Average Ejection Fraction Research Articles

Abstract 15970: Risk of Heart Failure Preserved Ejection Fraction in Obstructive Sleep Apnea: A Single Center Retrospective Analysis

Background: Inherent characteristics of patients with Obstructive Sleep Apnea (OSA), such as age, obesity, diabetes and hypertension increase the risk for cardiovascular diseases including heart failure (HF). Herein, we sought to elucidate if there is an increased likelihood of having heart failure with preserved ejection fraction (HFpEF) as OSA severity increases. Furthermore, we correlated a validated H2FpEF score system in this cohort with clinical and imaging findings for HFpEF. Results: Out of 585 charts reviewed from patients diagnosed with OSA, a total of 108 patients with a concomitant transthoracic echocardiogram (TTE) and electrocardiogram performed were identified. The median age was 59 years old with 55.6% being males and Hispanic predominance 64.5%. The comorbidities found in our cohort involved hypertension (63.9%), diabetes mellitus (30.6%), coronary artery disease (15.7%), HF (13%), atrial fibrillation (8.3%), and stroke (7.4%). Mean BMI was 32.48 kg/m 2 and average neck size 16.02 inches. TTE findings demonstrated an average ejection fraction of 58±7% and mean pulmonary artery systolic pressure of 24±10 mmHg. OSA severity distribution is shown in Table 1. No significant association was found between grade of severity of OSA with clinical diagnosis of HF, nor with diastolic dysfunction by TTE. The average probability of HFpEF by validated score was 50%, and the distribution of the score was the same across severity of OSA (p=0.260). Pearson’s correlation showed a significant positive relationship between age, BMI and PASP, and H2FpEF score (p<0.01 for all), however, no relation was found when correlating with neck size, apnea-hypopnea index and mean oxygen saturation. Conclusion: Although patients with OSA might have a higher H2FpEF score due to inherent characteristics, the clinical diagnosis of HFpEF in our population was lower than expected by H2FpEF score, in which the degree of severity was not associated with a higher H2FpEF score.

Protective Effects of Daratumumab on Carfilzomib-Related Cardiac Dysfunction in Patients with Relapsed Multiple Myeloma: Results from an Observational Study

Protective Effects of Daratumumab on Carfilzomib-Related Cardiac Dysfunction in Patients with Relapsed Multiple Myeloma: Results from an Observational Study

A novel non-invasive electrical synchrony method to improve cardiac resynchronization therapy responders

Abstract Introduction Cardiac resynchronization therapy (CRT) has emerged as an important treatment for patients with heart failure and reduced ejection fraction (EF) despite optimal pharmacological therapy. Some studies showed non-responders rate near 30%. Nowaday there is no gold standard method for selection, evaluation and follow up on this group of patients. Multiple techniques used and operator dependence made echocardiogram failed. Synchromax 2 is a device designed to evaluate non-invasive electrical synchrony. It is fast, reproducible and non-operator dependent. Synchromax was evaluated and correlated with other techniques in previous studies. Objective Evaluate CRT response rate guided by electrical synchrony during the device implantation and follow up. Material and methods 43 patients were evaluated in an institution in Buenos Aires. A ICD-CRT was implanted in all patients due dilated cardiomyopathy, low EF (less than 35%) and left bundle branch block (LBBB). Non-invasive electrical synchrony evaluation (Synchromax 2) was performed in all patients in baseline condition, during device implantation and the follow up. Synchrony index and curves were analyzed. Curve type 4 and index between 0,4 and 0,7 were considered synchronous. Curve type 6 and 10 and index more than 0.7 were considered disynchronous. Interventricular intervals were modified to achieve the best curve and synchrony index. Super responders were considered when EF increased >50%. Baseline and 6 month after implantation echocardiogram were performed. Results Mean age 64 years. 39% females. Non-coronary dilated cardiomyopathy was main aetiology (63,1%). EF baseline average was 27%. A baseline index more than 0,7 was in 73,3% of the patients. Curve 6 was the most frequent (55,2%). Follow up average EF was 39% (increased 12%), the super responders rate was 18,6% (8 patients). Type 4 curve and index between 0,4 and 0,7 were achieved in 28 cases (65,1%). EF increased from 23% (baseline) to 42% (follow up). Average 19%. Type 4 curve was not achieved in 15 patients (34,9%). In this group, EF increased from 29% (baseline) to 34% (follow up). Average 5%. Conclusion Electrical synchrony evaluation using Synchromax 2 during ICD-CRT device implantation improves responders rate. When synchronous type 4 curve is achieved EF improves significantly. If type 4 curve is not found results will be unsuccessfully. Synchromax is fast, simple and non-operator dependent. Funding Acknowledgement Type of funding source: None

Prevalence of cardiac abnormalities in sickle cell disease identified using cardiac magnetic resonance imaging

