Recovery Of Ejection Fraction Research Articles

Alcoholic cardiomyopathy: an update.

Alcohol-induced cardiomyopathy (AC) is an acquired form of dilated cardiomyopathy (DCM) caused by prolonged and heavy alcohol intake in the absence of other causes. The amount of alcohol required to produce AC is generally considered as >80 g/day over 5 years, but there is still some controversy regarding this definition. This review on AC focuses on pathogenesis, which involves different mechanisms. Firstly, the direct toxic effect of ethanol promotes oxidative stress in the myocardium and activation of the renin-angiotensin system. Moreover, acetaldehyde, the best-studied metabolite of alcohol, can contribute to myocardial damage impairing actin-myosin interaction and producing mitochondrial dysfunction. Genetic factors are also involved in the pathogenesis of AC, with DCM-causing genetic variants in patients with AC, especially titin-truncating variants. These findings support a double-hit hypothesis in AC, combining genetics and environmental factors. The synergistic effect of alcohol with concomitant conditions such as hypertension or liver cirrhosis can be another contributing factor leading to AC. There are no specific cardiac signs and symptoms in AC as compared with other forms of DCM. However, natural history of AC differs from DCM and relies directly on alcohol withdrawal, as left ventricular ejection fraction recovery in abstainers is associated with an excellent prognosis. Thus, abstinence from alcohol is the most crucial step in treating AC, and specific therapies are available for this purpose. Otherwise, AC should be treated according to current guidelines of heart failure with reduced ejection fraction. Targeted therapies based on AC pathogenesis are currently being developed and could potentially improve AC treatment in the future.

Clinical characteristics of patients with better ejection fraction recovery after upgrading to cardiac resynchronization therapy

Abstract Background Chronic right ventricular (RV) pacing can cause cardiac systolic dysfunction and heart failure (HF), increased risk of HF hospitalization and adverse outcomes. In these patients upgrading to cardiac resynchronization therapy (CRT) may improve left ventricular function. Purpose We aimed to identify the profile of patients (their clinical, electrical and echocardiographic characteristics) who are more likely to make a significant change in left ventricular ejection fraction (LVEF) one year after revision of the RV pacing system to CRT. Methods This was a retrospective, observational, single-center study. We included patients with a permanent antibradycardia pacemaker who had no systolic dysfunction and HF symptoms at the time of pacemaker implantation and who experienced a drop in LVEF below 35% during follow-up, with development of HF symptoms and with at least 20% of ventricular pacing. In all patient's revision to CRT was performed at our center between January 2014 and December 2019. We excluded patients who were indicated for a system upgrade regardless of the percentage of ventricular pacing and those in whom the drop in LVEF is due to a new coronary event. We used patients’ medical records to collect data on baseline characteristics. LVEF was measured pre-revision and 12 months after upgrade. To examine the difference in LVEF change between specified subgroups of patients we used a t-test. Results During the defined period, 82 upgrade procedures from conventional pacemaker to CRT were done in our center. We excluded 12 patients with left bundle branch block (LBBB) QRS morphology, 4 with non-LBBB QRS morphology but with QRS duration over 150ms and 4 patients who died within a year after revision to CRT. Therefore, we analyzed 62 patients (20.9% female, mean age 66.9 ± 11.2 years, mean LVEF 25.9 ± 6.8). After 12 months, 58.1% of patients had an increase in EF above 5%, and the mean change in LVEF (ΔLVEF) was 7.8 ± 11.8. Compared to those with non-ischemic cardiomyopathy (NICMP), patients with ischemic etiology had statistically significantly less improvement in LVEF (ΔLVEF 1.8 ± 6.8 vs 13.1 ± 12.7, p < 0.01), as well as patients with an RV apical pacing compared to those with a septal lead position (ΔLVEF 5.1 ± 9.1 vs 14.1 ± 14.7, p = 0.021). Patients with narrower paced QRS complex (<150ms) before upgrade had a significantly greater improvement in LVEF compared to those with a wider paced QRS complex (≥150ms) (ΔLVEF 10.9 ± 12.2 vs 4.8 ± 10.7, p = 0.04), and those with post-revision paced QRS width above 150ms had significantly lower change in LVEF compared to those with a narrower paced QRS (ΔLVEF 4.6 ± 9.8 vs 11.1 ± 12.8, p = 0.028). Conclusion Patients with NICMP and with width of the paced QRS complex before and after revision to CRT below 150ms had significantly greater improvement in LVEF 12 months after the upgrade. The position of RV lead significantly affects the success of the upgrade procedure.

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

LONG–TERM FUNCTIONAL LIMITATIONS ON CARDIOPULMONARY EXERCISE TESTING IN A COHORT OF PATIENTS WITH EMOTIONS–TRIGGERED TAKOTSUBO SYNDROME

