Depressed Left Ventricular Ejection Fraction Research Articles

Biomarkers to predict improvement of left ventricular ejection fraction after atrial fibrillation ablation

Abstract Background Atrial fibrillation (AF) and heart failure (HF) frequently coexist. Catheter ablation (CA) of AF is increasingly used in patients with AF and HF. However, prediction of improvement of HF after CA is challenging. Aim We aimed to evaluate the value of biomarkers, alone and in conjunction with a clinical tool (Antwerp score) to predict left ventricular ejection fraction (LVEF) recovery after CA in patients with AF and HF. Methods Patients undergoing CA for AF with depressed LVEF (<50%) were included. Plasma levels of 13 biomarkers were measured immediately prior to CA. Patients were categorized into "responders" (LVEF normalisation after CA in case of HFmrEF and at least 10% LVEF improvement and LVEF > 40% at follow-up in case of HFrEF) and "non-responders" (no LVEF recovery after CA). Models were constructed by comparing the plasma levels of the various biomarkers in responders and non-responders and by adjusting for age, sex, and Antwerp score and subsequent biomarkers were then combined according based on likelihood-ratios. The predictive power of the biomarkers alone and combined in outcome prediction, as well as improvement of the Antwerp score was then evaluated. Results Out of 1665 patients undergoing CA of AF, we included 208 patients with depressed LVEF (median age 63 years, 19% female, median LAVI 42 ml/m2, median LVEF 43%). The median follow-up time was 30 months [IQR 20-34] and the median time to LVEF recovery was 8 months [IQR 3-22]. Of these, 161 (77%) were responders and 47 (23%) were non-responders. Out of 13 biomarkers, four biomarkers (ANG2, GDF15, FGF23 and MyBPC3) were significantly different between responders and non-responders (p ≤0.001). A biomarker panel using these four biomarkers could predict LVEF recovery after CA for AF with an AUC of 0.72 (95%CI 0.64-0.81) overall, 0.69 (95%CI 0.59-0.78) in HFmrEF and 0.88 (95%CI 0.77-0.98) in HFrEF (Figure, A). Only ANG2 and GDF15 remained significantly associated with LVEF recovery after adjustment for age, sex, and the Antwerp score. The AUC of the Antwerp score for prediction of LVEF recovery improved from 0.75 (95% CI 0.67-0.83, Figure, B) to 0.78 (95% CI 0.70-0.86, Figure, C) in the overall population, from 0.71 (95% CI 0.61-0.81) to 0.74 (95% CI 0.64-0.84) in case of HFmrEF and from 0.87 (95% CI 0.78-0.97) to 0.92 (95% CI 0.85-0.99) in case of HFrEF when ANG2 and GDF15 were included in the model. Conclusion A biomarker panel using ANG2, GDF15, FGF23 and MyBPC3 performs similarly for prediction of LVEF recovery after CA in AF compared to the Antwerp score. The biomarkers ANG2 and GDF15 slightly improve the predictive value of the Antwerp score.Figure

A CASE OF DUAL–SITE LEFT VENTRICULAR PACING PERFORMED VIA A PERSISTENT LEFT SUPERIOR VENA CAVA IN A PATIENT WITH COMPLETE ATRIO–VENTRICULAR BLOCK AND RIGHT SUPERIOR VENA CAVA OCCLUSION