Abstract Background Sickle cell disease (SCD) affects thousands of individuals in the United Kingdom causing significant morbidity and mortality. Modern therapies have been successful in increasing life expectancy, however these patients have an increased risk of cardiovascular complications and the extent to which sickle cell disease affects cardiac function is not well understood. Cardiac magnetic resonance imaging (MRI) is the gold standard imaging modality for evaluating myocardial function. It is known that sickle cell patients can present with pulmonary hypertension, left ventricular diastolic dysfunction, and atrial enlargement however the prevalence of other cardiac abnormalities has not been sufficiently investigated with cardiac MRI. In addition, the European Society of Cardiology (ESC) updated their definition of Heart Failure in 2016 and therefore will need to be re-assessed in this population. Purpose To evaluate the prevalence of cardiac abnormalities in the sickle cell population using cardiac MRI and based on the recently updated diagnostic criteria. Methods We conducted a retrospective review including all patients with sickle cell disease at a large tertiary hospital in London, United Kingdom who had been referred for cardiac MRI between 2011 and 2019. Data was collected data on various measures of cardiac function including: left ventricular ejection fraction (LVEF), left ventricular hypertrophy, left and right atrial enlargement, regional wall motion abnormalities, valvular disease, myocardial scarring, and cardiac iron load. Results 82 patients and 123 cardiac MRI scans were reviewed in this study. 68% of patients were female and the average age at time of scan was 37 years. The average left ventricular ejection fraction was 57% (n=82). Cardiac abnormalities were identified in 60% of patients. The most common cardiac abnormalities reported were: valvular regurgitation (46%; n=28), left atrial enlargement (28%; n=19), right atrial enlargement (16%; n=11), left ventricular hypertrophy (11%; n=8), regional wall motion abnormalities (10%; n=7), and myocardial scar with late gadolinium enhancement (9%; n=7). 28% of the patients were diagnosed with Heart Failure; 11% of the patients satisfied the diagnostic criteria for HFpEF (Heart failure with preserved ejection fraction, n=9), 10% with HFrEF (Heart Failure with reduced ejection fraction, n=8), and 7% with HFmrEF (Heart Failure with mid-range ejection fraction, n=6). Conclusion Sickle cell disease affects cardiac function in the majority of patients resulting in numerous cardiac abnormalities. We have described the overall extent of these effects using data from cardiac MRI scans, which has not been commonly used thus far. This has implications for both the diagnosis and subsequent management of cardiac abnormalities in this population, and it can be used to further investigate and guide the development of targeted treatments for these patients. Funding Acknowledgement Type of funding source: None

Impact of pre-treatment with acetylsalicylic acid on the severity of a first myocardial infarction in diabetic patients

Abstract Introduction Diabetes Mellitus (DM) is one of the main risk factors for cardiovascular disease (CVD). Guidelines on the use of acetylsalicylic acid (ASA) for primary prevention of CVD in this population are conflicting. A potential reduction in the severity of a first episode of Acute Myocardial Infarction (AMI) could be seen has an additional argument for the use of ASA in primary prevention. Aim: To evaluate the impact of prior intake of ASA on the presentation, severity and short-term prognosis of AMI in diabetic patients without history of CVD. Methods Retrospective analysis of diabetic patients without previous evidence of CVD diagnosed with type 1 AMI between January 2002 and December 2018, inserted in a multicentric registry of acute coronary syndromes. Patients were dichotomized according to whether or not they were taking ASA prior to the index event. Groups were compared according to clinical, analytical and imaging endpoints. Results A total of 2596 patients were included, predominantly men (66.4%), with a mean age of 68±12 years old. Patients on ASA (19.7%) were significantly older (71±10 vs. 67±12, p<0.001) and had a higher prevalence of hypertension (89.2% vs 77.9%, p<0.001), dyslipidaemia (69.8% vs. 61.1%, p<0.001) and chronic kidney disease (10.6% vs. 4.9%, p<0.001). Overall, there was a lower prevalence of AMI with ST-segment elevation (36.5% vs. 50.8%, p<0.001) in patients on ASA. However, the same group of patients had a significantly higher probability of evolution in Killip class > I (25.4% vs. 17.0%, p<0.001), a higher median BNP elevation (315 [126–623] vs. 166 [64–431], p<0.001); and a lower average ejection fraction upon discharge (49.0±12 vs. 51±12, p=0.011). Patients on prior regular intake of ASA also had a higher prevalence of multivessel disease (38.4% vs. 28.9%, p<0.001) and multiple significant stenosis (70.2% vs. 61.7%, p<0.001). There was no significant difference regarding the percentage of electrical complications (2.3% vs. 1.2%, p=0.06), use of intra-aortic balloon pump (1.0 vs. 0.9%, p=0.74) and in-hospital death (3.0% vs. 2.4%, p=0.46). In a logistic regression model adjusted for age, sex, comorbidities and previous medication as variates, prior ASA intake was an independent predictor of a lower rate of AMI with ST-segment elevation (ExpB −0.34; 95% CI: 0.57–0.89; p=0.003). On the contrary, when adjusted to these variables, prior ASA intake was not an independent predictor of higher BNP (p=0.13) or higher probability of multivessel disease (p=0.22) or presence of ≥1 significant stenosis (p=0.31). Conclusions In this population of diabetic patients with a first episode of ACS, prior use of ASA in the context of primary prevention was associated with a significant lower rate of ST-segment elevation myocardial infarction. Funding Acknowledgement Type of funding source: None

A Multibiomarker Latent Class Analysis in Moderate to Advanced Heart Failure: Differentiating Factors.