Abstract Background In patients with prior Takotsubo syndrome (TTS), long lasting functional cardiac limitations were described as compared with normal subjects. Emotions–triggered Takotsubo syndrome (E–TTS) has more favorable outcomes than TTS preceded by a physical trigger or by no identifiable factors. The aim of the present study was to assess long–term cardiac functional limitations in a cohort of asymptomatic E–TTS patients. Methods We enrolled n=39 asymptomatic patients with a diagnosis of E–TTS. Cardiopulmonary exercise tests (CPET) were performed at 30 [12–40] months median follow–up from the acute event. A cohort of n=39 individuals matched for age, sex, body mass index and comorbidities served as control. Results Despite recovery of left ventricular ejection fraction, patients with prior E–TTS had lower peak VO2 and percentage of predicted peak VO2 (17.8 ± 3.6 vs 22.5 ± 6.5; P < 0.001 and 75.2 ± 14.1 % vs 100.6 ± 17.1%, P <0.001), VO2 at anaerobic threshold (AT) (11.1 [10.1–12.9] vs 14.4 [12.5–18.7]; P <0.001), peak O2 pulse (9.7 ± 2.5 vs 13.1 ± 3.5; P <0.001) and higher VE/VCO2 slope (30.4 ± 3.7 vs 27.2 ± 3.5; P <0.001) compared with matched controls. We found no statistically significant differences in heart rate reserve (HRR), respiratory equivalent ratio (RER), mean blood pressure and peak PetCO2 between patients and controls. Conclusions Despite their overall favorable outcome, asymptomatic patients with E–TTS were found to have long–term subclinical functional cardiac impairments. CPET proved to be a useful tool in the long–term evaluation of E–TTS patients after recovery of LVEF. Further studies are needed to fully clarify the origin of the detected CPET abnormalities as well as their prognostic relevance in patience with recovered E–TTS.

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 performance 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; 39–19% female; median indexed left atrial volume 42 (33–52) mL/m2; median LVEF 43 (38–46)%). At a median follow-up time of 30 (20–34) 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 their combination 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.

Left atrial diastasis strain slope is a marker of hemodynamic recovery in post-ST elevation myocardial infarction: the Laser Atherectomy for STemi, Pci Analysis with Scintigraphy Study (LAST-PASS).

Left atrial (LA) mechanics are strongly linked with left ventricular (LV) filling. The LA diastasis strain slope (LADSS), which spans between the passive and active LA emptying phases, may be a key indicator of the LA-LV interplay during diastole. This study aimed to investigate the LA-LV interdependencies in post-ST elevation myocardial infarction (STEMI), with particular focus on the LADSS. Patients with post-anterior STEMI who received primary percutaneous coronary intervention underwent contrast cardiac magnetic resonance imaging (MRI) during acute (5-9 days post-STEMI) and chronic (at 6 months) phases. The LADSS was categorized into three groups: Groups 1, 2, and 3 representing positive, flat, and negative slopes, respectively. Cross-sectional correlates of LADSS Group 2 or 3 compared to Group 1 were identified, adjusting for demographics, LA indices, and with or without LV indices. The associations of acute phase LADSS with the recovery of LV ejection fraction (LVEF) and scar amount were investigated. Sixty-six acute phase (86.4% male, 63.1 ± 11.8 years) and 59 chronic phase cardiac MRI images were investigated. The distribution across LADSS Groups 1, 2, and 3 in the acute phase was 24.2%, 28.9%, and 47.0%, respectively, whereas in the chronic phase, it was 33.9%, 22.0%, and 44.1%, respectively. LADSS Group 3 demonstrated a higher heart rate than Group 1 in the acute phase (61.9 ± 8.7 vs. 73.5 ± 11.9 bpm, p < 0.01); lower LVEF (48.7 ± 8.6 vs. 41.8 ± 9.9%, p = 0.041) and weaker LA passive strain rate (SR) (-1.1 ± 0.4 vs. -0.7 [-1.2 to -0.6] s-1, p = 0.037) in the chronic phase. Chronic phase Group 3 exhibited weaker LA passive SR [relative risk ratio (RRR) = 8.8, p = 0.012] than Group 1 after adjusting for demographics and LA indices; lower LVEF (RRR = 0.85, p < 0.01), higher heart rate (RRR = 1.1, p = 0.070), and less likelihood of being male (RRR = 0.08, p = 0.058) after full adjustment. Acute phase LADSS Groups 2 and 3 predicted poor recovery of LVEF when adjusted for demographics and LA indices; LADSS Group 2 remained a predictor in the fully adjusted model (β = -5.8, p = 0.013). The LADSS serves both as a marker of current LV hemodynamics and its recovery in post-anterior STEMI. The LADSS is an important index of LA-LV interdependency during diastole. https://clinicaltrials.gov/, identifier NCT03950310.

Obesity is associated with long-term outcome of catheter ablation of atrial fibrillation in patients with dilated cardiomyopathy.

Patients with atrial fibrillation (AF) and dilated cardiomyopathy (DCM) often exhibit cardiac dysfunction and a poor prognosis. However, the specific reasons are unclear. This study aimed to describe the impact of obesity in patients with AF and DCM. Seventy-four consecutive patients with AF and DCM were enrolled and classified by body mass index. We measured primary endpoints, including cardiac death, recurrent AF, recurrent atrial tachyarrhythmia and stroke, as well as secondary endpoints. In multivariate analysis, compared to the normal-weight group, the overweight and obese groups had greater incidences of recurrent AF (0.0 vs 30.3 vs 40.0%, respectively, log-rank p = 0.048) and rehospitalisation (9.1 vs 36.4 vs 45.0%, respectively, log-rank p = 0.035). Compared to the normal-weight group, five-year outcomes for primary endpoints were inferior in the overweight and obese groups (18.2 vs 30.3 vs 50.0%, respectively, log-rank p = 0.042). Overweight patients exhibited more benefit in recovery of left ventricular ejection fraction after ablation (from 39.1 to 50.0%, p = 0.005) than the normal-weight group (from 43.1 to 52.3%, p = 0.199) and obese group (from 44.9 to 51.2%, p = 0.216). Patients with AF and DCM with overweight or obesity exhibited worse long-term outcomes in recurrent AF than normal-weight patients. However, overweight patients showed the most benefit in cardiac function after ablation.

