Depressed Left Ventricular Ejection Fraction Research Articles

Risk stratification of severe aortic stenosis according to new guidelines: long term outcomes.

Current ESC and ACC/AHA guidelines for the management of valvular heart disease assign a class Ia indication for aortic valve replacement (AVR) only to patients with symptomatic severe aortic valve stenosis and asymptomatic patients with depressed left ventricular ejection fraction (LVEF <50%) or positive exercise test. We examined the long-term outcomes for patients undergoing AVR for aortic stenosis over a 11-year period at our institution compared to current international guidelines for AVR. Patients who had undergone isolated AVR for severe aortic valve stenosis between January 2001 and December 2012 were selected. The population was divided into subgroups based on preoperative LVEF (< or ≥50%) and on presence/absence of symptoms (NYHA =I or ≥II, respectively). We identified 607 patients with a median follow-up (FU) time of 5.75 years (IQR 3.24-8.00 years). The presence of symptoms did not have a significant impact on cardiovascular mortality (P=0.201). Patients with LVEF <50% displayed a higher long-term cardiovascular mortality rate (P=0.015). Multivariate analysis showed that preserved LVEF was a protective factor for asymptomatic patients (P=0.021), while preoperative LVEF did not affect the mortality rate in symptomatic patients (HR 0.88; 95% CI, 0.54-1.44). Correspondingly, asymptomatic patients with reduced LVEF were found to be at a higher risk of long-term mortality compared to the other groups (P=0.011). The only other independent risk factor for death was age (HR 6.46; 95% CI, 2.22-18.76). According to our data, current international class I indications for symptomatic patients ensure good long-term survival, while class I indications for asymptomatic patients with reduced LVEF are associated with poor long-term survival. Our results suggest that early surgery should also be considered also for asymptomatic patients with preserved LVEF, particularly in cases of very low operative risk.

HEART FAILURE AND PREGNANCY: TO DELIVER OR TO CARRY ON

SESSION TITLE: Cardiovascular Disease SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Management of acute decompensated heart failure and life-threatening arrhythmias during pregnancy is challenging. Increasing physiological demands of pregnancy and limited pharmacological treatment options often push physicians to pursue early delivery. We report a rare case of cardiomyopathy manifesting as incessant ventricular tachycardia during second trimester of pregnancy. CASE PRESENTATION: A 30 year-old Caucasian female with no past medical history presented to the hospital with shortness of breath, palpitations, and lower extremity swelling during the 26th week of her first pregnancy. Electrocardiogram and telemetry revealed a high burden of non-sustained polymorphic ventricular tachycardia (VT) (figure 1). Patient was transferred to intensive care unit (ICU) and transthoracic echocardiogram (TTE) showed biventricular failure with left ventricular ejection fraction (LVEF) of 20%, severe left atrial dilation and mitral regurgitation (figure 2). Patient was started on esmolol and lidocaine infusions. A pulmonary artery catheter was placed for hemodynamic monitoring (figure 3). Diuresis was also initiated. Given the persistent VT and evidence of lidocaine toxicity, mexiletine was initiated and lidocaine discontinued. After 7 days, the frequency of ventricular ectopic beats significantly decreased. Considering the likelihood of peripartum cardiomyopathy, bromocriptine was administered, but patient could not tolerate it due to worsening hypotension and nausea. With increasing cardiovascular demands of pregnancy and persistent severe cardiomyopathy, a decision was made to pursue caesarian section at 28 weeks. Given the stress of surgery and mortality associated with it, an Impella CP left ventricular assist device was placed immediately prior to caesarian section. Patient tolerated both procedures well and was subsequently weaned off Impella CP device in the surgical ICU. Baby was also viable. Patient was eventually discharged on metoprolol and mexilitine along with standard therapy as well as a LifeVest. Follow up TTE at 4 months showed slight improvement in LEVF at 25%. Cardiac magnetic resonance imaging revealed extensive patchy and transmural late gadolinium enhancement (figure 3). DISCUSSION: Management of incessant ventricular tachycardia in pregnancy can be difficult as amiodarone is associated with fetal growth retardation. Lidocaine, procainamide and mexiletine are the recommend anti-arrhythmic agents for stable cases. In patients with severely depressed LVEF, caesarean section carries a high mortality rate. Preemptive use of circulatory left ventricular assist device such as Impella CP is potentially life saving. CONCLUSIONS: Cardiomyopathy in pregnancy can present as incessant ventricular tachycardia and should alert physician for further work up. Reference #1: Arany Z, and Elkayam U. Peripartum Cardiomyopathy. Circulation. 2016;133(14):1397-409. DISCLOSURES: No relevant relationships by Anthony Lubinsky, source=Web Response No relevant relationships by Assad Oskuei, source=Web Response

