Follow-up Left Ventricular Ejection Fraction Research Articles

Validation of the Castle HTx data in a real world scenario

Abstract Background Pulmonary vein isolation (PVI) is recommended in patients with symptomatic atrial fibrillation (AF) and reduced left ventricular ejection fraction (LVEF). Recently the Castle HTx (CHTx) trial showed a significant mortality reduction in end stage heart failure patients undergoing PVI in addition to optimized medical therapy (OMT) compared to OMT only. Aim Objective of this analysis is to validate results of Castle HTx study in a real world scenario. Methods All patients between September 2021 und September 2023 referred for PVI at our center with symptomatic AF und LVEF ≤35% were included in this retrospective analysis at the University Hospital Cologne. Results A total of 119 PVI in patients with LVEF≤35% were successfully performed (mean age 63.3±10.1 years, 96 patients (81%) male, 43 (36%) paroxysmal AF, 76 (64%) persistent AF) matching inclusion criteria used in CHTx. Cryo-PVI was used in 50 (42%), RF-PVI in 60 (50%) and PFA in 9 (8%) patients. Complete follow-up (FU) with a mean of 549.6±430.2 days was obtained in 108 patients, comparable to CHtx (540 days). During FU 11 patients (10%) died from any cause (CHTx 8 patients (8%)), 2 patients (2%) received a left ventricular assist device (CHTx 1 patient (1%)) and no patient had urgent heart transplantation (CHTx 1 patient (1%)). For 30 patients (28%) recurrence of AF was detected and 72% remained in sinus rhythm. In 6 patients (5%) post-procedural complications occurred: 5 inguinal hematoma, 1 decompensation. During FU LVEF was statistically significantly improved (EF initial 26.9±6.5%, EF FU (n=80) 37.1±12.8%, p<0.001) (CHTx EF initial 29.0±6.4%, EF FU (n=92) 37.2±9.1%). Conclusion The findings of the Castle HTx patients have been validated in a real-world setting. PVI for rhythm control in end stage heart failure patients is safe and highly effective. Our patient cohort, matched to the Castle HTx ablation group, showed freedom from AF rate of 72% after mean FU time of 550 days. Furthermore, LVEF was improved significantly in our cohort echoing the results from CHTx.

Prognostic value of mid-term cardiovascular magnetic resonance follow-up in patients with non-ischemic dilated cardiomyopathy: a prospective cohort study

BackgroundThe prognostic value of follow-up cardiovascular magnetic resonance (CMR) in dilated cardiomyopathy (DCM) patients is unclear. We aimed to investigate the prognostic value of cardiac function, structure, and tissue characteristics at mid-term CMR follow-up. MethodsThe study population was a prospectively enrolled cohort of DCM patients who underwent guideline-directed medical therapy with baseline and follow-up CMR, which included measurement of biventricular volume and ejection fraction, late gadolinium enhancement, native T1, native T2, and extracellular volume. During follow-up, major adverse cardiac events (MACE) were defined as a composite endpoint of cardiovascular death, heart transplantation, and heart-failure readmission. ResultsAmong 235 DCM patients (median CMR interval: 15.3 months; interquartile range: 12.5–19.2 months), 54 (23.0%) experienced MACE during follow-up (median: 31.2 months; interquartile range: 20.8–50.0 months). In multivariable Cox regression, follow-up CMR models showed significantly superior predictive value than baseline CMR models. Stepwise multivariate Cox regression showed that follow-up left ventricular ejection fraction (LVEF; hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.91–0.96; p < 0.001) and native T1 (HR, 1.01; 95% CI, 1.00–1.01; p = 0.030) were independent predictors of MACE. Follow-up LVEF ≥ 40% or stable LVEF < 40% with T1 ≤ 1273 ms indicated low risk (annual event rate < 4%), while stable LVEF < 40% and T1 > 1273 ms or LVEF < 40% with deterioration indicated high risk (annual event rate > 15%). ConclusionsFollow-up CMR provided better risk stratification than baseline CMR. Improvements in the LVEF and T1 mapping are associated with a lower risk of MACE.

Clinical and echocardiographic impact of physiological estimulation in patients with preserved ejection fraction: a randomized clinical trial

Abstract Introduction Right ventricular stimulation in the apex (RVAS) produce dysynchrony, leading to left ventricle systolic dysfunction (LVSD) in some cases. Circumstances that can worsen the LVSD are a high burden of RVAS, and the presence of previous LVSD and/or intraventricular conduction disease (IVCD). Direct activation of the specialized conduction system with physiological stimulation (PS) can preserve this physiological pattern and shorten de QRS when the impairment is proximal to the pacing site. Most of the studies with PS has been focused on patients with LVSD, with few and scarce evidences regarding pacients without LVSD. Objectives and methods: This is a parallel, single blinded, unicentric, randomized trial of patients with preserved of mild reduced left ventricular ejection fraction (LVEF) submitted to a pacemaker implantation due to atrioventricular block (AVB), with previous IVCD (wide QRS) an anticipated high rate of ventricular pacing. Patients were randomized 1:1 to RVAS vs PS and followed for 6 months. Clinical, ECG, echocardiography and analytic parameters were compared. The primary endpoint was the change in the LVEF at 6 months in each group. The secondary endpoints were the changes in the left ventricular end-diastolic diameter (LVEDD), the QRS duration, the pro–B-type natriuretic peptide (NT-proBNP), the NYHA class, and the Minnesota Living with Heart Failure Questionnaire (MLWHFQ) in each group. Results The study included 57 patients of 77±9,6 years. Of all patients, 53% were treated with RVAS and 47% with PS. There were 2 patients with crossover to RVAS for technical difficulties and 1 patient with crossover to PS due to apical scar. There were no differences in the basal QRS duration (142.08±20,2 ms), LVEF (58.87±7,2%), NT-proBNP (3336,03±7258,68 pg/ml), or MLWHFQ (22,19±14,68), between both groups (Table 1). Acutely significant differences were observed in the change of QRS duration among groups (+16±29 ms in the RVAS group vs -17±25 ms in the PS group, p&amp;lt;0,001). At 6 months follow-up LVEF showed a non-significant reduction of 0.8±1.1% in the PS group compared to a significant reduction of 5.1±1.7% in the RVAS group (difference 4,26% IC 0,1-8,43 p=0,022). No differences were observed regarding the values of the NT-ProBNP and the MLWHFQ between groups at 6 months (Table 2). Conclusions In patients with preserved LVEF requiring pacemaker implantation for AVB, PS shorten the QTS duration and preserves the LVEF compared to RVAS.Basal characteristics of groupsDifferences in outcomes between groups

Cardiac resynchronosation and left ventricular ejection fraction improvement with single ventricular conduction pacing system lead

Abstract Background Conduction system pacing is a new modality to obtain physiologic pacing (PP) and normal to near normal cardiac synchrony; they often obtain shorter QRS durations and they could replace the need of Bi-V (CRT) implants if LVEF improves as much with less leads implanted. Methods From our cohort of 340 physiologic pacing attempts (2019-2023), we extracted all patients (pts) with available ultrasounds before and after implants, aiming to describe the variation of Left Ventricular Ejection Fraction (LVEF) over time; all attempts, including failures were analyzed. Results A total of 146 pts completed follow-up LVEF evaluation. Pts were 36,8% females; median age was 79 +/- 8.5 years. Indications were: SSS 25%, AV block 41% (including 11 post TAVR), Pacemaker induced cardiomyopathy (PIMC) 27% and AV node ablation in 7%. Success to achieve cardiac resynchronisation (defined as a QRS shorter than 140ms and a LVAT shorter than 90ms, or 20% reduction in QRS width) was obtained in 82,6% of pts (higher success rate achieved with LBB-P: 88,4% vs 55,5% for His-P). Procedural time (pts in-out) was 88min (+/- 37min). Pts with a QRS larger than 150ms (CRT indication) were 49% of the cohort. Patients with a LVEF less than 50% accounted for 54,8% of the cohort. Mean QRS duration was 141,9ms (+/-36) pre-implant and 129,3ms (+/- 19) post implant. Mean LVEF was 43,6% (+/- 14) before implant and increased to 50,2% (+/-12) post implant for the entire cohort, in pts with CRT indication, variation persisted: mean LVEF improved from 33,2 to 43,8% and QRS duration from 172,9 to 136,8ms. Pts with less than 50% LVEF had a response rate of 75,5% (increase in LVEF from 4-41%), and 33% of patients increase their LEVF between 10-30% (deemed super responders), only one pt decrease 10% her LVEF (a His failure implant). Conclusion Cardiac resynchronisation is feasible with only one ventricular lead, potentially with longer duration of batteries and lesser costs. Response rate is similar to CRT historical controls but super responders are twice to three times higher than historical controls.

Abstract 15015: Clinical Outcomes of Patients With Heart Failure With Improved Ejection Fraction After Acute MI: A Multicenter Prospective Study From the COREA-AMI Registry

Background: The 2021 Universal Definition of Heart Failure introduce a new classification, heart failure with improved ejection fraction (HFimpEF). As yet, little is known about the long-term clinical outcomes of patients with HFimpEF after acute myocardial infarction (AMI). Methods: From a multicenter, prospective cohort of AMI patients undergoing PCI, patients with an initial TTE at the time of PCI and at least one follow-up TTE 1 month to 2 years after the initial event were considered for analysis. HFimpEF was defined as initial left ventricular ejection fraction (LVEF)≤40% and at least one follow-up LVEF&gt;40% with an increase of ≥10% from baseline. Persistent HFrEF was defined as LVEF ≤40% without interval improvement. Patients with LVEF&gt;40% were defined as having preserved LVEF. The primary endpoint was all-cause mortality. Results: In total, 3038 patients with repeated TTE measurements were selected for initial analysis. 187 patients were identified as having HFimpEF, 190 patients had persistent HFrEF, 631 patients had HFmrEF, and 2030 patients had preserved EF. Kaplan-Meier analysis revealed that HFimpEF was associated with improved survival compared to chronic HFrEF, but inferior to preserved LVEF (log-rank p&lt;0.001). Even after multivariate Cox regression analysis was done to account for confounding variables, HFimpEF was associated with reduced mortality compared to persistent HFrEF (HR 0.49, 95% CI 0.31-0.78). Compared to patients with preserved LVEF, HFimpEF patients had a tendency toward higher mortality, but did not reach statistical significance (HR 1.18, 95% CI 0.80-1.76). Conclusion: HFimpEF is associated with decreased all-cause mortality compared to persistent HFrEF in patients with AMI. Figure 1. Kaplan-Meier Survival Analysis According to Changes in LVEF

High serum lactate dehydrogenase as a predictor of cardiac insufficiency at follow-up in elderly patients with acute myocardial infarction

BackgroundImpairment of cardiac function progresses after acute myocardial infarction (AMI). Lactate dehydrogenase (LDH), a marker of cardiac injury and an enzyme in anaerobic glycolysis, is suggested as a risk factor for patient mortality in inflammatory diseases. MethodsIn this study, 448 older and 445 younger AMI patients were recruited and followed up. The effect of baseline serum LDH on post-infarction cardiac function was assessed at follow-up. ResultsElderly patients in the high baseline LDH group had a high risk of being diagnosed with cardiac insufficiency during follow-up (adjusted hazard ratio: 3.643, P = 0.007), and the follow-up left ventricular ejection fraction of the quartile subgroup tended to decrease with increasing in baseline serum LDH (adjusted odds ratio: 1.301, P = 0.001) for each 100 U/L increase. The LVDd and LVVd of elderly patients in the high LDH group were not significantly different from those of patients in the normal LDH group at baseline but were further increased in the high LDH group at follow-up. In younger patients, the effect of LDH on post-infarction cardiac structure and function was similar to that in older patients, but unlike older patients, Cox regression analysis showed that LDH was not the predominant influence. ConclusionLongitudinal changes in cardiac function were independently associated with high baseline serum LDH levels in patients with AMI. Baseline LDH levels are superior to other myocardial injury markers and may be a useful parameter in predicting future cardiac dysfunction after AMI, especially in the elderly.

Ischemic Postconditioning Confers No Benefit to Left Ventricular Systolic Function: A Meta-Analysis of Cardiac Magnetic Resonance Imaging Results

Ischemic postconditioning (IPoC) is a technique suggested to reduce reperfusion injury in patients suffering acute ST-elevation myocardial infarction (STEMI), although its use is highly controversial. This meta-analysis aimed to evaluate the effect of IPoC with percutaneous coronary intervention in patients with acute STEMI, as measured by follow-up left ventricular ejection fraction (LVEF) on cardiac magnetic resonance imaging. The investigators searched PubMed, Embase, and Web of Science for all randomized controlled trials published during the last 2 decades. After the removal of duplicates, 2,021 articles from online databases had been identified using relevant search criteria. The included randomized controlled trials had studied patients with acute STEMI and Thrombolysis in Myocardial Infarction flow 0 to 1 at presentation and had measured follow-up LVEF using cardiac magnetic resonance imaging. Overall, 11 studies (n=1,339 patients) qualified for inclusion. In each study, the control group did not differ significantly from the experimental group. The pooled data from included studies were analyzed using standardized mean difference between IPoC and control groups, and the 95% confidence interval for LVEF; the results were visualized using a forest plot. Bivariate regression analyses and 1-way analyses of LVEF coefficient ratios were done to isolate for various clinical and procedural parameters. An analysis of pooled data of the IPoC (n=674) and control (n=665) groups showed that IPoC did not significantly impact follow-up LVEF (using standardized mean difference 0.10, 95% confidence interval 0.00 to 0.21). Further analysis showed that IPoC did not improve follow-up LVEF when isolating for relevant clinical and procedural parameters. In conclusion, the use of IPoC as an adjunctive therapy to percutaneous coronary intervention seemingly provides no benefit to left ventricular systolic function, as quantified with cardiac magnetic resonance imaging, in patients with acute STEMI with Thrombolysis in Myocardial Infarction flow 0 to 1.

Atorvastatin for Anthracycline-Associated Cardiac Dysfunction

Anthracyclines treat a broad range of cancers. Basic and retrospective clinical data have suggested that use of atorvastatin may be associated with a reduction in cardiac dysfunction due to anthracycline use. To test whether atorvastatin is associated with a reduction in the proportion of patients with lymphoma receiving anthracyclines who develop cardiac dysfunction. Double-blind randomized clinical trial conducted at 9 academic medical centers in the US and Canada among 300 patients with lymphoma who were scheduled to receive anthracycline-based chemotherapy. Enrollment occurred between January 25, 2017, and September 10, 2021, with final follow-up on October 10, 2022. Participants were randomized to receive atorvastatin, 40 mg/d (n = 150), or placebo (n = 150) for 12 months. The primary outcome was the proportion of participants with an absolute decline in left ventricular ejection fraction (LVEF) of ≥10% from prior to chemotherapy to a final value of <55% over 12 months. A secondary outcome was the proportion of participants with an absolute decline in LVEF of ≥5% from prior to chemotherapy to a final value of <55% over 12 months. Of the 300 participants randomized (mean age, 50 [SD, 17] years; 142 women [47%]), 286 (95%) completed the trial. Among the entire cohort, the baseline mean LVEF was 63% (SD, 4.6%) and the follow-up LVEF was 58% (SD, 5.7%). Study drug adherence was noted in 91% of participants. At 12-month follow-up, 46 (15%) had a decline in LVEF of 10% or greater from prior to chemotherapy to a final value of less than 55%. The incidence of the primary end point was 9% (13/150) in the atorvastatin group and 22% (33/150) in the placebo group (P = .002). The odds of a 10% or greater decline in LVEF to a final value of less than 55% after anthracycline treatment was almost 3 times greater for participants randomized to placebo compared with those randomized to atorvastatin (odds ratio, 2.9; 95% CI, 1.4-6.4). Compared with placebo, atorvastatin also reduced the incidence of the secondary end point (13% vs 29%; P = .001). There were 13 adjudicated heart failure events (4%) over 24 months of follow-up. There was no difference in the rates of incident heart failure between study groups (3% with atorvastatin, 6% with placebo; P = .26). The number of serious related adverse events was low and similar between groups. Among patients with lymphoma treated with anthracycline-based chemotherapy, atorvastatin reduced the incidence of cardiac dysfunction. This finding may support the use of atorvastatin in patients with lymphoma at high risk of cardiac dysfunction due to anthracycline use. ClinicalTrials.gov Identifier: NCT02943590.

Changes in left ventricular systolic function for 1 year in patients with acute heart failure &amp;lt;50 years of age

Abstract Funding Acknowledgements Type of funding sources: None. Background Though old age is an important risk factor for cardiovascular disease including heart failure (HF), HF can develop in young patients and can have a greater impact on a quality of life because they are active individuals. Purpose We evaluated the clinical characteristics and prognosis according to change of left ventricular (LV) function in younger patients with acute HF. Methods Study data were obtained from a multicenter cohort that included patients hospitalized for acute HF. Patients who were under 50 years of age and had available data regarding baseline and one-year follow-up left ventricular ejection fraction (LVEF) were included in this analysis. Patient were classified into two groups according changes in LVEF: the improved or stationary group whose LVEF improved or maintained at one-year follow-up; the aggravated LVEF group whose LVEF deteriorated at one-year follow-up. Results Among 437 patients, 14.6% of patients had experienced worsening of LVEF at the one-year follow-up. The patients in aggravated LVEF group had a worse clinical profile than patients with improved or stationary LVEF. During follow-up (median 1946 days), a total of 56 patients (12.8%) died. Among them, the aggravated LVEF group had higher incidence of all-cause death (32.8% vs. 9.4%, p &amp;lt; 0.001). The aggravated LVEF group showed significant lower cumulative all-cause death free survival rate than improved or stationary LVEF group (Figure). In addition, the aggravated LVEF group had significantly higher incidence of cardiac death (14.1% vs. 2.9%, p &amp;lt; 0.001), readmission (76.6% vs. 55.5%, p = 0.002), readmission due to cardiac cause (57.8% vs.30.8%, p &amp;lt; 0.001), and HF readmission (51.6% vs. 26.0%, p &amp;lt; 0.001). After adjusting for confounding factors, Cox regression analysis showed that use of angiotensin converting enzyme inhibitors at discharge was independently associated with 63% reduced risk of aggravated LVEF (Odds ratio 0.37, 95% confidence interval 0.168–0.791, p = 0.001). Conclusions Poor clinical prognosis is expected if LVEF worsens after 1 year in young patients with HF. Clinicians need to be aware of the deteriorating characteristics of young HF patients and provide delicate treatment.

Evaluation of the pharmacotherapeutic impact on contractility recovery in patients with newly diagnosed, acute onset dilated cardiomyopathy.

In patients with acute onset dilated cardiomyopathy (DCM) an improvement of left ventricular ejection fraction (LVEF) can occur as an effect of complex therapy. The aim of the study was to evaluate a pharmacotherapeutic impact on LVEF recovery in newly diagnosed DCM heart failure (HF) patients. A total of 2436 patients hospitalized due to acute decompensated HF were retrospectively analyzed. Finally, 24 patients with newly diagnosed DCM (51.4 ± 16.3 years, New York Heart Association 2.3 ± 0.7, LVEF 25 ± 10%) were observed (13.4 ± 16.0 months) in terms of the result of complex therapy. Patients were divided according to LVEF improvement on follow-up echocardiography: "recovery group" (LVEF improvement > 5%; n = 13) and "nonrecovery group" (∆LVEF ≤ 5%; n = 11). Evaluation of baseline parameters showed lower LVEF (19 ± 6 vs 31 ± 10%; P = .0048) and lower incidence of arterial hypertension (27% vs 73%; P = .043) in "recovery" group. After follow-up period LVEF was similar in both groups; however, significant LVEF improvement was demonstrated only in the "recovery group" (19 ± 6% to 34 ± 8%; P < .001). Only the "recovery group" showed significant HF symptoms reduction (New York Heart Association class: 2.5 ± 0.7 to 1.6 ± 0.6; P = .003). The "recovery group" had prescribed higher doses of loop diuretic (equivalent dose of furosemidum: 80 ± 38 mg vs 43 ± 24 mg; P = .025). Despite optimal therapy, significant LVEF improvement is observed only in the half of the patients with newly diagnosed DCM with HF with reduced EF. Prescription of higher doses of loop diuretics may have positive effect on the reduction of symptoms in newly diagnosed DCM HF patients. Lack of other risk factors such as arterial hypertension may increase the chance of LVEF recovery.

Native T1 high region and left ventricular ejection fraction recovery in patients with dilated cardiomyopathy.

Native T1 mapping is used to assess myocardial tissue characteristics without gadolinium contrast agents. The focal T1 high-intensity region can indicate myocardial alterations. This study aimed to identify the association between the native T1 mapping including the native T1 high region and left ventricular ejection fraction (LVEF) recovery in patients with dilated cardiomyopathy (DCM). Patients with newly diagnosed DCM (LVEF of < 45%) who underwent cardiac magnetic resonance imaging with native T1 mapping were included in the analysis. Native T1 high region was defined as a signal intensity of > 5 SD in the remote myocardium. Recovered EF was defined as a follow-up LVEF of ≥ 45% and an LVEF increase of ