Complete Left Ventricular Ejection Fraction Recovery Research Articles

The prognostic impact of follow-up cardiac metaiodobenzylguanidine imaging on left ventricular trajectory after acute decompensation.

Cardiac metaiodobenzylguanidine (MIBG) imaging provides prognostic information in patients with heart failure (HF). Recently, the trajectory of left ventricular ejection fraction (LVEF) has been a focus in patients with reduced LVEF admitted for acute decompensated HF (ADHF). We sought to investigate the prognostic value of follow-up cardiac MIBG imaging in ADHF patients with reduced LVEF in relation to LVEF trajectory. We prospectively studied 145 ADHF patients with a reduced LVEF of <40%. The cardiac MIBG heart-to-mediastinum ratio (the late HMR) was measured on the delayed image at discharge and at the 6-month follow-up (6FUP). At 6 months after discharge, 54 (37%) patients had complete recovery of LVEF ≥50% (HFcorEF), and 43 (30%) patients had partial recovery of LVEF 40-50% (HFparEF), while the remaining 48 (33%) patients had no functional recovery of LVEF (HFnorEF). The late HMR at the 6FUP in HFcorEF patients was significantly greater than that in HFparEF and HFnorEF patients. During a follow-up period of 4.3 ± 2.6 years, 43 patients had cardiac events, defined as a composite of readmission for worsening HF and cardiac death. Patients with a lower late HMR at the 6FUP had a greater risk of cardiac events than those with a higher late HMR at the 6FUP in the group with recovered LVEF, especially HFparEF, which was not observed in the HFnorEF subgroup. Follow-up MIBG imaging after discharge could provide additional prognostic information in ADHF patients with recovered left ventricular function.

The prognostic impact of follow-up cardiac Metaiodobenzylguanidine imaging: relation to differential trajectories in left ventricular ejection fraction after acute decompensation

Abstract Background Cardiac metaiodobenzylguanidine (MIBG) imaging provides prognostic information in patients with heart failure (HF). Recently, the trajectory of left ventricular ejection fraction (LVEF) has been focused in patients with reduced LVEF admitted for acute decompensated heart failure (ADHF). We sought to prospectively investigate the prognostic value of the follow-up cardiac MIBG imaging in ADHF patients with reduced LVEF, in relation to LVEF trajectory. Methods We prospectively studied 145 ADHF patients with reduced LVEF&amp;lt;40%. The cardiac MIBG heart-to-mediastinum ratio (late HMR) was measured on the delayed image at the discharge and 6 months’ follow-up (6FUP). HF recovered LVEF (HFrecEF) was defined as those with a second measurement of LVEF at 6FUP of ≥ 40% with a 10-point increase from baseline LVEF, according to the previous report. Furthermore, in the present study, HFrecEF was classified into the two groups; patients with partial recovery of LVEF (≥40%, &amp;lt;50%) (HFparEF) and complete recovery of LVEF (≥50%) (HFcorEF). The endpoint was a cardiac event (CE) defined as a composite of cardiac death and unplanned hospitalization for worsening HF. Results At 6 months after the discharge, HFrecEF was observed in 97 (67%) of 145 study patients and the remaining 48 (33%) patients did not have HFrecEF (HFnorEF). In the subgroup of HFrecEF, 43 (30%) patients had HFparEF and 54 (37%) patients had HFcorEF. Late HMR at 6FUP in HFcorEF patients was significantly greater than those in HFparEF and HFnorEF patients, which was also observed at the discharge with non-significant difference. The change of late HMR significantly correlated with the improvement in LVEF (r=0.33, p&amp;lt;0.001). During a follow-up period of 4.3 ± 2.6 years, 28 patients in HFnorEF, 11 patients in HFparEF and 4 patients in HFcorEF had CEs, respectively. Kaplan-Meier analysis revealed that HFnorEF patients had a significantly higher risk of cardiac events than those with HFparEF and HFcorEF. (58.3% vs 25.6% vs 7.4% P &amp;lt; 0.0001). Patients with lower late HMR at 6FUP had a greater risk of CEs than those with higher late HR at 6FUP in HFrecEF, especially in HFparEF, which was not observed in HFnorEF subgroup. Conclusion The follow-up MIBG imaging after the discharge could provide the additional prognostic information in ADHF patients with recovered LV function.