Unprotected versus protected high-risk percutaneous coronary intervention with the Impella 2.5 in patients with multivessel disease and severely reduced left ventricular function.

Selecting a revascularization strategy in patients with multivessel disease (MVD) and severely reduced left ventricular ejection fraction (LVEF) remains a challenge. PCI with Impella 2.5 may facilitate high-risk PCI, however long-term results comparing unprotected versus protected PCI are currently unknown. We sought to evaluate the outcome of patients undergoing protected compared to unprotected percutaneous coronary intervention (PCI) in the setting of MVD and severely reduced LVEF.We included patients with MVD and severely reduced LVEF (≤35%) in this retrospective, single-centre study. Patients that underwent unprotected PCI before the start of a dedicated protected PCI program with Impella 2.5 were compared to patients that were treated with protected PCI after the start of the program. The primary endpoint was defined as major adverse cardiac and cerebrovascular events (MACCE) during a 1-year follow-up. The secondary endpoints consisted of in-hospital MACCE and adverse events.A total of 61 patients (mean age 70.7 ± 10.9 years, 83.6% male) were included in our study, of which 28 (45.9%) underwent protected PCI. The primary endpoint was reached by 26.7% and did not differ between groups (P = .90). In-hospital MACCE (P = 1.00) and in-hospital adverse events (P = .12) also demonstrated no significant differences. Multivariate logistic regression identified procedural success defined as complete revascularization and absence of in-hospital major clinical complications as protective parameter for MACCE (OR 0.17, 95% CI 0.04–0.70, P = .02).Patients with MVD and severely depressed LVEF undergoing protected PCI with Impella 2.5 demonstrate similar in-hospital and one-year outcomes compared to unprotected PCI.

Prophylactic ECMO during TAVI in patients with depressed left ventricular ejection fraction.

This study investigated the impact of prophylactic veno-arterial extracorporeal membrane oxygenation (pECMO) in patients with depressed left ventricular ejection fraction (dLVEF) undergoing transcatheter aortic valve implantation (TAVI). Out of 1490 patients undergoing TAVI at two centers (2010-2015), 222 patients had dLVEF (≤ 40%). Of these, 21 patients (10%) underwent TAVI with pECMO. Complications and outcome according to pECMO were analyzed in the entire and in a propensity-matched population. In the entire population, patients with pECMO had a higher logEuroScore I (33% ± 19 vs. 25% ± 17; p = 0.037), worse LVEF (26% ± 7 vs. 32% ± 7; p = 0.001), more major bleedings (29% vs. 9%; p = 0.015), higher transfusion rate (30% vs. 10%; p = 0.019) and longer in-hospital stay (9.0 [7.0;14.0] vs. 7.0 [5.0;10.0] days; p = 0.024). After propensity matching only transfusion rate remained higher with pECMO (30% vs. 7%; p = 0.025). In the entire population, rate and risk of 30-day mortality was higher with pECMO (24% vs. 6%, HR 95%CI 4.29 [1.51-12.19]; p = 0.006). In the matched population, this effect was attenuated (24% vs. 12%, HR 95%CI 2.09 [0.61-7.23]; p = 0.243). Cumulative rate and risk of 1-year mortality did not differ in the entire (log-rank p = 0.069; 39% vs. 22%, HR 95%CI 1.99 [0.94-4.24]; p = 0.074) nor in the matched population (log-rank p = 0.520; 39% vs. 31%, HR 95%CI 1.34 [0.55-3.28]; p = 0.523). In patients with dLVEF undergoing TAVI, periprocedural pECMO support does not seem to improve patient outcome.