Abstract Patient A 64 year old male admitted for syncope. EKG presented 3rd degree AV block. Attempting to place temporary pacemaker was unsuccessful due to occlusion of the right femoral vein and the presence of a catheter for hemodialysis in the left femoral vein. He also has complete thrombosis of the right internal jugular vein, proximal superior vena cava and right femoral vein. He was referred to ICCU for monitoring, asymptomatic with no signs of congestion or hypoperfusion. Dopamine was started at 4 mcg/kg/min and then isoprenaline 0.06 mcg/kg/min. Initial work up Echocardiography showed depressed LV ejection fraction (LVEF 40%). Chest and abdomen angio–CT showed persistence of a superior left vena cava (PSLVC), which drained in the coronary sinus (CS). Right axillary and subclavian veins were occluded, and also right superior vena cava and right jugular vein. Left jugular, axillary and subclavian veins were pervious. Left femoral and right iliac–femoral veins showed significantly narrowing of the vessel lumen. Diagnosis and Management Our indication for this patient was CRT rather than RV pacing. The implant of a leadless AV pacemaker was also considered, but it was considered unfeasible due to limited access from the femoral veins. The presence of a PSLVC cava draining into CS was confirmed with angiography in the EP Lab. At the beginning of the procedure two episodes of asystole occurred. A first bipolar lead was rapidly placed in a postero–lateral branch of the CS, to obtain a stable temporary pacing. We then placed a quadripolar, active fixation, left ventricular pacing lead via the PSLVC into an antero–lateral branch of the CS. Finally, we placed a right atrium active fixation pacing lead in the right atrium again through the PSLVC. Vascular accesses were cephalic left vein and axillary vein. Acceptable sensing and pacing parameters were achieved. The bipolar LV lead was connected to the IS–1 RV port for sensing and the quadripolar lead was connected to the IS–4 LV port for pacing. Programming was DDDR 60–130 with active LV pacing only. Total procedural time was 180 minutes. No complications occurred. At discharge electric parameters were stable. Echocardiography showed an improvement in LVEF (45% vs 40%) and ECG showed atrio–ventricular LV pacing. Conclusion As far as we know this is the first reported case of a CRT delivered by two left ventricle pacing leads both placed via a PLSVC, with no need to place a pacing lead in the right ventricle.

Biomarkers to predict improvement of left ventricular ejection fraction after atrial fibrillation ablation

BackgroundAtrial fibrillation (AF) and heart failure frequently coexist. Prediction of left ventricular ejection fraction (LVEF) recovery after catheter ablation (CA) for AF remains difficult. ObjectiveThe purpose of this study was to evaluate the value of biomarkers, alone and in combination with the Antwerp score, to predict LVEF recovery after CA for AF. MethodsPatients undergoing CA for AF with depressed LVEF (<50%) were included. Plasma levels of 13 biomarkers were measured immediately before CA. Patients were categorized into “responders” and “nonresponders” in a similar fashion to the Antwerp score derivation and validation cohorts. The predictive power of the biomarkers alone and combined in outcome prediction was evaluated. ResultsA total of 208 patients with depressed LVEF were included (median age 63 years; 19% female; median indexed left atrial volume 42 mL/m2; median LVEF 43%). At a median follow-up time of 30 months, 161 (77%) were responders and 47 (23%) were nonresponders. Of 13 biomarkers, 4—angiopoietin 2 (ANG2), growth differentiation factor 15 (GDF15), fibroblast growth factor 23, and myosin binding protein C3—were significantly different between responders and nonresponders (P ≤ .001) and combined could predict the end point with an area under the curve of 0.72 (95% confidence interval [CI] 0.64–0.81) overall, 0.69 (95% CI 0.59–0.78) in heart failure with mildly reduced ejection fraction, and 0.88 (95% CI 0.77–0.98) in heart failure with reduced ejection fraction. Only ANG2 and GDF15 remained significantly associated with LVEF recovery after adjustment for age, sex, and Antwerp score and significantly improved the accuracy of the Antwerp score predictions (P < .001). The area under the curve of the Antwerp score in the outcome prediction improved from 0.75 (95% CI 0.67–0.83) to 0.78 (95% CI 0.70–0.86). ConclusionA biomarker panel (ANG2 and GDF15) significantly improved the accuracy of the Antwerp score.

Sex-related differences in patients presenting with heart failure–related cardiogenic shock

BackgroundHeart failure–related cardiogenic shock (HF-CS) accounts for a significant proportion of all CS cases. Nevertheless, there is a lack of evidence on sex-related differences in HF-CS, especially regarding use of treatment and mortality risk in women vs. men. This study aimed to investigate potential differences in clinical presentation, use of treatments, and mortality between women and men with HF-CS.MethodsIn this international observational study, patients with HF-CS (without acute myocardial infarction) from 16 tertiary-care centers in five countries were enrolled between 2010 and 2021. Logistic and Cox regression models were used to assess differences in clinical presentation, use of treatments, and 30-day mortality in women vs. men with HF-CS.ResultsN = 1030 patients with HF-CS were analyzed, of whom 290 (28.2%) were women. Compared to men, women were more likely to be older, less likely to have a known history of heart failure or cardiovascular risk factors, and lower rates of highly depressed left ventricular ejection fraction and renal dysfunction. Nevertheless, CS severity as well as use of treatments were comparable, and female sex was not independently associated with 30-day mortality (53.0% vs. 50.8%; adjusted HR 0.94, 95% CI 0.75–1.19).ConclusionsIn this large HF-CS registry, sex disparities in risk factors and clinical presentation were observed. Despite these differences, the use of treatments was comparable, and both sexes exhibited similarly high mortality rates. Further research is necessary to evaluate if sex-tailored treatment, accounting for the differences in cardiovascular risk factors and clinical presentation, might improve outcomes in HF-CS.Graphical abstractSex-related differences in clinical characteristics, shock severity, and mortality in patients with heart failure–related cardiogenic shock. Summary for the main study findings. AMI, acute myocardial infarction; CI, confidence interval; HF-CS, heart failure–related cardiogenic shock; LVEF, left ventricular ejection fraction; MCS, mechanical circulatory support; SCAI, Society for Cardiovascular Angiography & Interventions.