Heart failure with reduced ejection fraction in young women: Management and outcomes in Reunion island

Heart failure with reduced ejection fraction (HFrEF) is a public health problem in France and around the world, with an increasing prevalence and a high mortality-rate. There is no data about HFrEF in young women in Reunion Island. We sought to describe characteristics, management, and evolution of HFrEF in young women in Reunion Island. We retrospectively enrolled all 18- to 44-year-old women, hospitalized between 01/01/2014 and 12/31/2019 with a new diagnosis of cardiac failure with left ventricular ejection fraction (LVEF) ≤ 45%. One hundred and thirty patients were included. Thirty-six patients (28%) had an ischemic cardiopathy, 88 (68%) a non-ischemic dilated cardiomyopathy. Among them, 40 (45%) had a peripartum cardiomyopathy, 27 (30%) an idiopathic cardiomyopathy, 5 (6%) an anthracycline-induced cardiomyopathy. Mean age was 36 ± 6 years, mean LVEF 29 ± 10%. Most frequent cardiovascular risk factors were: tobacco use (44%), hypertension (32%), and diabetes (25%). Obesity (39%) was particularly represented regardless of the type of cardiopathy. At discharge, 83% of patients were treated with beta-blockers and 86% with angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers. Fifty-three patients (49%) had a complete LVEF recovery (≥ 50%) after one year, with a significantly higher rate in peripartum cardiomyopathy (71%) than in non-peripartum dilated cardiomyopathy (33%, P = 0.02). The overall one-year mortality-rate was 11%, significantly higher in non-peripartum dilated cardiomyopathy (19%) than peripartum cardiomyopathy (3%) and ischemic cardiopathy (8%). One patient underwent cardiac transplantation after a myocardial infarction. HFrEF has a high mortality-rate in young women in Reunion Island. In these young patients, dilated cardiomyopathy is frequent, but ischemic cardiopathy has a particularly high incidence due to the high prevalence of cardiovascular risk factors.

Heavy Burden of Toxic Dilated Cardiomyopathy Among Young Adults: A Retrospective Study and Review of the Literature.

Dilated cardiomyopathy (DCM) is a well described entity for heart failure (HF) with reduced left ventricular ejection fraction (LVEF). Recently, drugs and other substance of abuse have been recognised as potential triggers for DCM. The aim of this study was to assess the survival in patients ≤ 65 years of age with toxic cardiomyopathy (TCM). Left ventricular remodelling and the potential usefulness of left ventricular assist devices (LVADs) was also assessed. This was a single-centre retrospective study from January 2003 to August 2019 of 553 patients ≤ 65 years old with LVEF < 40% at a tertiary-care cardiology centre. A total of 201 patients (36%) had a diagnosis of idiopathic DCM. Further analysis identified 38 patients (19%) for which a TCM was the most likely etiology (amphetamine [50%], cocaine [37%], anabolic steroids [8%], and energy drinks [5%]). Despite a mean LVEF of 17 ± 8% at presentation, most patients (n= 27; 71%) had event-free survival with guideline-directed medical therapy, and 61% (n= 23) recovered an LVEF ≥ 40% after a median follow-up of 21 ± 23 months. Seven patients (18%) required an LVAD and 1 patient (3%) a transplantation. All LVADs were explanted or decommissioned after partial or complete LVEF recovery after a median support time of 11 ± 4 months. TCM induced by substance abuse is a frequent cause of HF, accounting for almost 20% of patients ≤ 65 years of age with DCM of unknown etiology. Treatment must be tailored on an individual basis. Mechanical circulatory support demonstrated its usefulness in carefully selected patients.