Catheter Ablation Versus Non-Ablative Strategies for Ventricular Tachycardia in Patients with Ischemic Cardiomyopathy on Implantable Cardioverter-Defibrillator: A Systematic Review and Meta-Analysis

Background: Ventricular tachycardia (VT) is an abnormal rapid rhythm originating from the lower ventricles occurring commonly in patients with cardiomyopathic hearts. Three treatment options are available: implantable cardioverter defibrillator (ICD), antiarrhythmic medications or catheter ablation (or a combination of these options). This systematic review aimed to compare the efficacy of catheter ablation vs non-ablative techniques as treatment for VT in patients with ischemic cardiomyopathy. Methods: This was a systematic review and meta-analysis of prospective studies that compared ablative vs non-ablative strategies in patients with ischemic heart disease and depressed left ventricular ejection fraction (LVEF). Outcomes of interest included the post-treatment rate of recurrent VT, appropriate ICD shocks and mortality. Results: Pooled findings of five studies showed a non-significant difference in the odds of VT post-treatment between the ablation arm and the non-ablation arm (OR 0.61; 95% CI 0.34-1.10; p=0.10). Heterogeneity was high (I2=55%). Sensitivity analysis excluding one pilot study contributing to the heterogeneity revealed a statistically significant reduction in the odds of recurrent VT (OR 0.54; 95% CI 0.31-0.94; p=0.0.03). Pooled findings of four studies showed that ablation resulted in a lower rate of appropriate shocks post-treatment compared with the non-ablative group (OR 0.51; 95% CI 0.30-0.87; p=0.01. There was no significant difference in the mortality rate between catheter ablation and non-ablative strategies (OR 0.77; 95% CI 0.47-1.25; p=0.29). Conclusion: Catheter ablation on top of ICD placement reduced the risk of post-treatment VT and appropriate shocks. However, these did not translate into a reduction in mortality. KEYWORDS: catheter ablation, non-ablative strategies, implantable cardioverter defibrillator, ischemic cardiomyopathy.

Abstract 225: LVEF Over Time: Trends and Analysis of a National VA Database

Background: Patients who are diagnosed with heart failure (HF) are almost universally characterized by left ventricular ejection fraction (LVEF) at the time of diagnosis, where the most common dichotomy is preserved LVEF (HFpEF, LVEF &gt; 50%) or reduced LVEF (HFrEF, LVEF &lt; 40%). The concept of recovered LVEF (&lt; 40% to &gt; =50%) is considered by some to indicate a separate category of HF. We sought to study the natural history of a patient’s LVEF using natural language processing among a large cohort of patients. Methods: We identified 457,457 patients in the VA Health Care System between 2005 and 2016 with a first outpatient diagnosis of heart failure with an LVEF between 6 months before or one year after the heart failure diagnosis and a second LVEF after the diagnosis. We used all LVEF data from 2005-2016 obtained from previously validated natural language processing of echo reports. LVEF at baseline was grouped into deciles (1-29, 30-39, 40-49, 50-59, 60-69 and &gt;=70%). Results: The 457,457 patients had 8,857,436 echos over a mean 4 +/- 3 years of follow-up (median 11 echos per patient). At the time of diagnosis the mean age was 69 +/- 11 years, 97.6% male, 19% were African-American, 45% had a diagnosis of diabetes, and 61% had a diagnosis of ischemic heart disease. During follow-up among those with an initial LVEF &lt; 40%, between 21% and 31% recovered their LVEF to over 50% at some point during follow-up (Table). A similar frequency was noted for those dropping to an LVEF &lt; 40% if the initial LVEF was high. When the last LVEF was used to define change, then a recovered LVEF (&gt;50%) was less common (9% if initial LVEF was &lt; 20%, 8% if the initial LVEF was 20-29%, 13% if the initial LVEF was 30-39%). The final LVEF was &lt; 40% in 30% of patients with an initial LVEF of 40-49%, 15% if the initial LVEF was 50-59%, 9% if the initial LVEF was 60-69%, and 6% if the initial LVEF was &gt;=70%. Conclusion: In this multiyear study of a national cohort, LVEF varied substantially over time, with a recovered LVEF (&lt;40% to &gt;=50%) noted at some point in 20-30% depending on initial LVEF. However, when the last LVEF is used, recovery occurred in only 8-13%. Thus, approximately half of patients with a recovered LVEF at some point will revert to depressed LVEF.