Long-Term Functional Limitations on Cardiopulmonary Exercise Testing in Emotion-Triggered Takotsubo Syndrome.

Background: In patients with prior Takotsubo syndrome (TTS), long-lasting functional cardiac limitations were described as compared with normal subjects. Emotion-triggered Takotsubo syndrome (E-TTS) has more favorable outcomes than TTS preceded by a physical trigger or by no identifiable factors. The aim of the present study was to assess long-term cardiac functional limitations in a cohort of asymptomatic E-TTS patients. Methods: We enrolled n = 40 asymptomatic patients with a diagnosis of E-TTS. Cardiopulmonary exercise tests (CPET) were performed at 30 (12-40) months median follow-up from the acute event. A cohort of n = 40 individuals matched for age, sex, body mass index and comorbidities served as control. Results: Despite recovery of left ventricular ejection fraction, patients with prior E-TTS had lower peak VO2 and percentage of predicted peak VO2 (17.8 ± 3.6 vs. 22.1 ± 6.5; p < 0.001 and 75.2 ± 14.1% vs. 100.6 ± 17.1%, p < 0.001), VO2 at anaerobic threshold (AT) (11.5 [10.1-12.9] vs. 14.4 [12.5-18.7]; p < 0.001), peak O2 pulse (9.8 ± 2.5 vs. 12.9 ± 3.5; p < 0.001) and higher VE/VCO2 slope (30.5 ± 3.7 vs. 27.3 ± 3.5; p < 0.001) compared with matched controls. We found no statistically significant differences in heart rate reserve (HRR), respiratory equivalent ratio (RER), mean blood pressure and peak PetCO2 between patients and controls. Conclusions: Despite its favorable outcome, patients with E-TTS in our population were found to have subclinical long-term functional cardiac limitations as compared with a control cohort.

Cardiac Magnetic Resonance Studies in a Large Animal Model that Simulates the Cardiac Abnormalities of Human Septic Shock.

Septic shock, in humans and in our well-established animal model, is associated with increases in biventricular end diastolic volume (EDV) and decreases in ejection fraction (EF). These abnormalities occur over 2 days and reverse within 10 days. Septic non-survivors do not develop an increase in EDV. The mechanism for this cardiac dysfunction and EDV differences is unknown. Purpose-bred beagles randomized to receive intrabronchial Staphylococcus aureus (n=27) or saline (n=6) were provided standard ICU care including sedation, mechanical ventilation, and fluid resuscitation to a pulmonary arterial occlusion pressure of over 10mmHg. No catecholamines were administered. Over 96h, cardiac magnetic resonance imaging, echocardiograms, and invasive hemodynamics were serially performed, and laboratory data was collected. Tissue was obtained at 66h from six septic animals. From 0-96h after bacterial challenge, septic animals vs. controls had significantly increased left ventricular wall edema (6%) and wall thinning with loss of mass (15%) which was more pronounced at 48h in non-survivors than survivors. On histology, edema was located predominantly in myocytes, the interstitium, and endothelial cells. Edema was associated with significantly worse biventricular function (lower EFs), ventricular-arterial coupling, and circumferential strain. In septic animals, from 0-24h, the EDV decreased from baseline and, despite cardiac filling pressures being similar, decreased significantly more in non-survivors. From 24-48h, all septic animals had increases in biventricular chamber sizes. Survivors biventricular EDVs were significantly greater than baseline and in non-survivors, where biventricular EDVs were not different from baseline. Preload, afterload, or HR differences did not explain these differential serial changes in chamber size. Systolic and diastolic cardiac dysfunction during sepsis is associated with ventricular wall edema. Rather than differences in preload, afterload, or heart rate, structural alterations to the ventricular wall best account for the volume changes associated with outcome during sepsis. In non-survivors, from 0-24h, sepsis induces a more severe diastolic dysfunction, further decreasing chamber size. The loss of left ventricular mass with wall thinning in septic survivors may, in part explain, the EDV increases from 24-48h. However, these changes continued and even accelerated into the recovery phase consistent with a reparative process rather than ongoing injury. What is new?: Utilizing multimodal imaging and hemodynamics, we demonstrate the cardiac changes of sepsis have injury and reparative phases.The injury phase (0-24h) has EDV decreases more profound in non-survivors and is associated with worse ventricular compliance, myocardial edema, and diastolic dysfunction.The recovery phase has left ventricular mass loss with wall thinning in survivors that explains the EDV increases (24-96h). These progressed into the EF recovery phase consistent with a reparative process removing damaged tissue.This is the first controlled CMR sepsis study supporting ventricular wall edema is a fundamental aspect of sepsis pathophysiology and dry mass loss a reparative mechanism.What are the clinical implications?: Despite optimizing filling pressures, the cardiac changes in ventricular wall structure and function associated with survival and non-survival in sepsis still occurred, thereby discounting fluid resuscitation as the major factor of therapeutic importance for cardiac function and survival.The changes reported here have potential implications for sepsis treatment especially in the field of fluid resuscitation. These findings yield new understanding into the pathophysiology of sepsis cardiac dysfunction and allow for novel phenotyping and prognosticating of the syndrome with ventricular compliance and EDVs. This also offers potentially high yielding targets for research for new therapeutic approaches for sepsis and heart failure.

CMR characterization of patients with heart failure and left bundle branch block

Abstract Aims We aimed to identify the distinctive cardiovascular magnetic resonance (CMR) features of patients with left bundle branch block (LBBB) and heart failure with reduced ejection fraction (HFrEF) of presumed non-ischaemic aetiology. The secondary aim was to determine whether these individuals exhibit characteristics that could potentially serve as predictors of left ventricular ejection fraction (LVEF) recovery as compared with patients without LBBB. Methods and results We prospectively recruited patients with HFrEF (LVEF ≤ 40%) on echocardiography who were referred for early CMR examination. Patients with an established diagnosis of coronary artery disease and known structural or congenital heart disease were excluded. LV recovery was defined as achieving ≥10% absolute improvement to ≥40% in LVEF between baseline evaluation to CMR. A total of 391 patients were recruited including 115 (29.4%) with LBBB. Compared with HF patients without LBBB, those with LBBB exhibited larger left ventricles and smaller right ventricles, but no differences were observed with respect to LVEF (35.8 ± 12 vs. 38 ± 12%, P = 0.105). The overall rate of LV recovery from baseline echocardiogram to CMR (70 [42–128] days) was not significantly different between LBBB and non-LBBB patients (27.8% vs. 31.5%, P = 0.47). Reduced LVEF remained an independent predictor of LV non-recovery only in patients with LBBB. Conclusion Patients presenting with HFrEF and LBBB had larger LV cavities and smaller RV cavities than those without LBBB but no difference in prevalence of scar or ischaemia. The rates of LV recovery were similar between both groups, which supports current guidelines to defer device therapy until 3–6 months of guideline-directed medical therapy, rather than early CMR and device implantation.

Incremental prognostic value of speckle tracking echocardiography and early follow-up echo assessment in predicting left ventricular recovery after reperfusion for ST-segment elevation myocardial infarction (STEMI).

Up to 50% of patients do not achieve significant left ventricular ejection fraction (LVEF) recovery after primary percutaneous intervention (PPCI) for STEMI. We aimed to identify the echocardiographic predictors for LVEF recovery and assess the value of early follow-up echocardiography (Echo) in risk assessment of post-myocardial infarction (MI) patients. One hundred one STEMI patients undergoing PPCI were enrolled provided EF below 50%. Baseline echocardiography assessed LVEF, volumes, wall motion score index (WMSI), global longitudinal strain (GLS), global circumferential strain (GCS), and E/e'. Follow-up echocardiography after 6weeks reassessed left ventricular volumes, LVEF and GLS.GCS was not assessed at follow up. Patients were classified into recovery and non-recovery groups. Predictors of LVEF recovery and major adverse cardiovascular events (MACE) at 6 months were analysed. The mean change of EF was 8.04±3.32% in group I versus -.39±5.09 % in group II (p<.001). Recovered patients had better baseline GLS, baseline GCS, E/e', and follow-up GLS. Multivariate regression analysis revealed E/e', GCS, and follow-up GLS after 6weeks to be strong independent predictors for LVEF recovery. Composite MACE was considerably higher in group II (32.7% vs. 4.1%, p<.001) mainly driven by higher heart failure hospitalisation Multivariate regression analysis revealed baseline GLS, E/e', and ejection fraction (EF) percentage recovery as strong independent predictors for MACE. Multiparametric echocardiographic approach incorporating LVEF, strain parameters, and diastolic function could allow early optimal risk stratification after STEMI treated with PPCI. Follow-up GLS and LVEF percentage change are the strongest predictors for early LV recovery and long term clinical outcome, respectively.