Heart failure with reduced ejection fraction in young women: Management and outcomes in Reunion Island

Heart failure with reduced ejection fraction (HFrEF) is a public health problem in France and around the world, with an increasing prevalence and a high mortality-rate. There is no data about HFrEF in young women in Reunion Island. We sought to describe characteristics, management, and evolution of HFrEF in young women in Reunion Island. We retrospectively enrolled all 18 to 44-year-old women, hospitalized between 01/01/2014 and 12/31/2019 with a new diagnosis of cardiac failure with left ventricular ejection fraction (LVEF) ≤ 45%. One hundred and thirty patients were included. Thirty-six patients (28%) had an ischemic cardiopathy, 88 (68%) a non-ischemic dilated cardiomyopathy. Among them, 40 (45%) had a peripartum cardiomyopathy, 27 (30%) an idiopathic cardiomyopathy, 5 (6%) an anthracycline-induced cardiomyopathy. Mean age was 36 ± 6 years, mean LVEF 29 ± 10%. Most frequent cardiovascular risk factors were: tobacco use (44%), hypertension (32%), and diabetes (25%). Obesity (39%) was particularly represented regardless of the type of cardiopathy. At discharge, 83% of patients were treated with beta-blockers and 86% with angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers. Fifty-three patients (49%) had a complete LVEF recovery (≥ 50%) after one year, with a significantly higher rate in peripartum cardiomyopathy (71%) than in non-peripartum dilated cardiomyopathy (33%, P = 0,02). The overall one-year mortality-rate was 11%, significantly higher in non-peripartum dilated cardiomyopathy (19%) than peripartum cardiomyopathy (3%) and ischemic cardiopathy (8%). One patient underwent cardiac transplantation after a myocardial infarction. HFrEF has a high mortality-rate in young women in Reunion Island. In these young patients, dilated cardiomyopathy is frequent, but ischemic cardiopathy has a particularly high incidence due to the high prevalence of cardiovascular risk factors.

346 Baroreflex sensitivity and autonomic function in Takotsubo syndrome long after the acute phase

Abstract Aims Takotsubo Syndrome (TS) occurs as an acute coronary syndrome (ACS) characterized by severe left ventricular (LV) dysfunction that typically recovers spontaneously within days or weeks and in the absence of obstructive coronary artery disease. Although during the acute phase it is well documented that an exaggerated sympathetic tone plays a central role in the development of TS, whether an impaired sympatho-vagal balance may persist long after the acute phase, despite the recovery of left ventricular function, is still an open issue. Interestingly, recent evidences suggest that an impairment in central autonomic network not only persist long after the acute event but also may be pre-existent before the acute onset of TS. The Aim of the study was to investigate whether an impairment of the autonomic function is still present long after a TS event. Methods and results We evaluated 67 patients (91% female, mean age 66 ± 8 years) divided into three groups: 24 with a history of TS (1 year after acute event), 21 subjects with a previous history of acute coronary syndrome (ACS) and complete LV ejection fraction recovery (1 year after acute event) and 22 age- and gender-matched healthy subjects. All patients underwent a non-invasive beat-to-beat arterial blood pressure and heart rate recording (short term: 5 min), after at least 3 days of β-blockers wash-out, to obtain heart rate variability (HRV) and spontaneous baroreflex sensitivity (sBRS) data. An overall autonomic dysfunction was found in both TS and ACS groups compared to controls. In particular, a lower heart rate variability, expressed as lower SDNN, has been found in TS and ACS groups compared to controls (31 ± 12 vs. 25 ± 11 vs. 41 ± 22; P = 0.006—Figure A) as a consequence of blunted vagal tone, expressed as lower RMSSD (20 ± 12 vs. 19 ± 11 vs. 40 ± 37; P = 0.007—Figure B) and higher sympathetic tone, expressed as higher LF/HF ratio (P = 0.007 Figure C) which was found to be higher in TS even when compared to ACS (TS: 3.5 ± 2.5 vs. ACS: 2.1 ± 1.7; P = 0.011). Moreover, fractal analysis of HRV showed higher complexity of heart rate regulation, expressed as higher fractal dimension (DFA 1.48 ± 0.06 vs. 1.53 ± 0.05 vs. 1.40 ± 0.10; P &amp;lt; 0.0001—Figure D), in both TS and ACS compared to controls. Interestingly, spontaneous BRS showed the lowest values in the TS group (sSBP: 5.6 ± 2.6 vs. 7.5 ± 3.0 vs. 12.1 ± 11.9; P = 0.027—Figure E), associated with highest levels of sympathetic peripheral control of systolic blood pressure (SBP), expressed as LF-BRS (13.7 ± 9.6 vs. 8.3 ± 5.2 ± 6.8 ± 5.8; P = 0.008—Figure F). Conclusions An autonomic dysfunction, characterized by a hyper-sympathetic tone, reduced baroreflex sensitivity and increased peripheral adrenergic control of blood pressure, persists in TS patients long after the acute phase.