Biomarker science in heart failure (HF) is advancing quickly in our ability to diagnosis and treat patients with this complex syndrome. Researchers are urged to not use single-marker strategies, but instead evaluate biomarkers in patterns to better understand their relationship to one another, as well as disease progression. Latent class mixture modeling allows researchers to determine novel associations between biomarkers. The objectives of this study were to identify and compare latent classes of cardiovascular biomarkers among patients with moderate to advanced HF. This was a cross-sectional study of 96 participants with moderate to advanced HF. Latent class mixture modeling was used to identify unique classes of biomarkers and their associations to sociodemographic and clinical variables. The average age of the sample was 54 years, with most of the sample being men (77%) and having an average ejection fraction of 23%. Two unique classes of biomarkers were identified. Latent class 1 had higher levels of all biomarkers, whereas latent class 2 had lower levels. The higher biomarker class had, on average, more neurohormonal activation and fluid retention; however, the higher levels of biomarker class were not more likely to be diagnosed with advanced HF or have more comorbidities. By identifying classes of biomarkers, providers may be better able to identify patients who are at risk of progressing into advanced HF quicker or those who are more likely to have more severe complications, such as fluid overload or renal disease.

Reversibility of Cardiac Involvement in Acromegaly Patients After Surgery: 12-Month Follow-up Using Cardiovascular Magnetic Resonance.

PurposeCardiac comorbidity is one of the leading causes of death among acromegaly patients. We aimed to investigate the reversibility of acromegalic cardiac involvement after surgical treatment using the gold standard method, cardiovascular magnetic resonance, and to explore the effects of endocrine remission and gender on reversibility.MethodsIn this single-center, prospective cohort study, fifty untreated acromegaly patients were enrolled. Comprehensive cardiac assessments were performed using a 3.0 T magnetic resonance scanner before and 3 and 12 months after transsphenoidal adenomectomy.ResultsPreoperatively, left ventricular (LV) enlargement (13.0%), LV systolic dysfunction (6.5%), right ventricular (RV) enlargement (4.3%), RV systolic dysfunction (2.2%) and myocardial fibrosis (12.0%) were identified. On average, the LV and RV ejection fractions of acromegaly patients were higher than the healthy reference values. Male patients had thicker LV myocardia, wider ventricular diameters and more dilated pulmonary artery roots than female patients. After surgery, LV myocardial hypertrophy was reversed, the left atrium was remodeled, and ventricular systolic dysfunction recovered to normal. Cardiac alterations were detected early in the 3rd postoperative month and persisted until the 12th month. The interventricular septum was initially thickened in the 3rd postoperative month and then recovered at the 12th month. Notable postoperative cardiac reversibility was observed in male patients but did not occur in all female patients. Patients achieving endocrine remission with normalized hormone levels had thinner LV myocardia than patients without normalized hormone levels.ConclusionOur findings demonstrated that some of the cardiac involvement in acromegaly patients is reversible after surgical treatment which lowers hormone levels. Endocrine remission and gender significantly impacted postoperative cardiac reversibility.

MICS CABG: a single-center experience of the first 100 cases.

To study the learning curve and outcomes of the first 100 cases of minimally invasive cardiac surgery (MICS) coronary artery bypass grafting (CABG) performed at our center. From January 2017 to November 2019, a total of 100 patients underwent CABG via left anterior thoracotomy approach. We have studied the operative times within the MICS CABG patients to analyze our learning curve. We also studied the postoperative outcomes and compared these with those of patients who underwent sternotomy during the same period. The mean age was 59.33 ± 9.95 (range 37-82) years. The numbers of males and females were 72 and 28 respectively. The preoperative average ejection fraction (EF) was 51.08 ± 9.75%. All these patients underwent CABG via left thoracotomy approach, after satisfying the exclusion criteria. All patients received left internal mammary artery (LIMA) to left anterior descending (LAD) as a standard graft, with the radial artery and saphenous vein being the next alternative conduits. The average length of the incision was 6.06 ± 0.45cm. Only 2 cases were done on pump. The average number of grafts per patient was 2.33 ± 0.92. The mean operative time was 132.40 ± 11.56min. The mean duration of ventilation was 4.79 ± 1.90h and average intensive care unit (ICU) stay was 2.62 ± 0.84days. There was one conversion and no mortalities in our study. We had analyzed our operative times and noticed a significant reduction after the first 20 cases, which was our learning curve. MICS CABG can be performed for multivessel disease with the same comfort as for a single or a double vessel disease, once the learning curve has been achieved. Only significant difference from the sternotomy approach was noted in the longer operative times for MICS CABG during the learning curve, and not thereafter. Significant benefits of MICS over sternotomy were noticed in the immediate postoperative parameters like duration of ventilation, mean drainage, postoperative pain, ICU stay, and hospital stay, with no difference in postoperative adverse events.