PERCUTANEOUS PERIPHERAL CARDIOPULMONARY BYPASS FOR TRANSFEMORAL TAVR PATIENTS WITH SEVERELY DEPRESSED EJECTION FRACTION WITHOUT GENERAL ANESTHESIA

Patients with severely depressed left ventricular ejection fraction (LVEF ≤30%) are at increased risk of hemodynamic compromise during transcatheter aortic valve replacement (TAVR). Use of cardiopulmonary bypass (CPB) support to provide stability during valve positioning and deployment is well

Incidence, characteristics, risk factors and outcomes of supraventricular arrhythmias in Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) is a medical entity mimicking an acute coronary syndrome (ACS). During the acute phase, several complications may occur, even if the prognosis is generally favorable. Only small studies reported a description of supraventricular arrhythmia (SA) in TTC and little is known about related incidence. We sought to describe the characteristics, incidence, predictive factors and outcomes of SA inpatients presenting with TTC. Over a twelve-year period, we reviewed all patients ( n = 5484) referred to our coronary care unit (CCU) for a suspicion of ACS. All patients presented with a confirmed diagnosis of TTC and a normalization of left ventricular ejection fraction (LEVF) during follow-up. In CCU, all patients were continually monitored by 12-lead ECG to detect the occurrence of SA. TTC was diagnosed in 88 patients according to the Mayo Clinic criteria, in sinus rhythm at the time of diagnosis. Incidence of SA among TTC was 14%. A difference was observed between patients with or without SA occurrence: age, hypertension, systolic pulmonary artery pressure and duration of hospitalization. Of note, patient with SA had significantly more depressed left ventricular ejection fraction at admission ( P = 0.006). A large part of patient presenting SA required the use of diuretic for heart failure during hospitalization ( P = 0.026). In multivariate analysis, the factors significantly associated with an increased risk of VA were: age ( aOR = 1.19, 95% CI: 1.01–1.39, P = 0.029) and LEVF ( aOR = 0.89, 95% CI: 0.8–0.97; P = 0.037). There was no significant difference in mortality rate between patients with or without SA during follow-up. SA occurred in 14% of patients at the acute phase of TTC and independent predictive factors of SA were age and LEVF. During the acute phase, identification of high-risk SA patients allows better management, with ECG monitoring and therapeutic intervention in the CCU.

The Role of Mechanical Circulatory Support During Percutaneous Coronary Intervention in Patients Without Severely Depressed Left Ventricular Function

Currently, there are no data on the use of mechanical circulatory support (MCS) in patients without severely depressed left ventricular ejection fraction (LVEF) during high-risk percutaneous coronary intervention (PCI). We analyzed data from the global catheter-based ventricular assist device (cVAD) registry on the clinical use of MCS in high-risk PCI in patients without severely depressed LVEF, defined as LVEF > 35%. Patients without cardiogenic shock from the catheter-based ventricular assist device registry, who underwent elective or urgent PCI with an Impella 2.5 or Impella CP, were included. Patients who received MCS after the start of the PCI were excluded. A total of 891 patients were included, of whom 661 had LVEF ≤ 35% and 230 had LVEF > 35%. Patients with LVEF > 35% compared with patients with LVEF ≤ 35% were older (72.12 ± 11.70 years vs 68.68 ± 11.01 years; p <0.001), had more extensive coronary artery disease with more diseased vessels (1.90 ± 0.71 vs 1.73 ± 0.79; p = 0.005), more multivessel intervention (1.74 ± 0.69 vs 1.55 ± 0.73; p <0.001), and more use of rotational atherectomy (21.21% vs 14.90%; p = 0.046), respectively. Additionally, they had a high prevalence of high-risk clinical features such as renal failure (24.89%) and diabetes mellitus (45.37%). Despite these high-risk features, the major adverse cardiovascular and cerebral event rates were favorable overall, with no differences between the 2 groups (3.48% vs 4.54%; p = 0.574). Despite having LVEF > 35%, this selected group of patients had severe co-morbidities and complex angiographic features; hence, PCI with hemodynamic support was deemed necessary. In addition, PCI with elective MCS was feasible and safe in this patient population.