COVID-19 Associated Myocarditis: A Monocentric Series of 33 Cases

Introduction: Myocarditis is defined by an inflammatory myocardial infiltrate with necrosis of non-ischemic origin in three forms: fulminant, acute and chronic. Diagnosis is guided by clinical presentation, ECG, echocardiography and biology, and confirmed by MRI and myocardial biopsy. The prognosis depends on clinical manifestations, echocardiographic features and serum troponin levels. Management is based on the treatment of heart failure (HF). For two years, the world has been experiencing a pandemic related to SARS-CoV2 that can affect the heart with ischemic or non-ischemic lesions (myocarditis, most often fulminant) whose treatment is non-specific. Trials with corticosteroids and immunosuppressant drugs have yielded discordant results.&#x0D; Objective: To describe the evolutionary modalities of COVID-19 associated myocarditis and identify factors of poor ejection fraction recovery under HF treatment.&#x0D; Method: This observational, retrospective, single-center study, in 2021, included patients with non-fulminant COVID-19 associated myocarditis suspected at echocardiography and biology and confirmed on MRI. Patients with previous HF and reduced left ventricular ejection fraction (LVEF) were excluded (n=06). Patients were divided into two groups according to LVEF three months later (LVEF&gt;50% v. LVEF&lt;50%) and compared to identify factors predicting a poor LVEF recovery.&#x0D; Results: 33 patients (19♂/14♀) aged between 30–61 years with acute non-fulminant COVID-19 associated myocarditis were included. All had ECG repolarization abnormalities. The mean LVEF at baseline was 44.3% +/- 6.3 (30–52%) with an average troponin level 480 times normal (20–2,100). Beta-blocker and RASB treatment was initiated in all patients, spironolactone (37.5 mg) in 13 patients with LVEF &lt;40% and furosemide if congestive signs (17 patients/51.5%). Clinical, electrical, biological and echocardiographic monitoring was performed at one and three months. Eight patients developed uncomplicated pericardial effusion. A significant improvement in LVEF&gt;50% was observed in 29 patients. One patient with LVEF of 38% presented with incessant ventricular tachyarrhythmia that necessitated an ICD. Three patients kept LVEF&lt;50%. Sex, congestive signs, ECG and coronary angiogram abnormalities do not seem to influence the LVEF evolution (p at 0.62, 1.00, 1.00, 0.56, 0.50, and 0.23, respectively). Age &gt;60 years, troponins &gt;1,200 times normal, pericardial effusion and a combined criterion of the three seem to be a good predictor of poor LVEF evolution (p at 0.07, 0.02, 0.035 and 0.01, respectively).&#x0D; Discussion: The absence of fulminant forms in our series explains the absence of mortality at three months (&gt;30% in the literature). Acute non-fulminant COVID-19 associated myocarditis has a good prognosis with LVEF recovery in 87.88%. The factors of poor LVEF recovery are the age &gt;60 years, troponins &gt;1,200 times normal, pericardial effusion, and the combined criterion of the three (p respectively at 0.07, 0.02, 0.035, 0.01). The routine prescription of corticosteroids in the COVID-19 protocol made it impossible to analyze its impact on COVID-19 associated myocarditis.&#x0D; Interpretation: Cardiac manifestations are not uncommon during COVID-19; they can be ischemic or non-ischemic. There is no specific therapy for non-fulminant COVID-19 associated myocarditis and the evolution seems favorable. Patients with predictive factors of poor progress should have longer follow-ups.&#x0D; Informed consent: All participants gave their informed consent to participate in this study and share the results

Recovery of left ventricular ejection fraction in Takotsubo Syndrome

Abstract Introduction Takotsubo Syndrome (TTS) is a condition of transient left ventricular dysfunction that is typically triggered by emotional or physical stress. Left ventricular ejection fraction (LVEF) recovery in TTS occurs over a wide-range interval, varying from days to weeks. Purpose Our purpose was to access the prognostic impact of delayed recovery of LVEF in patients with TTS. Methods We performed a retrospective analysis of patients admitted in a single centre between 2008 and 2022 with the diagnosis of TTS, with a LVEF &amp;lt;50% at admission. Patients were divided into two groups: Group A- patients with the recovery of ejection fraction during hospitalization (LV EF ≥ 50% at the pre-discharge echocardiogram) and Group B- patients that had a delay in recovery, with LV EF &amp;lt;50% at the pre-discharge echocardiogram. Major adverse cardiovascular events (MACCE) included heart failure hospitalization, cardiovascular mortality, stroke and TTS recurrence. Results We included 63 pts, 88,9% females, mean age of 69,38 ±12,5 years. Group A included 27 pts, with a median LV EF of 37% (IQR 33-41) and group B included 36 pts with a median LV EF of 36% (IQR 33-38,8), with no statistically significant difference between the two groups (p= 0,347). The median pre-discharge LV EF was 60,0% (IQR 56-65,6) in group A and 42,0% (IQR 37-47) in group B (p&amp;lt;0,005). The hospitalization length (HL)was similar between the two groups (mean HL of 7,9 ±7,8 in group A versus 8,1 ±8,4 days in group B, p= 0,93). The two groups were similar in terms of basal characteristics, with more prevalence of psychiatric disease in group A (13,9% vs 33,3%, p= 0,066). We found no statistically differences in clinical presentation and evolution during hospitalization (Killip class, cardiogenic shock, ventricular arrhythmias) and in the rates of concomitant coronary artery disease (14,8% group A versus 26,5% group B, p= 0,270). Also, the in-hospital medication and at discharge (Angiotensin-converting enzyme inhibitors, beta blockers, spironolactone and aspirin) were identical between the two groups. There was a tendency for more prescription of anticoagulants at discharge in group B (45,7% versus 22,2%, p = 0,055). During a median follow-up of 41,0 months (IQR 14,0-54,5), group B had a higher rate of MACCE (34,4% versus 20,0%, log rank p= 0,033). In a multivariate analysis, after adjusting for possible confounders, delayed recovery of LV EF was an independent predictor of MACCE with a HR 6,1 (95% CI: 1,50-24,9, p= 0,012) (Fig.1). Conclusions In this population, delayed recovery of LV EF in TTS was an independent predictor of major adverse cardiovascular events. These findings suggest that this population should be targeted in clinical trials to investigate possible interventions and these patients should have a closer follow-up.

The determinant role of high-density lipoprotein cholesterol on the recovery of left ventricle ejection fraction after acute coronary syndromes

Abstract Background Higher levels of high-density lipoprotein cholesterol (HDLc) have been associated to lower atherosclerosis-associated cardiovascular disease. Patients admitted for acute coronary syndromes (ACS) usually have low levels of HDLc. Methods Between 2015 and 2020 a total of 1,794 patients were admitted from an ACS; 75 (4.23%) died within the hospitalization, 619 (36.0%) were discharged having a LVEF &amp;lt;0.50 from whom 562 (90.79%) had an echocardiogram available within the first 12 months after discharge. We evaluated the evolution of LVEF and assessed the percentage of patients with postdischarge LVEF &amp;gt;0.35 or &amp;gt;0.50. Multivariate analyses were performed by competing risk regression considering all-cause mortality as a competing event and adjusted by risk factors, age, medical treatment at discharge and revascularization; results are presented as sub-hazard ratio (sHR). Results Mean (standard deviation) age was 65.61 (12.16), 21.% were males, 28.6% had DM and 51% were discharged after an ST-elevation myocardial infarction (STEMI). During the ACS, LVEF was 43.19 (11.12) and 33.92% had LVEF ≤0.35. Mean HDLc was 40.73 (13.94) mg/dL and no differences were observed in patients with LVEF 0.35 or &amp;lt;0.20. Median time to postdischarge echocardiogram was 200 days (IQ range 90-295). Postdischarge LVEF was 48.61 (12.83), 54.8% had LVEF &amp;gt;0.50 and 14.41% had LVEF ≤0.35. Eleven patients died before having a postdischarge echocardiogram. Patients with postdischarge LVEF &amp;lt;0.50 had the same age and sex but had more frequently STEMI (56.13 vs. 47.71%; p=0.048), Killip class &amp;gt;I (47.43% vs. 25.82%; p&amp;lt;0.01), lower LVEF at the ACS (37.24 (0.58) vs. 48.17 (0.58); p&amp;lt;0.01) and specially LVEF&amp;lt;0.35 (45.68% vs. 20.19%; p&amp;lt;0.01). Patients who had postdischarge LVEF &amp;lt;0.50 had lower HDLc (38.19 (0.79) vs 41.11 (0.70) mg/dL; p&amp;lt;0.01) and lower LDLc (85.64 (37.64) vs. 97.45 (35.95) mg/dL; p&amp;lt;0.001) and glomerular filtration rate (73.47(24.57) vs. 78.54 (20.60) ml/min/1.72m2; p&amp;lt;0.001); no differences were observed in triglycerides, hemoglobin or C-reactive protein. The competing risk regression identified an independent predictive value of HDLc for LVEF improvement (figure). HDLc &amp;gt;40 mg/dL in the ACS was independently associated to higher probability of postdischarge LVEF &amp;gt;0.50 (sHR: 1.28 95% CI 1.07-1.53; p&amp;lt;0.001). Conclusions HDLc levels, measured during an ACS hospitalization, predict LVEF recovery in patients discharged with LVEF &amp;lt;0.50.

Predictive role of intracoronary electrocardiography for procedural success in patients with ST-elevation myocardial infarction developing coronary no-reflow

Abstract Background The no-reflow phenomenon (NRP) is associated with increased mortality and development of heart failure in patients with ST-segment elevation myocardial infarction (STEMI). Although there is no definitive method for NRP treatment in current guidelines, methods to predict the success of procedures with NRP are also limited. There is a need for a practical, real-time method for predicting the outcome of procedures in NRP patients. Intracoronary electrocardiography (ic-ECG) which is simple, cost-effective, and a bedside indicator of myocardial ischemia, is proposed as a potential solution in this study. Purpose The aim of this study was to examine the potential of ic-ECG in predicting the success of primary percutaneous intervention (pPCI) in patients with STEMI and the development of coronary no-reflow. Methods This was a prospective investigation that included 71 patients diagnosed with acute anterior STEMI and underwent pPCI between November 2021 and May 2022. The patients were separated into two groups based on the Thrombolysis in Myocardial Infarction (TIMI) flow grade criteria, with those having a grade of less than 3 defined as NRP. The NRP group was further analyzed to determine the relationship between the percentage of ST-segment resolution (STR) in the ic-ECG records taken during pPCI and short-term major adverse cardiovascular events rates and left ventricular ejection fraction (LVEF) recovery status. Results A total of 71 patients, with a mean age of 56.8 years and 76.1% of them being male, were included in the study. Of these patients, 26 were found to have developed NRP, while TIMI-3 flow was observed in 45 patients. In the NRP group, various parameters were found to be associated with LVEF recovery, such as peak troponin value (6267.8±2488.4 ng/ml vs 3244.6±3183 ng/ml, p=0.013) basal low-density lipoprotein cholesterol (LDL-C) (138.8±29.9 mg/dl vs 104.5±40 mg/dl, p=0.021), total cholesterol value (222.7±69.2 mg/dl vs 167.5±44.5 mg/dl, p=0.024), and ic-ECG STR level (21±22.3% vs 65.5±17%, p&amp;lt;0.001). The results of the multivariate analysis and subsequent ROC analysis showed that an ic-ECG STR ratio greater than 42% (sensitivity 100%, specificity 84.6%) was an independent predictive factor for LVEF improvement (Table 1). Conclusions The results showed that the STR rate measured by ic-ECG was significantly associated with LVEF recovery and was an independent predictive factor for LVEF recovery with a sensitivity of 100% and specificity of 84.6%. The study highlights the usefulness of ic-ECG in predicting pPCI success in NRP patients and supports its integration into clinical practice.

Abstract 15859: Cardiopulmonary Exercise Function in Methamphetamine-Associated Heart Failure

Introduction: The role of methamphetamine (meth) cessation in the functional recovery of methamphetamine-associated HF (meth-HF) is unknown. Objective To evaluate the role of active meth use on cardiopulmonary function in participants with meth-HF. Methods: We recruited participants from a longitudinal cohort study of meth-HF and used cardiopulmonary exercise testing (CPET) with maximal effort upright cycle ergometer to assess exercise cardiorespiratory function. Descriptive analysis was used to study associations between cardiopulmonary function and 1) active use and 2) ejection fraction (EF) recovery. Results: Of those assessed for eligibility (n = 55), 11 were deceased and 30 could not be contacted/declined participation. Ten studies were completed of the 14 scheduled, with three no-shows and one termination due to pre-test PVCs. Of those who completed studies, 90% were male, median age was 52 years [40, 54] and duration of HF was 33 months [16, 58]. Five were active users, and five had a recovered EF. All were on quad-guideline-directed medical therapy (GDMT) for a median duration of 15 months [9.1, 29]. Baseline EF was 28% [21, 42], and EF closest to CPET date was 50% [42, 59]. Peak VO 2 (% predicted) in prior vs. active use was 73 [66, 75] and 60 [48, 66]; in persistently low vs. recovered EF, it was 75 [66, 75] and 63 [60, 66] ( Figure 1A ). Adjusted heart rate reserve (aHRR, %) in prior vs. active use was 42 [37, 43] and 46 [44, 58]; in persistently low vs. recovered EF, it was 58 [44, 62] and 37 [35, 43] ( Figure 1B ). In prior vs. active use, VO 2 pulse (VO 2 /HR, mL/beat) was 16 [15, 17] and 13 [12, 15]. One participant died of sudden cardiac death between CPET and time of analysis. Conclusions: To our knowledge, this is the first study looking at cardiorespiratory fitness in the setting of meth use and HF. Our preliminary findings suggest that peak VO 2 and aHRR remain low, which suggests the presence of persistent cardiac effects of meth use despite cessation of use and/or recovery of EF.

Abstract 14154: Myotonic Dystrophy and Stress Induced Cardiomyopathy

Myotonic dystrophy type 1 (MD1) is an autosomal dominant neuromuscular disease that can affect skeletal, smooth, and cardiac muscle. Patients often have cardiac involvement such as conduction diseases, ventricular arrhythmia, sudden cardiac death, cardiomyopathy and pulmonary hypertension. We describe a patient with MD1 who suffered recurrent takotsubo cardiomyopathy. Case: A 39-year-old female with history of myotonic dystrophy type 1, takotsubo cardiomyopathy with recovered ejection fraction (EF) 50-55%, gastroparesis and orthostatic hypotension presented with chest pain, nausea, vomiting, dyspnea, and diaphoresis. Initially she was hypotensive and tachycardic. The initial physical exam revealed intact mentation, cachexia, 4/5 muscle strength in all four extremities, lack of JVD, warm and well-perfused extremities without edema. Notable lab findings included a lactic acid of 2.3 mmol/L, high sensitivity troponin of 5000 ng/L and proBNP of 1520 pg/mL. Her initial ECG revealed first degree AV block, left anterior fascicular block, ST elevations in leads V 2 -V 3 and T wave inversions in lateral leads. She was admitted for further evaluation. A transthoracic echocardiogram (TTE) showed an EF of 20-25% with apical akinesis and ballooning, with a small apical mural thrombus. She was started on a heparin drip and ischemic work up was deferred given her normal coronary arteries three years prior. Serial TTEs showed improvement of her EF to 54% within two weeks. She was managed with gentle diuresis but she was unable to tolerate guideline directed medical therapy (GDMT) due to symptomatic hypotension. Improvement in her symptoms was noted with the EF recovery. Discussion: There is currently no known association between takotsubo cardiomyopathy and myotonic dystrophy type 1. To our knowledge there is one case in the literature that reported a recurrent takotsubo cardiomyopathy in MD1 patient, and this case is the second. These two cases highlight the possibility that MD1 patients may be at risk of recurrent takotsubo cardiomyopathy. We believe that additional research is needed to investigate a possible causative relationship between the two disease entities.

Abstract 361: Effect of Percutaneous Ventricular Assisted Device on a Recovery of Myocardial Function in Swine Model With Prolonged Cardiac Arrest

Background: Percutaneous ventricular assist device (pLVAD) support and Transient aortic balloon occlusion (AO) can preserve cerebral and cardiac blood flow during cardiopulmonary resuscitation (CPR), but it remains unclear if pLVAD reduces post-cardiac arrest myocardial dysfunction. Hypothesis: pLVAD support immediately after the return of spontaneous circulation (ROSC) improves early recovery of myocardial function following prolonged cardiac arrest. Aims: Evaluate the association between early post-ROSC pLVAD support and recovery of myocardial function in a swine model of prolonged cardiac arrest. Methods: This is a secondary analysis of a subset of animals that achieved ROSC in a study comparing pLVAD, transient AO or both during CPR after prolonged cardiac arrest. pLVAD, aortic occlusion, or both were initiated after 24 minutes of ventricular fibrillation cardiac arrest (8 min no-flow and 16 min mechanical CPR). AO was discontinued post-ROSC, and pLVAD support or standard care were continued. Beginning 60 minutes post-ROSC, pLVAD support was weaned to &lt;1.0 L/min while maintaining a MAP &gt;70 mmHg, and subsequently removed at 4 hours when feasible. The primary outcome was the recovery of cardiac index (CI) and left ventricular ejection fraction (LVEF) at 4 hours post-ROSC. Data are shown as mean (standard error). Results: Seventeen animals achieved ROSC without complication and were included in this analysis (pLVAD group, n = 11 [8 were removed from pLVAD], and standard care group, n = 6). For the primary outcome, the pLVAD group had significantly higher CI of 4.2(0.3) vs. 3.1(0.4) L/min/m2 (p=0.043) and LVEF 60(3) vs. 49(4) % (p=0.029) at 4 hours after ROSC, respectively, when compared with the standard care group. Focusing on the early period within 60 minutes after ROSC when maximum pLVAD flow was maintained, the pLVAD group had significantly higher coronary perfusion pressure (62[4] vs. 47[5] mmHg, p=0.019), lower LV stroke work index (3.9[3.0] vs. 14.9[4.4] cJ/m2, p=0.043), and lower total pulmonary resistance index (13.2[4.8] vs. 21.5[14.4] Wood Unit, p=0.001). Conclusion: These results suggest that early pLVAD support after ROSC is associated with better recovery myocardial function compared to standard care after prolonged cardiac arrest.