Initial Experience of A Heart Failure Disease Management Clinic During the Covid-19 Era

BackgroundThe COVID-19 pandemic has necessitated significant alterations in ambulatory heart failure (HF) care, primarily with the introduction of telemedicine. We describe our initial experience caring for patients in the COVID-19 era in the Johns Hopkins Heart Failure Bridge Clinic (JHHFBC), an ambulatory disease management and diuresis clinic aimed at preventing hospitalizations.MethodsThe JHHFBC sees about 2500 patients per year with 25% of those patients needing intravenous diuretics in the clinic. Starting March 16, 2020, we implemented a COVID-specific workflow incorporating telemedicine, which the clinic had previously not been utilizing. Patient visit outcomes were adjudicated, including change in diuretic dosing, intravenous diuretic administration, and need for hospitalization.ResultsFrom March 16, 2020 to April 24, 2020 we had 116 patients seen 164 times (Figure 1). The average age of patients was 61 ± 14 years, 50% female, and 70% Black. Average left ventricular ejection fraction was 25 ± 21% with 45% nonischemic cardiomyopathy, 14% ischemic cardiomyopathy, 6% amyloid, 35% had heart failure with preserved ejection fraction. The majority of patients were New York Heart Association (NYHA) class II or III (109, 94%). Reasons for clinic referral included an equal frequency of post hospital discharge, worsening HF symptoms and routine follow up. Of the 96 telemedicine visits, 23% resulted in oral diuretic dose adjustment and 6 patients were referred for in-person visits. Of the 68 in-person visits, 34 (50%) resulted in intravenous diuretic administration in clinic, with 8 referrals to the emergency department or for direct admission. There were 2 referrals for cardioversion and 3 referrals to hospice by the clinic. Two of 16 clinic patients that were tested for Covid 19 were positive.ConclusionWe found that HF patients could be effectively managed via telemedicine, however a subset still benefit from in-person assessment and access to ambulatory intravenous diuresis to avoid hospitalization. We hope these initial experiences will lend insights to optimization of future outpatient HF care, including the use of telemedicine, even after the current global health emergency.

Clinical Outcomes after Weaning from Venoarterial-Extracorporeal Membrane Oxygenation: A Single Center Review

Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to manage refractory cardiac failure. This study attempts to characterize the clinical outcomes and weaning success rates of patients placed on VA-ECMO. Methods An IRB-approved retrospective chart review of VA-ECMO cases at UCLA from 2015-2019 was conducted. Inclusion criteria included initiation of VA-ECMO for cardiac arrest, primary graft dysfunction, and cardiogenic shock. Diagnoses with primarily right ventricular failure were excluded. The primary outcome was survival at 30 days after ECMO decannulation without relapse to mechanical circulatory support. Patients were stratified into “weaned” verses “not weaned” groups. Weaned patients were further stratified into “successfully weaned” verses “unsuccessfully weaned” based on 30 day survival. Hemodynamic, laboratory, and echocardiogram parameters were compared. Echocardiograms prior to ECMO decannulation were reviewed for LV/RV systolic function and valvular function. T test was used to determine statistical significance among clinical parameters. Results Preliminary analysis showed that 117 patients met inclusion criteria. 43% were weaned from ECMO while 57% were unable to be weaned. Characteristics of both groups are described (Figure). The most common indications for ECMO were cardiac arrest and cardiogenic shock, the average duration was >100 hours, and bleeding was the leading complication. Among weaned patients, 84% survived to 30 days post-decannulation (Figure). 41 (82%) patients were successfully weaned compared to 9 (18%) who were unsuccessful (8 died, 1 relapsed to ECMO). Between the two groups, hemodynamic and laboratory parameters were similar (Figure). The average left ventricular ejection fraction on lowest ECMO flow rates was 43% in the successfully weaned group compared to 42% in the unsuccessfully weaned group. On average, both groups had mild right ventricular dysfunction. Conclusions While less than 50% of patients placed on VA-ECMO were weaned and decannulated, the majority of weaned patients survived to 30 days post-decannulation without relapse to mechanical circulatory support. These data suggest that clinical data, as described here, can be used when determining whether to wean patients off ECMO. Further studies are needed to evaluate clinical metrics that can be used to refine the ECMO weaning process and improve post-decannulation outcomes.

A Dedicated Guideline Directed Medical Therapy Clinic Improves Quality of Care and Outcomes In Patients with Heart Failure and Reduced Ejection Fraction

Introduction Congestive heart failure is associated with significant morbidity and mortality. Based on the results of landmark trials, current guidelines recommend that patients with heart failure and reduced ejection fraction (HFrEF) be treated with a regimen of medications, referred to as guideline directed medical therapy (GDMT), at target doses. Unfortunately, recent studies have shown that GDMT at target doses is only achieved in 1% of eligible patients. Hypothesis Enrollment into a dedicated GDMT Clinic will increase the proportion of patients with HFrEF on GDMT at target doses and improve several heart failure parameters. Methods A prospective pilot cohort study was conducted enrolling 19 patients with HFrEF (EF ≤ 40%) into a GDMT Clinic. The proportion of patients on GDMT at target doses as well as heart failure parameters including ejection fraction (EF), LV end-diastolic diameter (LVIDd), 6 minute walk test (6MWT), Minnesota Living with Heart Failure Questionnaire (MLWHFQ) and PHQ-9 scores were compared at baseline and 3 months post intervention. Results The mean age of our cohort was 66.4 ± 8.6 years and the median duration of heart failure diagnosis was 15 months. 21% were female, 84% were Caucasian, 63% had non-ischemic cardiomyopathy, and 68% were NYHA class II. At baseline, 0% of eligible patients were on target doses of beta-blocker or ACEi/ARB/ARNI and 67% were on target doses of MRA. After enrolling in the GDMT Clinic, there was a substantial increase in the number of patients on target doses of beta-blocker (26%), ACEi/ARB/ARNI (26%) and MRA (89%). 11% of patients were simultaneously on target doses of all three drug classes. The number of patients on an ARNI increased by 58%. All patients were on maximally tolerated GDMT post intervention, with further up-titration limited by medication side effects. At 3 months post intervention, average EF significantly increased from 27.7 ± 7.3% to 34.8 ± 7.6% (p = 0.002). Mean LVIDd significantly decreased from 6.1 ± 0.8 cm to 5.7 ± 0.8 cm (p = 0.04). Median 6MWT results increased from 304.8 m [IQR: 240.4 - 404.6] to 318.4 m [IQR: 261.3 - 428.8] (p = 0.99). Median MLWHFQ scores improved from 15.5 [IQR: 5.0 - 44.5] to 11.5 [IQR: 3.5 - 23.5] (p = 0.79). Median PHQ-9 scores increased from 1.5 [IQR: 0.5 - 5.0] to 2.0 [IQR: 0.5 - 5.0] (p = 0.79). Conclusions Enrollment of patients with HFrEF into a dedicated GDMT Clinic is an effective strategy to increase the proportion of patients on target doses of GDMT and improve clinical outcomes.

Relationship between device-detected subclinical atrial fibrillation and heart failure in patients with cardiac resynchronization therapy defibrillator.

BackgroundAtrial fibrillation (AF) is a leading preventable cause of heart failure (HF) for which early detection and treatment is critical. Subclinical‐AF is likely to go untreated in the routine care of patients with cardiac resynchronization therapy defibrillator (CRT‐D).HypothesisThe hypothesis of our study is that subclinical‐AF is associated with HF hospitalization and increasing an inappropriate therapy.MethodsWe investigated 153 patients with an ejection fraction less than 35%. We divided into three groups, subclinical‐AF (n = 30), clinical‐AF (n = 45) and no‐AF (n = 78). We compared the baseline characteristics, HF hospitalization, and device therapy among three groups. The follow‐up period was 50 months after classification of the groups.ResultsThe average age was 66 ± 15 years and the average ejection fraction was 26 ± 8%. Inappropriate therapy and biventricular pacing were significantly different between subclinical‐AF and other groups (inappropriate therapy: subclinical‐AF 13% vs clinical‐AF 8.9% vs no‐AF 7.7%: P = .04, biventricular pacing: subclinical‐AF 81% vs clinical‐AF 85% vs no‐AF 94%, P = .001). Using Kaplan‐Meier method, subclinical‐AF group had a significantly higher HF hospitalization rate as compared with other groups. (subclinical‐AF 70% vs clinical‐AF 49% vs no‐AF 38%, log‐rank: P = .03). In multivariable analysis, subclinical‐AF was a predictor of HF hospitalization.ConclusionsSubclinical‐AF after CRT‐D implantation was associated with a significantly increased risk of HF hospitalization. The loss of the biventricular pacing and increasing an inappropriate therapy might affect the risk of HF hospitalization.

Frequency, predictors and prognostic impact of implantable cardioverter defibrillator shocks in a primary prevention population with heart failure and reduced ejection fraction

The role of the implantable cardioverter defibrillator (ICD) in primary prevention real-world population is debated. We sought to evaluate the incidence, predictors and prognostic impact of ICD shocks in consecutive heart failure patients implanted for primary prevention at our tertiary institution. We retrospectively selected a sample of 497 patients (mean age 64.8 years, 82.1% men, average left ventricular ejection fraction, LVEF, 27.1%). At long-term follow-up (median time 70.4 months), total mortality was 40.8%, and 16.5% of patients had received at least one appropriate shock (3.12%/year). Inappropriate shock [odds ratio (OR) 1.93, 95% confidence interval (95% CI) 1.08-3.47; P = 0.027] and length of follow-up (1 year, OR 1.01, 95% CI 1.00-1.01; P = 0.0031) were associated with the occurrence of appropriate shock, whereas atrial fibrillation (OR 2.65, 95% CI 1.55-4.51, P < 0.001), length of follow-up (1-year OR 1.01, 95% CI 1.00-1.01, P < 0.001) and appropriate shock (OR 1.93, 95% CI 1.08-3.47, P = 0.027) were associated with the occurrence of inappropriate shock. Neither appropriate nor inappropriate shock independently increased mortality risk, whereas older age (hazard ratio 1.05; 95% CI 1.04-1.07; P < 0.001), atrial fibrillation (hazard ratio 2.25; 95% CI 1.67-3.02; P < 0.001) and lower LVEF (hazard ratio 0.97; 95% CI 0.94-0.99; P = 0.004) did. Incidence of shocks in real-world primary prevention ICD recipients might be lower than expected, and the association between ICD shocks and prolongation of survival is not as clear-cut as might be perceived. Further investigations from larger real-world samples are warranted.