Cardiac Magnetic Resonance as Risk Stratification Tool in Non-Ischemic Dilated Cardiomyopathy Referred for Implantable Cardioverter Defibrillator Therapy-State of Art and Perspectives.

Non-ischemic dilated cardiomyopathy (DCM) is a disease characterized by left ventricular dilation and systolic dysfunction. Patients with DCM are at higher risk for ventricular arrhythmias and sudden cardiac death (SCD). According to current international guidelines, left ventricular ejection fraction (LVEF) ≤ 35% represents the main indication for prophylactic implantable cardioverter defibrillator (ICD) implantation in patients with DCM. However, LVEF lacks sensitivity and specificity as a risk marker for SCD. It has been seen that the majority of patients with DCM do not actually benefit from the ICD implantation and, on the contrary, that many patients at risk of SCD are not identified as they have preserved or mildly depressed LVEF. Therefore, the use of LVEF as unique decision parameter does not maximize the benefit of ICD therapy. Multiple risk factors used in combination could likely predict SCD risk better than any single risk parameter. Several predictors have been proposed including genetic variants, electric indexes, and volumetric parameters of LV. Cardiac magnetic resonance (CMR) can improve risk stratification thanks to tissue characterization sequences such as LGE sequence, parametric mapping, and feature tracking. This review evaluates the role of CMR as a risk stratification tool in DCM patients referred for ICD.

Outcomes of Transcatheter Aortic Valve Replacement Patients With Different Transvalvular Flow-Gradient Patterns

Low-flow low-gradient (LF-LG) aortic stenosis (AS) may occur with preserved or depressed left ventricular ejection fraction (LVEF). Both situations represent the most challenging subset of patients to manage and generally have a poor prognosis. Few and controversial data exist on the outcomes of these patients compared with normal flow-high gradient (NF-HG) AS after transcatheter aortic valve replacement (TAVR). We sought to characterize different transvalvular flow-gradient patterns and to examine their prognostic value after TAVR. We enrolled 1,208 patients with severe AS and categorized as follow: 976 patients NF-HG (mean aortic pressure gradient [MPG] ≥40mm Hg), 107 paradoxical LF-LG (pLF-LG, MPG <40mm Hg, LVEF ≥50%, stroke volume index <35ml/m2), and 125 classical LF-LG (cLF-LG) (MPG <40mm Hg, LVEF <50%, stroke volume index <35ml/m2). When compared with NF-HG and pLF-LG, cLF-LG had a worse symptomatic status (New York Heart Association III to IV 86% vs 62% and 67%, p <0.001), a higher prevalence of eccentric hypertrophy and a higher level of LV global afterload reflected by a higher valvuloarterial impedance. Valvular function after TAVR was excellent over time in all patients. While 30-day mortality (p=0.911) did not differ significantly among groups, cLF-LG had a lower 5-year survival rate (LF-LG 50% vs pLF-LG 62% and NF-HG 68%, p <0.05). cLF-LG was associated with a hazard ratio for mortality of 2.41 (95% confidence interval 1.65 to 3.52, p <0.001). In conclusion, TAVR is an effective procedure regardless of transvalvular flow-gradient patterns. However, special care should be given to characterized hemodynamic of AS, as patients with pLF-LG had similar survival rates than patients with NF-HG, whereas cLF-LG is associated with a twofold increased risk of mortality at 5-year follow-up.