High-sensitivity cardiac troponin T, left ventricular function, and outcome in non–ST elevation acute coronary syndrome

Cardiac troponin (cTn) levels reflect infarct size and depressed left ventricular ejection fraction (LVEF) in patients with non-ST elevation acute coronary syndrome (NSTE-ACS). However, there is very limited information on whether cTn measured with a high-sensitivity (hs) assay would provide incremental prognostic information to the LVEF in NSTE-ACS patients. This was a registry-based study (SWEDEHEART registry) investigating 20,652 NSTE-ACS patients with available information on hs-cTnT (highest level recorded during the hospitalization) and the LVEF estimated using echocardiography. All patients had been followed for 1 year. Hs-cTnT levels independently predicted major cardiovascular events (MACE) in cohorts with normal, slightly depressed, moderately depressed, and severely depressed LVEF. The adjusted hazard ratios in these cohorts were 1.18 (95% CI 1.13-1.23), 1.12 (95% CI 1.06-1.18), 1.12 (95% CI 1.06-1.19), and 1.21 (95% CI 1.13-1.30), respectively. Hs-cTnT levels were particularly predictive for cardiovascular mortality and readmission for heart failure. Excluding patients with previous cardiac disease did not affect the overall interrelations of hs-cTnT and LVEF with MACE. Hs-cTnT levels provide incremental prognostic value independent of the LVEF in patients with NSTE-ACS. Hs-cTnT is particularly predictive for MACE in patients with severely depressed LVEF but also in those with a normal LVEF. Accordingly, a normal LVEF should not be used as an argument not to target patients to thorough workup.

Progression of Duchenne Cardiomyopathy Presenting with Chest Pain and Troponin Elevation.

Improved neuromuscular and respiratory therapies have altered the natural history of Duchenne muscular dystrophy (DMD) such that the most common cause of mortality is progressive cardiomyopathy. Despite imaging evidence of progressive cardiomyopathy, troponin I (cTn) is not significantly elevated in asymptomatic DMD patients. We describe eight boys with DMD evaluated for acute chest pain (ACP) and found to have acute cTn elevation with depressed left ventricular ejection fraction (LVEF). Of our eight patients, five presented with a primary complaint of ACP, while three presented with secondary myocardial injury in the context of systemic illness requiring hospitalization. Electrocardiograms showed diffuse ST changes and mean peak cTn level was 44±15.4 ng/mL (reference range <0.03 ng/mL). cTn levels normalized with only supportive care. Cardiac magnetic resonance imaging (CMR) was performed during the event on all but one patient, demonstrating increased late gadolinium enhancement (LGE) from 12.4±11.4% to 36.5±10.3% with associated deterioration of LVEF from 61±4.4% to 47.6±6.6% which remained depressed on follow-up CMR study (49.1±7.8%). All viral studies were negative. Additional investigations varied among patients, but no causative findings were demonstrated. ACP with cTn elevation occurs in DMD boys and may be indicative of cardiomyopathy progression as evidenced by acute left ventricular dysfunction and development or progression of myocardial fibrosis. This clinical presentation is under recognized. These events may represent an important pathophysiological mechanism in cardiomyopathy progression.

Contrast-Enhanced Echocardiography Has the Greatest Impact in Patients with Reduced Ejection Fractions