Biliary hyperkinesia: an indication for cholecystectomy?

The main indications for laparoscopic cholecystectomy are stone-related diseases in adults. With a normal abdominal ultrasound (US), a hepatobiliary iminodiacetic acid (HIDA) scan with ejection fraction (EF) is recommended to evaluate gallbladder function. Biliary dyskinesia or low gallbladder EF (EF < 35%) is a recognized indication for cholecystectomy. Recent articles report long-term resolution of symptoms in children with high EFs on the HIDA scan. The purpose of this study is to evaluate the response of patients with biliary colic and hyperkinetic gallbladder to cholecystectomy. We suggest that laparoscopic cholecystectomy might be a considerable surgical option in a subset of the adult population whose workup for food-related biliary abdominal pain is negative except for the high-value EF on HIDA scan. Data were consecutively collected from all patients who underwent laparoscopic cholecystectomy between June 2012 and June 2019 at a single institution. Cases were identified using Current Procedural Terminology codes. Patients older than 17years of age with the negative US (no stone, no sludge, no gallbladder wall thickening) and EF greater than 80% on cholecystokinin (CCK)-HIDA scan were included in this study. All patients were seen at 2weeks and 10-16months after surgeries. Over 7years from June 2012 until June 2019, of 2116 patients who underwent laparoscopic cholecystectomy, 59 patients (2.78%) met study criteria. Postprandial abdominal pain was the most common symptom (43, 72.90%) followed by nausea/vomiting. Forty-seven patients (74.6%) had a reproduction of symptoms with CCK infusion. The average EF was 88.51%. Final pathology showed chronic cholecystitis in 41 (69.5%) patients, cholesterolosis in 13 (22%), polyp in 2 (3.4%). Thirty-six (61%) patients had complete resolution of symptoms, 9 (15%) patients had partial resolution, and 14 (24%) patients had no change. There was a complete resolution rate of 61% and an improvement rate of 76%. In patients with biliary symptoms, negative ultrasound, and elevated EF on HIDA scan (EF > 80%), laparoscopic cholecystectomy led to a significant rate of symptomatic relief. Interestingly, 94% also had unexpected pathologic findings. This disease process requires further analysis, but this could represent a new indication for laparoscopic cholecystectomy in the adult population.

Efficacy of Telemedicine to Manage Heart Failure Patients during COVID-19 Lockdown

&lt;p&gt;&lt;strong&gt;Background and Objective: &lt;/strong&gt;Congestive Heart failure (CHF) is an increasing clinical syndrome with frequent exacerbation requiring a very close follow-up to prevent hospitalization. Due to current lockdown situation related to coronavirus disease 2019 (COVID-19) pandemic, CHF patients suffered by having limited access to their physicians and therefore are more vulnerable and at higher risk for CHF exacerbations requiring CCU admission. There is no data so far in Pakistan using telemedicine to manage CHF patients. The present study aimed to use telemedicine to manage CHF patients at home, keeping them safe from COVID-19 in order to prevent exacerbation of CHF. &lt;strong&gt;Methods:&lt;/strong&gt; A descriptive study was carried out at Shalamar Hospital, Lahore. A total of 31 established CHF patients were enrolled to manage them at home via telemedicine after taking the approval from Institutional Review Board. Patients were followed via telemedicine every two weeks for a total period of 8 weeks. Data was analyzed in SPSS version 20. Mean with standard deviation was calculated for quantitative variables like age. Frequency and percentages were calculated for qualitative variables. For determining any significant difference between the stratified groups, the Chi-Square test was applied hence taking Pvalue &amp;le; 0.05 as significant. &lt;strong&gt;Results:&lt;/strong&gt; Among 31 patients, mean age was 54.4 &amp;plusmn; 11.121 years. A total of 60% were males. Average Left Ventricle Ejection Fraction (LVEF) of 26.9% was seen. Patients were followed on defined CHF monitoring parameters including weight changes, new or worsening ankle edema or breathing difficulty. Patients were trained to record and report their daily vitals. A total of 14 patients reported CHF symptoms and 11patients required adjustment of diuretic dose with successful management. Only two patients ended up being admitted in Coronary Care Unit (CCU) for CHF exacerbation and at 8 weeks there was no significant change in the weight gain or renal functions as a result of medicine adjustment due to telemedicine. &lt;strong&gt;Conclusion&lt;/strong&gt;: Telemedicine during current lockdown related to COVID-19 pandemic is an effective strategy to manage CHF patients at home while keeping them safe from Corona virus infection.&lt;/p&gt;

