomarker of frailty in these patients. Methods: We studied 62 patients (age, mean 79 years, 95% confidence interval (CI) 77–81; 54.8% female) with severe aortic valve stenosis and candidates for AVR. We systematically assessed pre-intervention GDF15 levels for their relationship with frailty (Katz score) and echocardiographic parameters of left ventricular dysfunction/remodeling. Fifteen hypertensive patients with left ventricular (LV) hypertrophy served as controls. Results: Patients with aortic valve stenosis featured higher GDF15 levels than controls (1773, 95% CI 1574–1971 pg/mL vs. 775, 95% CI 600–950 pg/mL, respectively, p < 0.0001). Subjects in the upper GDF15 tertile were older (p = 0.004), with a more advanced NYHA functional class (p = 0.04) and a higher prevalence of impaired renal function (p = 0.004). Such patients also showed a higher frailty score (p = 0.04) and higher indices of LV dysfunction, including reduced global longitudinal strain (p = 0.01) and a higher left ventricular mass (p = 0.001). GDF15 was significantly related to the Katz score, and predicted (OR 1.05; 95% CI 0.9–1.1; p = 0.03) a low (<5) Katz score, independent of the relationship with LV mass, age, renal function or indices of LV dysfunction. Conclusions: GDF15 is increased in patients with severe aortic stenosis and appears to be a soluble correlate of patients’ frailty, independent of indices of left ventricular dysfunction.

Prevalence and prognostic impact of left-sided valve thickening in systemic light-chain amyloidosis.

Left heart valve thickening (LVT) was described in patients with light-chain amyloidosis (AL). This phenomenon reflects likely infiltration of the valve by amyloid proteins. However, the prevalence of LVT and its prognostic value have not been investigated in patients with AL. Comprehensive transthoracic echocardiography was performed at baseline in 150 patients [median age 68 (33-87) years; 59% male] with confirmed AL. The presence of abnormal mitral and/or aortic valve thickening (>3mm) was assessed in all included patients. Overall, 42% had LVT at the time of diagnosis. Compared to patients without LVT, those with LVT were older and had a more advanced NYHA functional class (63% in patients with NYHA III-IV vs. 33% in NYHA I-II, p<0.001). They also had higher left ventricular (LV) wall thickness and mass, larger left atrium, higher mitral annulus E/E' ratio and systolic pulmonary artery pressures, and lower LV ejection fraction (all p<0.05). Patients with more advanced Mayo Clinic stage had a higher incidence of LVT: 58% in stage III vs. 45% in stage II and 5% in stage I (p<0.001). During a median follow-up of 2years, 79 deaths occurred. The presence of LVT was significantly associated with reduced 5-year survival (32±7 vs. 64±6%). In multivariate analysis, after adjusting for age, gender, NYHA functional class, and LV ejection fraction, LVT remained significantly associated with higher all-cause mortality (hazard ratio 1.90, 95% CI 1.10-3.34, p=0.02). Left heart valve thickening is common in patients with AL and is associated with worse functional class, LV systolic and diastolic function, and more advanced stage of the disease. In addition, LVT appears to be a powerful marker of all-cause mortality.

Assessment of bendopnea impact on decompensated heart failure.

We have often found that patients with heart failure had shortness of breath when bending forward. The frequency of bendopnea in patients with decompensated heart failure (DHF), its repercussions on quality of life (QoL), and its prognosis have not yet been studied. This study was carried out to evaluate the characteristics, degree of limitation, and short-term prognosis of patients with bendopnea and DHF. We conducted a study of 250 patients admitted with DHF. Bendopnea was considered when shortness of breath occurred within 30 s of bending forward. It was present in 122 patients (48.8%). The mean time of onset was 13.4 ± 6.9 s. Patients with bendopnea presented a higher frequency of orthopnoea, paroxysmal nocturnal dyspnoea, oliguria, oedema, elevated jugular venous pressure, abdominal fullness, and worse functional class (P < 0.001). An enlargement of both atria was more frequent in these patients (P < 0.001). Pulmonary artery systolic pressure (PASP) was higher in the bendopnea group (P = 0.001). Body mass index and LVEF were not associated with presence of bendopnea. Subjective QoL limitation was present in 80.3% (36.1% mild, 44.2% moderate to severe limitation). Patients with bendopnea had a higher mortality rate (P = 0.025) and more advanced NYHA class (P < 0.001). Patients who died had a lower LVEF (P = 0.001), increased PASP (P = 0.08), and lower mean duration of shortness of breath than those who survived (P = 0.01). Bendopnea is related to advanced HF symptoms and it is associated with mortality in the short term and advanced NYHA functional class. This symptom produces moderate to severe limitation of QoL.

We Obtain A Hemodynamic Near Normalization? Clues from Three Long-Term Survivors on Epoprostenol Treatment

Pulmonary arterial hypertension is a disease with a poor prognosis characterized by right ventricular failure, due to an increase in pulmonary vascular resistance and pulmonary arterial pressure. The introduction of specific treatments in the past decade has dramatically changed the management of the disease, and the addition of parenteral prostanoids to oral therapy has shown to improve survival in responding patients, as demonstrated by the clinical cases exposed in this paper: three female patients with moderate or severe pulmonary arterial hypertension and advanced NYHA functional class at diagnosis were able to overcome a 10-year survival along with a significant improvement in clinical and hemodynamic status thanks to the introduction of intravenous epoprostenol treatment.

Outcome of Patients with Advanced Heart Failure Who Receive Device-Based Therapy for Primary Prevention of Sudden Cardiac Death: Insights from the Israeli ICD Registry.

Randomized clinical trials have shown conflicting data on the benefit of implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with more advanced heart failure (HF) symptoms. Using the Israeli ICD Registry data, we sought to examine the effect of HF functional class on the outcome of patients who receive device therapy in a real-world setting. The association between HF functional class (categorized as baseline New York Heart Association [NYHA] functional class I and II in [61%] vs class III and IV in [39%]) and clinical outcomes was assessed among 913 patients who received an ICD (n = 514) or a cardiac resynchronization therapy with a defibrillator (CRT-D; n = 399) device and were prospectively followed in the Israeli ICD Registry between July 2011 and June 2013. The risk associated with advanced HF functional class was significantly different in ICD and CRT-D recipients. In the former group, patients with NYHA classes III and IV experienced >3-fold increased risk of HF or death (hazard ratio [HR] = 3.28; P < 0.001), whereas among CRT-D recipients the risk was similar between patients with NYHA III/IV and those with less advanced HF symptoms (HR = 0.97 [95% confidence interval (CI) 0.54-1.78]; P = 0.42; P value for NYHA functional class by device type interaction = 0.002). The risk for ventricular arrhythmia (VA) was significantly lower among patients with more advanced NYHA functional class, regardless of device type (overall HR = 0.52; 95% CI 0.33-0.91; P = 0.04). Our findings suggest that patients with less advanced HF symptoms experience a greater risk for VA and the development of HF is attenuated in CRT-D recipients with more advanced NYHA functional class.

0224: Prevalence and prognostic significance of left-sided valvular thickening in patients with systemic light-chain amyloidosis

Cardiac involvement is frequent in systemic light chain amyloidosis (AL). Left-sided valvular thickening (LVT) have been described in AL reflecting heavy infiltration of the valvular endocardium by amyloid proteins. However, the exact prevalence at diagnosis and the prognostic significance of LVT in AL patients have never been investigated. to study the prevalence and the impact on long-term survival LVT in AL patients. Between 1998 and 2013, 150 AL patients were included at diagnosis (mean age was 68±11 ans, 59% were male). A comprehensive transthoracic echocardiography was performed at baseline. The presence of LVT was assessed visually and was found in 42% of patients. Compared to patients without LVT, those with LVT have more frequently advanced NYHA functional class. They also had significantly higher left ventricular (LV) wall thickening (p=0.01), LV mass (p=0.02), and mitral E/e’ (p=0.0009) and larger left atrial size (p<0.0001). Moreover, patients with advanced Mayo Clinic stage more frequently had LVT: 58%, 45%, and 5% in stage III, II, and I respectively (p<0.0001). Patients with severe symptoms more frequently exhibited LVT (63% in NYHA III-IV vs. 33% in NYHA I-II, p=0.0008). During a mean follow-up of 2.9±3 years, 79 deaths occurred (53%). The presence of LVT was significantly associated with reduced 1 and 5-year survival: 51±4% vs. 70±4% and 32±7% vs. 64±6% respectively (p=0.0002). In multivariate analysis, after adjustment for age, gender, NYHA class≥III, clearance of creatininemia, and LV ejection fraction, LVT remained an independant significant marker of mortality (Hazard ratio= 1.9, 95%CI: 1.10-3.34, p=0.02). The presence of LVT is a common finding in patients with AL and is associated with impaired both LV systolic and diastolic function, poorer functional status and advanced stage of the disease. In addition, LVT appeared as a powerful marker of mortality. Abstract 0224 – Figure: 5-year survival of AL-patients according to LVT

Clinical Characteristics, Mortality, Cardiac Hospitalization, and Ventricular Arrhythmias in Patients Undergoing CRT‐D Implantation: Results of the ACTION‐HF Study