Contrast-enhanced echocardiography (CE) helps to improve image quality in patients with suboptimal acoustic windows. Despite current recommendations, contrast use remains low. The aim of this study was to identify populations that would benefit more from contrast use. A total of 176 subjects (137 men; mean age, 60.8±13.7years) with technically difficult transthoracic echocardiographic studies who received clinically indicated intravenous contrast were prospectively studied. The impact on clinical decision making (including alterations in medical therapy, referral, imaging, or clinical procedures) was evaluated. The use of CE enabled biplane left ventricular (LV) ejection fraction measurement in 97.2% of studies and the interpretation of regional wall motion in 95% of studies. CE allowed definitive assessment of the presence or absence of LV thrombus in 99% of the cases. In the 174 patients whose ordering physicians could be reached at the time of image interpretation, changes in management occurred in 51% of subjects. There was no difference in the proportion of management changes betweeninpatients and outpatients (60.0% vs 48.1%, P=.225). Subjects with heart failure, cardiomyopathy, and arrhythmia had a higher proportion of changes (61.4% vs 44.2% [P=.031], 62.5% vs 45.0% [P=.028], and 72.0% vs 47.7% [P=.030], respectively). The proportion of management change after CE increased as pre-CE estimated ejection fraction decreased. Logistic regression showed that pre-CE estimated LV ejection fraction < 50% was the only significant predictor of change of management after contrast (P=.004). The use of CE has a significant impact on clinical decision making in patients with suboptimal acoustic windows, especially in those with depressed pre-CE LV ejection fractions.

Correction: Prognostic power of global 2D strain according to left ventricular ejection fraction in patients with ST elevation myocardial infarction.

[This corrects the article DOI: 10.1371/journal.pone.0174160.].

Maternally Inherited Diabetes and Deafness in 4 Family Members with DNA Mutation and at Least 4 Generations with Suggestive Disease Phenotype.

A 55-year-old woman presented at the emergency room suffering from dyspnea. Her medical history was notable for deafness, taking metformin for 30 years to treat type 2 diabetes, and depression. An analysis of the patient revealed an increase in lactate concentration (91 mg/dL, reference levels 4–20 mg/dL) and glucose (169 mg/dL). All other measurements were typical or within the reference range, including the presence of autoantibodies and insulin concentration. A chest x-ray showed cardiomegaly, and an echocardiography revealed systolic dysfunction with a severely depressed left ventricular ejection fraction with generalized hypokinesis. From this, the cardiologist diagnosed nonischemic dilated cardiomyopathy. The patient's family history was revealing (Fig. 1, Table 1): her grandmother (I) and mother (II), both dead, suffered from deafness; the latter also had type 2 diabetes. Her brother (IIIb) had been diagnosed with type 2 diabetes at age 30 years after taking an oral glucose tolerance test. The patient has 2 children. The son (IVb) is deaf and has worn a hearing aid since age 20; he has been diagnosed with Wolff-Parkinson-White syndrome. Her daughter (IVa) has also been diagnosed with diabetes, which emerged during pregnancy after taking an oral glucose tolerance test. The family's history, therefore, reveals a pattern of diabetes, deafness, and cardiac abnormalities. All these pathologies had …

Cardiac Magnetic Resonance Evaluation of Left Ventricular Myocardial Strain in Pulmonary Hypertension

We investigated the feasibility of detecting left ventricular (LV) cardiac magnetic resonance (CMR) strain abnormalities using feature-tracking in patients with pulmonary hypertension (PH). CMR was performed in 16 patients with all groups of PH and in 13 controls. Global and regional peak circumferential strains (%) (which have been shown to be robust by CMR), peak diastolic strain rate (%/s), and dyssynchrony index (ms) were quantified with feature-tracking software. Ventricular function and volumes were calculated from CMR, and right heart pressures were measured with catheterization. Left ventricular ejection fraction (LVEF) was similar in patients (60.2% ± 11.0%) and controls (61.9% ± 4.5%), P = .150. Global LV peak circumferential strain was significantly different in patients compared to controls, -16.7 ± 2.8% vs -19.9 ± 1.8%, respectively (P = .001). The greatest difference in strain was seen in the LV septum, -11.6 ± 4.3% in patients vs -16.7 ± 4.0% in controls (P < .001). There was a significant association between septal strain and right ventricular end-diastolic volume index (P = .047) in patients with PH; however, there were no associations with pulmonary artery pressures or right ventricular ejection fraction. Feature-tracking CMR can detect LV strain abnormalities in patients with PH and preserved or mildly depressed LVEF, with greatest abnormality in the septum. The association between septal strain and right ventricular end-diastolic volume index suggests that ventricular interdependence may be a mechanism of LV dysfunction in PH. Feature-tracking CMR may be useful for identification of LV dysfunction before LVEF significantly declines in patients with PH. The feasibility of detecting LV strain abnormalities in patients with PH shown by this study paves the way for a variety of future investigations into the applications of LV strain in this patient population.

Transcatheter Mitral Valve Implantation Using the HighLife System

ObjectivesThis study is the first report of 2 cases of HighLife (HighLife, Paris, France) implantation in humans. BackgroundTranscatheter mitral valve implantation represents a promising approach to treating mitral regurgitation in patients at increased risk of perioperative mortality. The HighLife transcatheter mitral valve is a 2-component system. The valve is implanted in the mitral position and is anchored by interacting and then reaching an equilibrium position with a previously positioned subannular implant. MethodsThe procedures were successfully performed in a 69-year-old man and a 65-year-old woman with severe functional mitral regurgitation. Both patients were in New York Heart Association functional class IV heart failure with depressed left ventricular ejection fraction and additional comorbidities. ResultsThe valve was implanted uneventfully in both patients. General anesthesia was used. The subannular implant was deployed through the transfemoral access, whereas the transcatheter mitral valve was released using the transapical access. Patients maintained hemodynamically stable. There were no intraoperative complications. Acutely, post-procedural echocardiograms demonstrated excellent prosthetic valve function with a low transvalvular gradient and no paravalvular leak and left ventricular outflow tract obstruction. Both patients had mild intraprosthetic regurgitation. Patient #1 survived at 5-months follow-up in New York Heart Association functional class II with excellent prosthesis performance. Patient #2 expired 4 days after a technically successful procedure, because the left ventricle did not tolerate the reduction of mitral regurgitation and despite a high dose of inotropic agents the left ventricular function rapidly deteriorated. ConclusionsTranscatheter mitral valve implantation using the 2-component HighLife system is technically feasible and can be performed safely. Early hemodynamic performance of the prosthesis was excellent.

Transapical aortic valve replacement is a safe option in patients with poor left ventricular ejection fraction: results from the Italian Transcatheter Balloon-Expandable Registry (ITER).

The most commonly used accesses for transcatheter aortic valve implantation (TAVI) are the transfemoral (TF-TAVI) and the transapical (TA-TAVI) ones. There are concerns about TA-TAVI use in patients with reduced left ventricular ejection fraction (LVEF). The aim of this retrospective multicentre study was to compare the outcomes of TA-TAVI and TF-TAVI in patients with poor LVEF. Patients with LVEF ≤35% were included in the analysis. Data were obtained from the Italian Transcatheter Balloon-Expandable Registry (ITER), which enrolled patients undergoing TAVI with the Sapien bioprosthesis in 33 national centres. Patients were divided into 2 groups according to the access: TA or TF. A multivariable logistic regression analysis was performed in order to evaluate whether the type of approach (TA and TF) has an impact on outcomes. Between 2007 and 2012, 1882 patients were enrolled in the Registry. LVEF ≤35% was found in 208 (11.1%) patients. TA-TAVI and TF-TAVI were performed in 69 (33.2%) and 139 (66.8%) patients, respectively. Overall 30-day mortality was 11.6% and 7.9% in TA and TF patients, respectively (P = 0.45). Overall Kaplan-Meier survival was significantly higher in the TF-TAVI group (log rank: P = 0.003). Age [odds ratio (OR) 1.066, P = 0.016], creatinine (OR: 2.301, P < 0.001), preoperative permanent pacemaker (OR: 4.662, P = 0.035) and TA approach (OR: 2.577, P = 0.006) were identified as independent predictors of overall mortality at follow-up. However, the TA approach resulted an independent variable of mortality only 3 years after TAVI. TAVI yields good results in patients with depressed LVEF. Age, preoperative creatinine and preoperative pacemaker are independently associated with mortality. The TA access is associated with mortality only after 3 years of follow-up, thus probably reflecting a worse general clinical status of these patients.

Circulating acylcarnitine profile in human heart failure: a surrogate of fatty acid metabolic dysregulation in mitochondria and beyond.