Decoding molecular signature on heart of septic mice with distinct left ventricular ejection fraction

Dysregulated cardiac function after sepsis in intensive care unit is known to predict poor long-term outcome and increase mortality. Their pathological feature and molecular mechanism remain unclear. We observed that septic patients with depressed left ventricular ejection fraction (LVEF) have the highest in-hospital and 28days mortality comparing to patients with hyperdynamic LVEF or with heart failure with preserved LVEF. Echocardiograms reveal that survivors post cecum ligation and puncture (CLP) on rodents have stable LVEF and non-survivors have fluctuated LVEF at CLP early phase. CLP-induced mice fall into three groups based on LVEF 24h post-surgery: high-, low-, and normal-LVEF. Transcriptomic and proteomic analyses identify jointly and distinctively changed genes, proteins and biologically essential pathways in left ventricles from three CLP groups. Notably, transmission electron microscopy shows different mitochondrial and sarcomere defects associated with LVEF variances. Together, this study systematically characterizes the molecular, morphological, and functional alterations in CLP-induced cardiac injury.

Echocardiographic Progression of Peak Tricuspid Regurgitant Velocity Among Medicare Beneficiaries

BackgroundPeak tricuspid regurgitant velocity (TRV) on transthoracic echocardiography (TTE) is a commonly obtained parameter and robust predictor of subsequent adverse clinical outcomes. ObjectivesThe purpose of this study was to determine the predictors and clinical significance of TRV progression. MethodsWe retrospectively linked consecutive outpatient TTE reports from our institution to 2005 to 2017 Medicare claims. Individuals with prior tricuspid surgery, endocarditis, tricuspid stenosis, missing TRV values, TTEs performed during inpatient hospitalization, or <2 TTEs were excluded. ResultsA total of 4,572 patients (mean age 67.8 ± 11.9 years, 50.4% female) received 13,273 TTEs over a median follow-up of 7.4 (IQR: 4.5-6.9) years. TRV increased by a mean of 0.23 (95% CI: 0.22 to 0.23 m/s/y, P < 0.001) (range, 0.01-0.80 m/s/y). Older age, depressed left ventricular ejection fraction, diabetes, hypertension, hyperlipidemia, atrial fibrillation, heart failure, and chronic kidney disease were associated with faster progression (all P < 0.05). Accounting for 23 demographic, clinical, and TTE variables, faster TRV progression was associated with a stepwise increased risk of all-cause mortality (TRV progression quartile 4 vs 1; adjusted HR: 2.17; 95% CI: 1.74-2.71; P < 0.001). Those with regression of TRV (n = 384 [8.4%]) had a lower mortality risk (adjusted HR: 0.40; 95% CI: 0.28-0.57; P < 0.001). ConclusionsIn this large, multidecade study of Medicare beneficiaries with serial TTEs performed in the outpatient setting, the mean rate of TRV progression was 0.23 m/s/y. Older age, left heart disease, and adverse metabolic features were associated with faster progression. Faster progression was associated with a graded risk for all-cause mortality.

The evolving state of cardiac resynchronization therapy and conduction system pacing: 25 years of research at EP Europace journal.

Cardiac resynchronization therapy (CRT) was proposed in the 1990s as a new therapy for patients with heart failure and wide QRS with depressed left ventricular ejection fraction despite optimal medical treatment. This review is aimed first to describe the rationale and the physiologic effects of CRT. The journey of the landmark randomized trials leading to the adoption of CRT in the guidelines since 2005 is also reported showing the high level of evidence for CRT. Different alternative pacing modalities of CRT to conventional left ventricular pacing through the coronary sinus have been proposed to increase the response rate to CRT such as multisite pacing and endocardial pacing. A new emerging alternative technique to conventional biventricular pacing, conduction system pacing (CSP), is a promising therapy. The different modalities of CSP are described (Hirs pacing and left bundle branch area pacing). This new technique has to be evaluated in clinical randomized trials before implementation in the guidelines with a high level of evidence.

Contemporary Review of the Management of Left Ventricular Thrombus

Although there is established evidence for the treatment of left ventricular thrombus (LVT) at the outset, the subsequent management of these patients is less well-defined. This review discusses the currently available evidence for the initial type and duration of anticoagulation for LVT and explores potential treatment options after the initial period of anticoagulation. Of 2,052 studies screened, 32 studies (with three randomised controlled trials) were included. The initial anticoagulation strategy was either warfarin or direct oral anticoagulants, with the majority of studies showing similar outcomes. If LVT persists, studies recommended continuing anticoagulation (n=11/17) or switching to a different class of anticoagulant (n=7/17). After resolution, five studies recommended continuing anticoagulation in the presence of high-risk features of recurrence (i.e. persistently depressed left ventricular ejection fraction and/or apical wall dyskinesia). Medical management should be optimised, together with the appropriate revascularisation strategy, as clinically indicated. Synthesising the evidence, a practical algorithm for the management of LVT is proposed.