The characteristics and outcomes of patients who undergo cardiac resynchronization therapy (CRT) device implantation in current clinical practice may differ from those of reference trial populations. Study objectives were to assess 2-year outcomes in a population implanted with a CRT plus defibrillator device in accordance with the standard of care and to evaluate any independent association between clinical variables and outcome. A total of 406 patients enrolled at 35 centers in Italy were followed up prospectively for 2 years. All patient management decisions were left to the treating physician's discretion, in accordance with clinical practice. ACTION-HF patients had a better baseline clinical status than patients enrolled in the COMPANION study: shorter HF history (1 vs 3.5 years, P < 0.01), less advanced NYHA functional class (III-IV: 73% vs 100%, P < 0.01), higher LVEF (26% vs 21%, P < 0.01), higher SBP (122 vs 112 mmHg, P < 0.01), and less diabetes (27% vs 41%, P < 0.01). This status was reflected in lower mortality (11.5% vs 26%) and a lower incidence of appropriate ICD shocks (12.1% vs 19.3%). AF history was an independent predictor of the combination of all-cause mortality and cardiac-cause hospitalization (HR: 3.31; P < 0.001). Recurrent or new atrial arrhythmias were independently associated with the development of ventricular arrhythmias (HR: 3.4; P < 0.001). This population appears clinically less compromised and had a lower incidence of adverse clinical outcomes than those of reference trials. However, we recorded a substantial burden of atrial arrhythmias, which was independently associated with a higher incidence of ventricular arrhythmias.

Mid-term results of coronary artery bypass graft surgery in patients 70 years of age or older

Background: This study aims to analyze the mid-term results of the coronary artery bypass graft (CABG) surgery in a group of patients 70 years of age or over. Methods: Between September 2001 and June 2009, 621 patients who were more than 70 years of age (453 males, 168 females; mean age 73.6±2.9 years; range 70 to 89 years) who underwent isolated cardiopulmonary CABG were analyzed retrospectively. Of these patients, 604 (97.3%) were followed up postoperatively. The mean duration of the follow-up was 2.5±1.4 years (range 0.3-6.9 years) with a total of 1532.5 patient/years. Results: The mean number of distal anastomoses and grafts per patient was 3.0±0.7 (range 2-5) and 2.8±1.1 (range 2-5), respectively. The 30-day mortality rate was 2.7% (n=17). Of the surviving 604 patients, 30 (4.8%) died during the follow-up period. The mean survival of these patients was 3.1±1.9 years (range 0.8-6.7 years). The preoperative advanced NYHA functional class and postoperative renal complications were associated with increased late mortality while comorbid preoperative diabetes and the use of the left internal thoracic artery graft were associated with lower mortality. Conclusion: Our study results suggest that patients who were more than 70 years old may benefit from CABG surgery. We found that early mortality is related to patientspecific factors, while mid-term mortality is associated with renal complications and preoperative advanced NYHA functional class. Diabetic patients who were administered left internal thoracic artery grafts benefit the most from CABG surgery during the mid-term follow-up.

ORAL PRESENTATION

ORAL PRESENTATION

Recombinant tissue plasminogen activator reduces incidence of catheter malfunction and bacteremia

Recombinant tissue plasminogen activator reduces incidence of catheter malfunction and bacteremia

Surgical Ventricular Restoration: The RESTORE Group Experience

Congestive heart failure may be caused by late left ventricular (LV) dilation following anterior infarction. Early reperfusion prevents transmural necrosis, and makes the infarcted segment akinetic rather than dyskinetic. Surgical ventricular restoration (SVR) reduces LV volume and creates a more elliptical chamber by excluding scar in either akinetic or dyskinetic segments. The international RESTORE group applied SVR in a registry of 1198 post-infarction patients between 1998 and 2003. Early and late outcomes were examined and risk factors identified.Concomitant procedures included coronary artery bypass grafting in 95%, mitral valve repair in 22%, and mitral valve replacement in 1%. Overall 30-day mortality after SVR was 5.3% (8.7% with mitral repair vs. 4.0% without repair, p < .001) Perioperative mechanical support was uncommon (< 9%). Global systolic function improved postoperatively, as ejection fraction increased from 29.6 +/- 11.0% to 39.5 +/- 12.3% (p < .001) and left ventricular end systolic volume index decreased from 80.4 +/- 51.4 ml/m(2) to 56.6 +/- 34.3 ml/m(2) (p < .001). Overall 5-year survival was 68.6 +/- 2.8%, Logistic regression analysis identified EF < or = 30%, LVESVI > o = 80 ml/m(2), advanced NYHA functional class, and age > or =75 years as risk factors for death. Five-year freedom from hospital readmission for CHF was 78%. Preoperatively, 67% of patients were class III or IV, and postoperatively 85% were class I or II.SVR improves ventricular function and is highly effective therapy in the treatment of ischemic cardiomyopathy with excellent 5-year outcome.