Heart failure (HF) is associated with metabolic perturbations, particularly of fatty acids (FAs), which remain to be better understood in humans. This study aimed at testing the hypothesis that HF patients with reduced ejection fraction display systemic perturbations in levels of energy-related metabolites, especially those reflecting dysregulation of FA metabolism, namely, acylcarnitines (ACs). Circulating metabolites were assessed using mass spectrometry (MS)-based methods in two cohorts. The main cohort consisted of 72 control subjects and 68 HF patients exhibiting depressed left ventricular ejection fraction (25.9 ± 6.9%) and mostly of ischemic etiology with ≥2 comorbidities. HF patients displayed marginal changes in plasma levels of tricarboxylic acid cycle-related metabolites or indexes of mitochondrial or cytosolic redox status. They had, however, 22-79% higher circulating ACs, irrespective of chain length (P < 0.0001, adjusted for sex, age, renal function, and insulin resistance, determined by shotgun MS/MS), which reflects defective mitochondrial β-oxidation, and were significantly associated with levels of NH2-terminal pro-B-type natriuretic peptide levels, a disease severity marker. Subsequent extended liquid chromatography-tandem MS analysis of 53 plasma ACs in a subset group from the primary cohort confirmed and further substantiated with a comprehensive lipidomic analysis in a validation cohort revealed in HF patients a more complex circulating AC profile. The latter included dicarboxylic-ACs and dihydroxy-ACs as well as very long chain (VLC) ACs or sphingolipids with VLCFAs (>20 carbons), which are proxies of dysregulated FA metabolism in peroxisomes. Our study identified alterations in circulating ACs in HF patients that are independent of biological traits and associated with disease severity markers. These alterations reflect dysfunctional FA metabolism in mitochondria but also beyond, namely, in peroxisomes, suggesting a novel mechanism contributing to global lipid perturbations in human HF.NEW & NOTEWORTHY Mass spectrometry-based profiling of circulating energy metabolites, including acylcarnitines, in two cohorts of heart failure versus control subjects revealed multiple alterations in fatty acid metabolism in peroxisomes in addition to mitochondria, thereby highlighting a novel mechanism contributing to global lipid perturbations in heart failure.Listen to this article's corresponding podcast at http://ajpheart.podbean.com/e/acylcarnitines-in-human-heart-failure/.

Tracking interlead heterogeneity of R- and T-wave morphology to disclose latent risk for sudden cardiac death

Sudden cardiac death (SCD) due primarily to ventricular fibrillation claims 1.5 million lives worldwide each year. In 45%-50% of cases, it is the first manifestation of underlying heart disease. Traditional risk factors including smoking, hypertension, age, sex, as well as depressed left ventricular ejection fraction lack sufficient sensitivity and specificity to forewarn of impending life-threatening arrhythmias. There has been a decades-long search for electrocardiographic (ECG) markers of SCD risk. Several interval-based indices such as QT dispersion and Tpeak-Tend interval held initial promise but ultimately yielded mixed results. Recently, the focus has been on interlead heterogeneity of R- and T-wave morphology. The new approaches have involved advanced analytical tools including vectorcardiographic techniques and second central moment analysis of QRS-aligned templates to quantify heterogeneity of depolarization and repolarization waveforms. The results of current studies appear to be robust and worthy of further exploration. This review examines the electrophysiological underpinnings of heterogeneity-based risk assessment and provides an update of clinical techniques. We also discuss future directions whereby tracking heterogeneity may help to disclose latent risk for SCD not only in ECG recordings made at rest but also during ambulatory ECG monitoring and exercise tolerance testing.

Protocolo de diagnóstico y tratamiento de la anemia en el paciente con insuficiencia cardíaca

IntroductionAfter the publication of major studies in patients with heart failure (HF) that differentiate the concept of anaemia and iron deficiency (ID), there is sufficient clinical evidence to identify ID as somewhat more than a comorbidity and it is possible that it plays a role in the pathophysiology of HF. Hence a diagnosis of ID and how to approach it are key factors in the treatment of HF. DiagnosisMonitoring the kinetics of iron by determining ferritin and transferrin saturation index should be undertaken after diagnosing HF, in episodes of decompensation and annually for the prompt detection of ID. TreatmentID in symptomatic HF patients with depressed left ventricular ejection fraction (LVEF) should be treated as soon as possible, in order to improve quality of life and prevent hospital readmission. Parenteral than oral iron is more effective for this purpose.