Maintaining sinus rhythm after electrical cardioversion

Abstract Introduction Atrial fibrillation (AF) and atrial flutter (AFL) are commonly terminated by electrical cardioversion (EC) when a rhythm control strategy is adopted. However, the long-term success following EC is variable. Purpose To determine the clinical characteristics and independent predictors of sinus rhythm (SR) maintenance after EC due to AF/AFL. Methods We conducted a retrospective study enrolling patients with AF/AFL referred to EC in our Cardiology Department, from September 2011 to September 2020. Clinical characteristics and echocardiographic studies were analysed. Primary endpoints were the incidence of ischemic stroke, all-cause and cardiovascular (CV) mortality. Independent predictors of SR maintenance were identified through a binary logistic regression analysis, considering p=0,05. Results A total of 719 patients with a median age of 67 years-old were included, and EC was successfully performed in 93,2%. AFL was diagnosed in 21%, 57,3% had arterial hypertension and 34,6% were obese. 62,1% had persistent AF/AFL, 19,6% presented with first diagnosed AF/AFL and 17,2% had paroxysmal episodes. Left ventricular ejection fraction (LVEF) was preserved in 66,7%. Maintenance of SR after one-year was documented in 64,7% of patients with successful EC. They had lower prevalence of chronic kidney disease (CKD) (2,6% vs 10,7%; p&amp;lt;0,001) and received less electrical shocks during EC (1,20 vs 1,39; p=0,005). There were no differences regarding antiarrhythmic therapy between both groups. Complete LVEF recovery after EC was more frequent in patients who maintained SR (58,8% vs 31,9%; p=0,008), with a greater prevalence of preserved LVEF after EC (88,8% vs 73,6%; p&amp;lt;0,001). During a median follow-up of 1368 days, these patients performed less additional EC (0,26 vs 0,65; p&amp;lt;0,001) and were less referred to ablation procedures (7,1% vs 15,1%; p=0,011). No differences were found regarding stroke rate, but all-cause mortality (12,8% vs 25%; p=0,002) and CV death (3,8% vs 10,9%; p=0,005) were significantly lower in patients who maintained SR. Absence of CKD (p=0,013), applying fewer electric shocks during EC (p=0,013) and preserved LVEF after EC (p=0,004) were independent predictors of SR maintenance. Conclusion In our study, most patients maintained SR one year after EC, which was associated with a lower all-cause and CV mortality. Absence of CKD, applying fewer electric shocks during EC and preserved LVEF after EC were independent predictors of SR maintenance. Funding Acknowledgement Type of funding sources: None.

Cardiotoxicity of Anthracyclines.

Cardiotoxicity is a feared side effect that may limit the clinical use of anthracyclines. It may indeed affect the quality of life and survival of patients with cancer, regardless of oncological prognosis. This paper provides an overview of anthracycline-induced cardiotoxicity in terms of definition, classification, incidence, risk factors, possible mechanisms, diagnosis, and treatment. We also report effective strategies for preventing cardiotoxicity. In addition, we discuss limiting current approaches, the need for a new classification, and early cardiotoxicity detection and treatment. Probably, anthracycline-induced cardiotoxicity is a continuous phenomenon that starts from myocardial cell injury; it is followed by left ventricular ejection fraction (LVEF) and, if not diagnosed and cured early, progressively leads to symptomatic heart failure. Anthracycline-induced cardiotoxicity can be detected at a preclinical phase. The role of biomarkers, in particular troponins, in identifying subclinical cardiotoxicity and its therapy with angiotensin-converting enzyme inhibitors (mainly enalapril) to prevent LVEF reduction is a recognized and effective strategy. If cardiac dysfunction has already occurred, partial or complete LVEF recovery may still be obtained in case of early detection of cardiotoxicity and prompt heart failure treatment.

Using biomarkers and early prophylactic treatment to prevent cardiotoxicity in cancer patients on chemotherapy

Cardiac toxicity induced by anticancer therapy is of considerable concern for, once it develops, it may compromise the clinical effectiveness of treatment independent of the oncologic prognosis. The main strategy to minimize cardiotoxicity is to detect high-risk patients and begin prophylactic treatment as early as possible. According to the current standard for monitoring cardiac function cardiotoxicity is usually detected only once a functional impairment has already occurred, thus precluding any chance of prevention. The measurement of cardio-specifi c biomarkers can be a valid diagnostic tool for the early identifi cation, assessment and monitoring of cardiotoxicity. The role of Troponin I in identifying patients with subclinical cardiotoxicity and their subsequent treatment with angiotensin- converting enzyme inhibitors to prevent left ventricular ejection fraction (LVEF) reduction and cardiac events, is emerging as an effective strategy against these complications. When this approach is not feasible, a complete LVEF recovery and a reduction in cardiac events may be achieved if left ventricular dysfunction (LVD) is detected early and the patient promptly treated with angiotensin-converting enzyme inhibitors, possibly in combination with beta-blocking agents.

Wearable Cardioverter-Defibrillator Therapy for the Prevention of Sudden Cardiac Death: A Science Advisory From the American Heart Association.

Sudden cardiac death (SCD) accounts for >300 000 deaths in the United States annually.1 Although the majority of these deaths occur in low-risk populations2 in which aggressive interventions are not practical, some higher-risk populations have been established in whom intervention with an implantable cardioverter-defibrillator (ICD) has been shown in randomized trials to reduce mortality.3–7 Additionally, there is a population of patients who may benefit from automatic emergency cardioversion-defibrillation but are not deemed appropriate candidates for ICD implantation at the time of presentation. This group is defined by 2 populations. The first subgroup comprises those who are at perceived risk but for whom there may be optimism for clinical improvement (eg, patients soon after revascularization or those with a recent diagnosis of myocardial infarction [MI] or cardiomyopathy). Alternatively stated, the optimal management of these patients at risk (or perceived risk) during the waiting period before an ICD is indicated remains unknown. The second subgroup includes those who have a clear indication for ICD but also have a contraindication to immediate ICD placement (eg, active infection or unknown prognosis). The wearable cardioverter-defibrillator (WCD) is a device designed for patients at risk of SCD who are not immediate candidates for ICD therapy. By providing automatic therapy, the WCD does not depend on a second person to defibrillate, as required with a manual or automated external defibrillator (AED). Unlike the ICD (including both transvenous and subcutaneous devices), the WCD requires no surgical operation, can be provided for a short period of time, is temporary, and is easily removed. These characteristics of the WCD, along with safety and efficacy data presented to the US Food and Drug Administration (FDA), resulted in approval in the United States in 2002.8 Because of the increasing use of the WCD and uncertainty of indications …