Abstract 15399: Cardiac Sympathetic Nerve Activity in Women With a History of Takotsubo Syndrome: A Novel Stress Myocardial Radionuclide Imaging Strategy

Introduction: Takotsubo syndrome (TTS) is characterized by transient left ventricular (LV) systolic dysfunction, triggered by physical or emotional stress, and associated with increased long-term cardiovascular morbidity. Cardiac iodine-123-meta-iodobenzylguanidine (mIBG) imaging has previously demonstrated sympathetic hyperactivity in the TTS subacute state which improves at follow-up during rest imaging. Cardiac neuronal dysfunction in response to stress has not been evaluated in recovered TTS. Hypothesis: Sympathetic hyperactivity, as measured by stress mIBG, is abnormal in TTS after recovery of LV ejection fraction (LVEF). Methods: To elicit a sympathetic challenge, women with history of TTS with recovered LVEF (n=19) and asymptomatic age- and sex-matched reference controls (n=10) underwent treadmill (6 minutes) with simultaneous mental-stress testing (public speaking with anger recall). mIBG (10 mCi) was injected during exercise, and planar and SPECT imaging were performed at 15 min (early) and 240 min (late), followed by Tc-99m tetrofosmin myocardial perfusion imaging. Early and late heart-to-mediastinal ratio (HMR) and washout rate (WR) corrected for background were calculated. Results: Median time from last TTS event was 23 months (range 4-56). Overall mean age was 60± 12 years, body mass index 25 ± 4kg/m 2 , resting LVEF 70 ± 7%, 41% hypertension and 0% diabetes with no difference between TTS and controls. TTS had higher resting (140 ± 22 vs 123 ± 19 mmHg, p=0.049) and peak (187 ± 17 vs 171 ± 15 mmHg, p= 0.018) systolic blood pressure. While the early HMR and WR were similar, the late HMR was significantly lower in the TTS group (Figure). Conclusions: Women with a history of TTS have lower late HMR but similar WR, suggesting neuronal dysfunction in response to sympathetic challenge persists long after recovery from TTS event. Further analysis of catecholamine levels and central nervous system neural pathways will explore the mechanism of dysregulation.

Abstract 15479: High Output Cardiac Failure Associated With Arteriovenous Fistula

Introduction: High output heart failure (HOHF) secondary to arteriovenous fistula (AVF) is known. However, having a high index of suspicion for the latter when encountering diuretic resistance in patients with a remote history of hemodialysis is key. Case A 68-year-old female with a history of kidney transplant in 2012 with no recent dialysis, hypertension, hyperlipidemia, pulmonary hypertension, heart failure with reduced ejection fraction, and atrial fibrillation presented with decompensated heart failure and acute kidney injury (AKI). Physical exam was remarkable for anasarca, and no apparent fistulas were noted. She was started on milrinone and furosemide drips. Clinical decision making Initial transthoracic echocardiogram (TTE) revealed an ejection fraction (EF) of 20%, which declined from 35%, along with new mitral and tricuspid regurgitation. Her hospitalization was complicated by altered mental status, worsening AKI requiring hemodialysis, atrial fibrillation with rapid ventricular response, and resistance to multiple diuretics and after-load reduction combinations. Diuretics and inotropic support were discontinued due to worsening clinical status. Given concerns for valvular disease, a transesophageal echocardiogram was obtained, confirming moderate to severe mitral and tricuspid valve regurgitation, bi-atrial enlargement, and reduced biventricular function. However, the patient was not clinically optimized for Mitra-clip. Further hemodynamics and volume status assessment with RHC revealed a mean PAP 44, PCWP 26, and CO 11 L/min. RHC results raised suspicion for HOHF. Interestingly, the patient was noted to have a right inguinal surgical scar with a palpable thrill, and an arteriovenous graft duplex revealed high volume flow. The patient underwent ligation of the right inguinal fistula. Repeat TTE two weeks post AVF ligation showed EF of 40% and improved functional mitral and tricuspid valve regurgitation. The patient ultimately was taken off hemodialysis and had clinically improved heart failure. GDMT was optimized, and outpatient evaluation for mitral valve intervention was scheduled. Conclusion Longstanding AVF can cause HOHF. Early index of suspicion is warranted for AVF ligation as it results in rapid EF recovery.