Global Longitudinal Strain Predicts Outcomes in Patients with Reduced Left Ventricular Function Undergoing Transcatheter Edge-to-Edge Mitral Repair.

The timing and selection of optimal candidates for mitral transcatheter edge-to-edge valve repair remains to be fully determined, especially in cases with severely depressed left ventricular ejection fraction (LVEF). The objective of this study is to evaluate the prognostic value of myocardial strain (LVGLS) in this setting. Retrospectively, 172 consecutive patients with LVEF ≤40% and severe MR treated with MitraClip were included. Four groups were generated according to the LVEF (<30% or ≥30%) and median LVGLS. The primary end-point was cardiovascular mortality. Procedural success was high (96.5%) and complications were rare. At one-year follow-up, 82.5% of patients maintained MR grade ≤2, 79.2% were at a NYHA class ≤II and a reduction of 80% in heart failure admissions was observed in all groups. Interestingly, among patients with a more depressed LVEF, LVGLS was found to be an independent predictor for cardiovascular mortality (HR: 3.3; 95% CI: 1.1-10, p = 0.023). Mitral valve repair with MitraClip is safe and it improves the mid-term functional class of patients regardless of LVEF. LVGLS can help in the selection of optimal candidates and timing for this procedure, as well as in the recognition of those patients with worse prognoses.

P71: Use of Veno-Arterial Extracorporeal Membrane Oxygenation and Impella for Cardiogenic Shock due to Cocaine Abuse

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella left ventricular assist device individually offer cardiovascular support for cardiogenic shock patients. Each modality has its own benefits and downfalls. We present a case in which a patient developed cocaine-induced coronary vasoconstriction resulting in cardiogenic shock with rapid systemic decompensation. We employed VA-ECMO and subsequent Impella to recover the patient. Methods: A 26-year-old male with a history of Graves’ Disease and chronic cocaine abuse presented to the ED with chest pain following cocaine ingestion. EKG showed sinus tachycardia and ST-elevations throughout, suspicious of coronary vasospasm. Labs showed an acute kidney injury as well as shock liver. Bedside echocardiogram (ECHO) revealed a severely depressed left ventricular ejection fraction (LVEF) of <10%. He was hemodynamically unstable for coronary catheterization and was emergently cannulated for VA-ECMO via the right femoral artery and left femoral vein. After we gained stability and slowly weaned the inotropic support. A follow-up ECHO revealed a dilated left ventricle and biventricular failure. With better hemodynamics, we did a catheterization showing coronary vasoconstriction, “clamping down” of distal vessels. (Figure 1) Due to the left ventricular dilation and its poor contractility, we decided to place an Impella. Results: The patient was supported on VA ECMO for 4 days, at which his LVEF recovered to 30-35%. The Impella device remained for an additional 3 days as his labs and hemodynamics improved. His LVEF at Impella removal was 40%. The patient was discharged in 14 days with a normal LVEF. Conclusion: One of the major downfalls of VA-ECMO is the lack of left ventricular unloading resulting in increased afterload and hindering recovery. An Impella can be used to help vent the left ventricle. This combination has been shown in several studies to improve outcomes in patients with acute coronary syndrome. The technique was employed with successful cardiac recovery in a patient who developed cardiogenic shock from coronary vasospasm from cocaine use.Figure 1. Coronary angiography showing coronary vasoconstriction due to cocaine use