0380: Cardiac tolerance of bevacizumab associated with trastuzumab and conventional treatment in patients with primary inflammatory HER2positive breast cancer

Breast cancer is the most frequent female cancer. Treatment of HER2+ tumours evolved with immunotherapy, leading to improved survival. Cardiac toxicity associated to trastuzumab is frequent but reversible in 75% of cases. However, only little is know about the cardiotoxicity of new anti-VEGF antibodies associated to trastuzumab. In this study, we aimed to assess the cardiac tolerance of bevacizumab associated with trastuzumab and chemotherapy in HER2+ breast cancer patients. This is a post-hoc analysis of the BEVERLY-2 study, aiming to assess the efficacy of neoadjuvant bevacizumab, trastuzumab, and chemotherapy for primary inflammatory HER2+ breast cancer. A cohort of 52 patients was prospectively included. Left ventricular ejection fraction (LVEF) was assessed by echocardiography and/or isotopic ventriculography every three months during the mean follow-up of 33±3,42 months. Mean age prior to chemotherapy was 49,75 years ±11,60. On inclusion, mean LVEF was 66,56±6,13.There was no significant difference between LVEF on inclusion and before the 5th cycle of chemotherapy fifth cycle (C5)(66,56%±6,13 vs 65,11%±7,68 ; p=0,24), whereas LVEF was significantly reduced at the end of the neoadjuvant therapy (62,07%±7,84 vs 66,56±6,13; p=0,0001). The nadir of LVEF was 57,87%±8,79 and occured generally during the adjuvant period. In 16 patients, LVEF decreased below 50% after neoadjuvant therapy but complete recovery of LVEF was observed in all at the end of the follow-up, 3 months after the end of the treatment (Figure 1, next page). In this study, with an effective treatment protocol for inflammatory breast cancer, reduction in LVEF was observed in 30% of patients, however, it was reversible in all. Nadir of LVEF was observed after the final adjuvant therapy (31%). This timing and the possibility of recovery should be considered when discussing the interruption of chemotherapy because of reduced LVEF during the follow up. Fig. 1 – Treatment protocol Fig.2 Evolution of LVEF during the follow up Abstract 0380 - Figures 1,2

Anthracycline-Induced Cardiomyopathy: Clinical Relevance and Response to Pharmacologic Therapy

The purpose of this study was to evaluate the clinical relevance of anthracycline-induced cardiomyopathy (AC-CMP) and its response to heart failure (HF) therapy. The natural history of AC-CMP, as well as its response to modern HF therapy, remains poorly defined. Hence, evidence-based recommendations for management of this form of cardiomyopathy are still lacking. We included in the study 201 consecutive patients with a left ventricular ejection fraction (LVEF) <or=45% due to AC-CMP. Enalapril and, when possible, carvedilol were promptly initiated after detection of LVEF impairment. LVEF was measured at enrollment, every month for the first 3 months, every 3 months during the first 2 following years, and every 6 months afterward (mean follow-up 36 +/- 27 months). Patients were considered responders, partial responders, or nonresponders according to complete, partial, or no recovery in LVEF, respectively. Major adverse cardiac events during follow-up were also evaluated. Eighty-five patients (42%) were responders; 26 patients (13%) were partial responders, and 90 patients (45%) were nonresponders. The percentage of responders progressively decreased as the time from the end of chemotherapy to the start of HF treatment increased; no complete recovery of LVEF was observed after 6 months. Responders showed a lower rate of cumulative cardiac events than partial and nonresponders (5%, 31%, and 29%, respectively; p < 0.001). In cancer patients developing AC-CMP, LVEF recovery and cardiac event reduction may be achieved when cardiac dysfunction is detected early and a modern HF treatment is promptly initiated.