Estudio retrospectivo de casos de insuficiencia cardíaca en adultos del 2011 al 2015 en un Hospital Dominicano

Introducción: la insuficiencia cardíaca (IC) es un síndrome caracterizado por un funcionamiento inadecuado de las capacidades cardíacas, que se asocia con discapacidad. Sus múltiples etiologías y factores de riesgo varían geográficamente, por lo que se plantea conocer las características clínicas de la IC en la República Dominicana, con el objetivo de sugerir mejoras en los servicios de salud.&#x0D; Métodos: se identificaron 2,119 casos de pacientes con IC en el Hospital General de la Plaza de la Salud (HGPS) y con base en esta población se calculó una muestra de 326 casos, a partir de un intervalo de confianza de 95 % y un margen de error de 5 %. Partiendo del cálculo de la muestra, se seleccionaron aleatoriamente 378 casos. Este sobre muestreo se realizó previendo la posible eliminación de algunos casos en los análisis finales. Luego de esto, se procedió a la extracción de datos.&#x0D; Resultados: el estudio mostró que la edad promedio fue de 69 años. Se evidenciaron diversos factores de riesgos predominantes como la hipertensión arterial 87.5 %, cardiopatía isquémica 50.4 %, valvulopatías 40 %, y la diabetes mellitus un 34.7 %. También se observaron conductas de riesgo en las que predominan el uso de tabaco (23.7 %), obesidad (17.4 %) y consumo de alcohol (7.8 %). El síntoma más frecuente fue disnea con 84.7 %. La fracción de eyección promedio fue 48 %. El tratamiento más común fue los diuréticos. La mortalidad registrada fue 11.1 %.&#x0D; Discusión: este estudio evidencia una alta ocurrencia de conductas y factores de riesgo, cuya intervención y subsecuente disminución pudiera significar cambios importantes a la prevalencia de la IC en el país.

Very early discharge after cardiac implantable electronic device implantations: is this the future?

To limit the ever-increasing healthcare costs, strategies to minimize hospitalization length are warranted. In this perspective, early discharge (the same day or after < 24h) post-cardiac implantable electronic device (CIED) implantation might represent a useful strategy; nevertheless, it is imperative first to understand the timing of (potentially lethal) complications and evaluate whether this is not only an effective but also a safe clinical decision. A retrospective cohort analysis of all patients undergoing new CIED implantation from Jan 2008 to Dec 2014 was conducted. Patient demographics, comorbidities, and timing of complications post CIED implantation were evaluated, and the timing of complications was divided into intra-operative, 0-6h (h), 6 to 24h, and > 24h post-implant. One-year post-implant follow-up (FU) was performed in our CIED clinic. A total of 1868 patients (68% men, average age 70years, 85% hypertension, 39% diabetes, 57% coronary artery disease, and average left ventricular ejection fraction (LVEF) 41%) received 703 (38%) pacemaker, 448 (24%) implantable cardioverter-defibrillator (ICD), 639 (34%) cardiac resynchronization therapy (CRT) devices, and 78 (4.2%) cardiac contractility modulation. A total of 199 (11%) patients experienced 214 complications. Most (75%) occurred > 24h post-implantation (with a median of 7days). At univariate analysis, complications occurred more often in patients with a lower LVEF, on anticoagulation/antiplatelet therapy, and undergoing ICD/CRT-D implantation (p< 0.05 for all). Most complications occur > 24h after first time CIED implantation. Therefore, it might not be optimal to discharge patients in ≤ 24h, unless extensive ambulatory monitoring for complications is available.

Clinimetric analysis of heart failure in Mexican patients.

Heart failure (HF) is a syndrome characterized basically by a circulatory deficit to cover the metabolic and energetic demands of the body. This condition has a broad spectrum in its clinical presentation, affects the quality of life significantly, impacts the family/social environment, and generates a great demand for health services. The purpose of this research is to report the situational diagnose of patients with HF in Mexico. We evaluated 292 patients, 70.2% were men. Average age was 56.7 ± 14.3 years. Ischemic heart disease is the main etiology (98 patients, 33.9%) followed by hypertensive (22.6%) and idiopathic (23.3%) heart disease. The associated clinical background was obesity (31.1%), systemic hypertension (36.7%), myocardial infarction (26.4%), and dyslipidemia (15.1%). The most common symptom was stress dyspnea (41.4%) and jugular vein engorgement at physical examination (32.5%). Anemia was observed in 1% of patients. The average left ventricular ejection fraction was 29.2 ± 10.6%. Sinus rhythm was the most frequently detected in 84.9%. 19.9% of patients had an implantable cardioverter-defibrillator or cardiac resynchronization therapy. 13.7% of patients with QRS > 130 ms. In our population, the meta-analysis global group in chronic heart failure risk score calculated was 16.8 ± 5.7 and for EMPHASIS 3.3 ± 1.5. We observed that age at presentation in HF in this analysis is at least 10 years younger than in other reports. The grade of obesity takes relevance in our group. The association of anemia and HF in Mexico is rare.