Impact of chronic obstructive pulmonary disease in patients with myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Background Chronic obstructive pulmonary disease (CPOD) is a common comorbidity in patients admitted with myocardial infarction (MI) and needs to be considered since it can condition therapeutic approach and potentially negatively impact their prognosis. Purpose We aim to evaluate the impact of CPOD in therapeutic approach, clinical course and in-hospital mortality in patients admitted with MI. Methods We retrospectively analysed a population of 2797 patients admitted with MI (C). We divided them into two distinct groups: those with an established diagnosis of CPOD (C1) and those without it (C2). Age, sex, personal history, in-hospital therapeutic, left ventricular ejection fraction (LVEF), electrocardiographical presentation and angioplasty were documented. We defined the following as complications: heart failure (HF), need for invasive and non-invasive mechanical ventilation, reinfarction, newly onset atrial fibrillation, high-grade atrioventricular block and need for temporary cardiac pacing. Mortality, incidence of complications and a combined outcome of both mortality and any of the previous complications were compared between groups. We applied a multivariate analysis to adjust the effect of CPOD to the presence of other potential predictors. Results C1 consisted of 6,3% of the population (N=173). These patients were older (69,8±10,6 vs 65,5±13,5 years; p&amp;lt;0,001), had a higher prevalence of hypertension (76,3% vs 68,7%; p=0,036) and chronic kidney disease (13,7% vs 5,6%; p&amp;lt;0,001). They presented less frequently with ST-segment elevation MI (38,3 % vs 47,4%; p=0,019), but more often with depressed LVEF (57,9% vs 47,2%, p=0,008). They received less beta-blockers (63,4% vs 80,2%; p&amp;lt;0,001) and had fewer rates of drug-eluting stents application (63,4% vs 80,2%; p&amp;lt;0,001); on the other hand, they were more frequently medicated with calcium-channel blockers (16,7% vs 8,1%; p&amp;lt;0,001) and diuretics (50,0% vs 31,6%; p&amp;lt;0,001) and more bare-metal stents were utilised (52,8% vs 37,4%; p=0,002). The diagnosis of CPOD was not associated with higher mortality in patients with MI, however C1 presented with an increased incidence of complications (33,1% vs 26,0%; OR =1,413 [1,019-1,959]; p=0,037) and of the combined outcome (34,3% vs 26,5%; OR=1,447 [1,046-2,000]; p=0,02). Though multivariate analysis, CPOD tends to be an independent predictor of mortality and/or development of complications, although it narrowly misses to achieve statistical significance (p=0,056); only age, medication with beta-blockers and depressed LVEF were statistically independent predictors. Conclusions The comorbid diagnosis of CPOD conditions the choice of medication in patients with MI and tends to be an independent predictor of mortality and/or development of in-hospital complications.

Ventricular tachycardia substrate ablation in patients with slightly depressed left ventricular ejection fraction. Predictors of VT-free survival in a prospective multicentre registry

Abstract Funding Acknowledgements Type of funding sources: None. Background There is no consensus about the need for ICD implantation in patients with slightly depressed left ventricle ejection fraction (LVEF) after catheter ablation for hemodynamically tolerated ventricular tachycardia (VT). Purpose This study aims to investigate predictors of mortality VT-free survival in this population. Methods We evaluated predictors of VT-free survival in patients with LVEF&amp;gt;40% from a prospective multicenter register of patients undergoing VT substrate ablation for hemodynamically tolerated VT. Decision to protect with ICD implantation at hospital discharge was performed according to the judgment of the treating cardiologist. The patients included in the study were followed every six months. Ventricular arrhythmia-free survival was the primary endpoint. Any episode of sustained VT (&amp;gt; 30 s) or appropriate ICD therapy was considered VT recurrence. Results One-hundred thirty-two patients [67±13 years, 91% male, 50±8% mean LVEF, 85 (65%) with ischemic heart disease] with a LVEF&amp;gt;40% were identified. Twenty-one (16%) of them were non-inducible at the end of the procedure and were discharged without ICD implantation as they were considered to have a low risk of recurrences. After a mean follow-up of 26±23 months, 32 (24%) patients had VT recurrences. A complete arrhythmogenic substrate elimination [HR: 0.34 (0.16-0.7), p&amp;lt;0.01] and the use multiple ventricular extrastimuli for hidden slow conduction (HSC) identification and ablation [HR: 0.51 (0.27-1.1), p=0.09] were related with VT-free survival (Figure 1). 53 (40%) patients fulfilled both criteria, having a 8% recurrence rate during the follow-up. Compared with the clinical decision making of ICD implantation at hospital discharge, the use of these two variables better identify patients at risk for VT recurrences, with a net reclassification improvement of 23% (Figure 2). Conclusions VT recurrence after VT substrate ablation in patients with slightly depressed LVEF remains high. However, complete substrate elimination and HSC analysis and ablation are related with higher VT-free survival and identify a subgroup of patients in whom ICD might be not beneficial.

Impact of in-Hospital Left Ventricular Ejection Fraction Recovery on Long-Term Outcomes in Patients Who Underwent Impella Support for HR PCI or Cardiogenic Shock: A Sub-Analysis from the IMP-IT Registry.