Evaluation of Right Ventricular Function and Various Models of Delayed Enhancement with Cardiac Magnetic Resonance Imaging in Patients with Repaired Tetralogy of Fallot

Background: Tetralogy of Fallot (TOF) is considered as the most frequent cyanotic congenital heart disorder. Right ventricular (RV) dysfunction is possible to be observed in patients with repaired TOF. Delayed enhancement (DE) is one of the recommended findings for RV dysfunction. Objectives: This study aimed at investigating the DE and its probable relationship with RV function through cardiac magnetic resonance (CMR). Patients and Methods: In this cross-sectional study, the values of cardiovascular magnetic resonance of 110 symptomatic patients, who had repaired TOF for 35 years, were gathered. We compared cardiac function indices (CFI) in patients with and without DE. Results: The patients had an average age of 21.93 ± 6.94 years (59.12% were male and 40.94% were female). 93.66% of the subjects showed DE and 6.44% of them did not have DE. 78.61% of the samples had DE of the right ventricular outflow tract (RVOT); whereas, 21.39% showed DE of the other sites. The differences between mean regurgitation fraction, average RV end-diastolic volume (RVEDV), average RV end systolic volume (ESV), and average RV ejection fraction in DE positive and negative patients were statistically significant (P values = 0.01, 0.04, 0.04, and 0.01, respectively.) Conclusion: DE commonly occurs as a complication of surgery to repair TOF and could be used as a factor for impaired RV function and other complications. Using CMR imaging for follow up of these patients could lead to diagnosis of these complications.

SAT-213 Relationship of Cardiovascular disease with dialysis dosage

Cardiovascular Disease (CVD) is the leading cause of death in End Stage Renal Disease (ESRD) patients on Maintenance Hemodialysis (MHD). The accumulation of uremic toxins play a part in the pathophysiology of cardiovascular disease that may progress to myocardial fibrosis, cardiomyopathy, left ventricular hypertrophy, vascular calcification and atherosclerosis. Thus, morbidity and mortality in hemodialysis patients is closely correlated to the delivered dialysis dose. The delivered dose is measured in MHD patients either by blood samples to calculate single pool Kt/V or by measuring the ionic dialysance in real time using online clearance monitoring (OCM). The aim of our study is to evaluate the influence of dialysis dose on the presence of CVD and to assess its relationship with echocardiographic parameters. 34 ESRD patients on MHD were included in the study from June 2019 to September 2019. Patients’ record, pre- and post- dialysis labs, Kt/V,OCM,URR, echocardiographic parameters including Left Atrial Volume Index (LAVI), Ejection Fraction (EF), Pulmonary Artery Systolic Pressure (PASP), presence of diastolic dysfunction and Left Ventricular Hypertrophy (LVH) were studied. Patients with a history of any cardiac event, a reduced EF or segmental wall motion abnormality on echocardiography were labelled as having CVD. Baseline echocardiographic measurements for each patient were analyzed. Data was analyzed using Statistical Package for Social Sciences (SPSS) version 25. Of the 34 hemodialysis patients there were 16 females and 18 males with age ranging from 17 to 87 years and mean age of 59.6 years (table 1). Patients had MHD vintage ranging from half a month to 79 months with a mean vintage of 33.9 months. 55.9% of patients had CVD. 14.7%(5) patients had a Kt/V of <1.4 and 85.3% (29) had Kt/V of >1.4. Average EF of patients with CVD was 46.9% and without CVD was 55.1%. Presence of CVD correlated negatively with EF (r = -0.541, p=0.001). Mean LAVI was 40.3ml/m2. 82.4% patients had a LAVI of >34ml/m2. Markers of dialysis dose OCM (r= -0.467, p=0.005), KT/V (r= -0.405, p=0.017), URR (r= -0.364, p=0.034) correlated negatively with the presence of CVD. Patients with a Kt/V of <1.4 had a higher prevalence of CVD and diastolic dysfunction. as compared to patients with Kt/V of >1.4 (table 3). A higher PASP was prevalent in patients with lower Kt/V as compared to those with high Kt/V. Patients with a Kt/V of <1.4 had a higher prevalence of moderately enlarged LAVI (42-48 ml/m2). OCM had a significant negative correlation with LAVI (r= -0.359, p=0.037). However, there was no statistically significant correlation of Kt/V with any of the parameters on echocardiography.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) The presence of Cardiovascular disease is related to dialysis dose. Sub-optimal dialysis is associated with CVD. Many echocardiographic parameters were related to the dose of dialysis. Patients with a lower Kt/V had higher LAVI and PASP. There was also an increased presence of diastolic dysfunction in patients with lower Kt/V. Thus, clearance during dialysis can influence cardiac clinical and echocardiographic parameters.