(1) Background: Percutaneous left ventricle assist devices (pLVADs) demonstrated an improvement in mid-term clinical outcomes in selected patients with severely depressed left ventricular ejection fraction (LVEF) undergoing percutaneous coronary interventions. However, the prognostic impact of in-hospital LVEF recovery is unclear. Accordingly, the present sub-analysis aims to evaluate the impact of LVEF recovery in both cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR PCI) supported with pLVADs in the IMP-IT registry. (2) Methods: A total of 279 patients (116 patients in CS and 163 patients in HR PCI) treated with Impella 2.5 or CP in the IMP-IT registry were included in this analysis, after excluding those who died while in the hospital or with missing data on LVEF recovery. The primary study objective was a composite of all-cause death, rehospitalisation for heart failure, left ventricle assist device (LVAD) implantation, or heart transplantation (HT), overall referred to as the major adverse cardiac events (MACE) at 1 year. The study aimed to evaluate the impact of in-hospital LVEF recovery on the primary study objective in patients treated with Impella for HR PCI and CS, respectively. (3) Results: The mean in-hospital change in LVEF was 10 ± 1% (p < 0.001) in the CS cohort and 3 ± 7% (p < 0.001) in the HR PCI group, achieved by 44% and 40% of patients, respectively. In the CS group, patients with less than 10% in-hospital LVEF recovery experienced higher rates of MACE at 1 year of follow-up (FU) (51% vs. 21%, HR 3.8, CI 1.7-8.4, p < 0.01). After multivariate analysis, LVEF recovery was the main independent protective factor for MACE at FU (HR 0.23, CI 0.08-0.64, p = 0.02). In the HR PCI group, LVEF recovery (>3%) was not associated with lower MACE at multivariable analysis (HR 0.73, CI 0.31-1.72, p = 0.17). Conversely, the completeness of revascularisation was found to be a protective factor for MACE (HR 0.11, CI 0.02-0.62, p = 0.02) (4) Conclusions: Significant LVEF recovery was associated with improved outcomes in CS patients treated with PCI during mechanical circulatory support with Impella, whereas complete revascularisation showed a significant clinical relevance in HR PCI.

Left bundle branch area pacing prevents pacing induced cardiomyopathy in long-term observation.

Left bundle branch area pacing (LBBAP) is one of the methods to deliver conduction system pacing which potentially avoids the negative impact of conventional right ventricular pacing. To assess echocardiographic outcomes in a long-term observation in patients with LBBAP implemented for bradyarrhythmia indications. A total of 151 patients with symptomatic bradycardia and LBBAP pacemaker implanted, were prospectively included in the study. Subjects with left bundle branch block and CRT indications (n = 29), ventricular pacing burden <40% (n = 11), and loss of LBBAP (n = 10) were excluded from further analysis. At baseline and the last follow-up visit, echocardiography with global longitudinal strain (GLS) assessment, 12-lead ECG, pacemaker interrogation, and blood level of NT-proBNP were performed. The median follow-up period was 23 months (15.5-28). None of the analyzed patients fulfilled the criteria for pacing induced cardiomyopathy (PICM). Improvement in left ventricular ejection fraction (LVEF) and GLS was observed in patients with LVEF <50% at baseline (n = 39): 41.4 ± 9.2% versus 45.6 ± 9.9%, and 12.9±3.6% versus 15.5±3.7%, respectively. In the subgroup with preserved EF (n = 62), LVEF and GLS remained stable at follow-up: 59.3 ± 5.5% versus 60 ± 5.5%, and 19 ± 3.9% versus 19.4 ± 3.8%, respectively. LBBAP prevents PICM in patients with preserved LVEF and improves left ventricle function in subjects with depressed LVEF. LBBAP might be the preferred pacing modality for bradyarrhythmia indications.

Risk of ventricular arrhythmias following implantable cardioverter-defibrillator generator change in patients with recovered ejection fraction: Implications for shared decision-making.

Guidelines indicate primary-prevention implantable cardioverter-defibrillators (ICDs) for most patients with left ventricular ejection fraction (LVEF) ≤ 35%. Some patients' LVEFs improve during the life of their first ICD. In patients with recovered LVEF who never received appropriate ICD therapy, the utility of generator replacement upon battery depletion remains unclear. Here, we evaluate ICD therapy based on LVEF at the time of generator change, to educate shared decision-making regarding whether to replace the depleted ICD. We followed patients with a primary-prevention ICD who underwent generator change. Patients who received appropriate ICD therapy for ventricular tachycardia or ventricular fibrillation (VT/VF) before generator change were excluded. The primary endpoint was appropriate ICD therapy, adjusted for the competing risk of death. Among 951 generator changes, 423 met inclusion criteria. During 3.4 ± 2.2 years follow-up, 78 (18%) received appropriate therapy for VT/VF. Compared to patients with recovered LVEF > 35% (n = 161 [38%]), those with LVEF ≤ 35% (n = 262 [62%]) were more likely to require ICD therapy (p = .002; Fine-Gray adjusted 5-year event rates: 12.7% vs. 25.0%). Receiver operating characteristic analysis revealed the optimal LVEF cutoff for VT/VF prediction to be 45%, the use of which further improved risk stratification (p < .001), with Fine-Gray adjusted 5-year rates 6.2% versus 25.1%. Following ICD generator change, patients with primary-prevention ICDs and recovered LVEF have significantly lower risk of subsequent ventricular arrhythmias compared to those with persistent LVEF depression. Risk stratification at LVEF 45% offers significant additional negative predictive value over a 35% cutoff, without a significant loss in sensitivity. These data may be useful during shared decision-making at the time of ICD generator battery depletion.

Clinical characteristics, etiological profile, treatment and long term outcomes in patients with non ischemic systolic heart failure; Himachal Pradesh heart failure registry (HP–HF registry)

BackgroundThe data on clinical characteristics, treatment practices and out comes in patients with Non- ischemic Systolic Heart Failure (NISHF) is limited. We report clinical characteristics, treatment and outcomes in patients with NISHF. Methods1004 patients with NISHF were prospectively enrolled and their demographics, clinical characteristics, and treatment were recorded systematically. Patients were followed annually for a median of 3 years (1 year to 8 years) for allcause death, major adverse cardiovascular events (MACE); composite of all-cause death, hospitalization of heart failure, and or for stroke. ResultsPatients of NISHF were middle-aged (58.8±16.2 years) population with severely depressed left ventricular ejection fraction (29.3±7.02%) and 31.1% had symptoms of advanced Heart failure. Hypertension (43.6%), obesity and or overweight (28.0%), Diabetes (15.0%), and valvular heart disease (11.8%) were the common risk factors. The guideline directed medical treatment was prescribed in more than 80% of the study cohort. Incidence of all cause death and MACE was 7 (6.8, 8.8) per 100 person years and 11(10, 13) per 100 person years respectively. The cumulative incidence of deaths and MACE was 35% (30%, 40%) and 49% (44%, 53%) at 8 years of follow-up. ConclusionsPatients of NISHF were middle-aged population with severely depressed LV systolic function with significant incident morbidity and mortality. Early detection of risk factors and their risk management and enhancing the use of guideline directed treatment may improve the outcomes. Keywords: Non-ischemic systolic heart failure, risk factors, outcomes, guideline directed treatment.

Left bundle branch area pacing: How to prevent a coronary venous fistula.

Left bundle branch area pacing: How to prevent a coronary venous fistula.

Incidence, determinants, and outcomes of recovered left ventricular ejection fraction (LVEF) in patients with non-ischemic systolic heart failure; a hospital-based cohort study

BackgroundThe data on incidence of recovered Left Ventricular Ejection Fraction (LVEF) and outcome in patients with non ischemic systolic heart failure is limited. We report the incidence, determinants and mortality in patients with recovered LVEF. Methods: The 369 patients with HFrEF with LVEF of less than 40% of non ischemic etiology with available follow up echocardiography study at one year were enrolled. The baseline data of clinical characteristics and treatment was recorded prospectively and were followed up annually for mean of 3.6 years (range 2 to 5 years) to record all cause death and LVEF measured echocardiographically. The recovered, partially recovered and no recovery of LVEF was defined based on increase in LVEF to 50% and more, 41% to 49% and to persistently depressed LVEF to 40% or lower respectively. ResultsThe LVEF recovered in 36.5%% of the cohort at 5 years. The rate of recovery of LVEF was slower in patients with no recovery of LVEF at one year compared to cohort with partially recovered LVEF (18% vs.53%) at five year. The Baseline LVEF was significantly associated with recovered LVEF, odd ratio (95% C.I.) 1.09(1.04, 1.14). The cumulative mortality at five years was significantly lower in cohort with recovered LVEF (18.1% vs. 57.1%). ConclusionsOne third of the patients had recovered LVEF and was significantly associated with baseline LVEF and lower mortality rate.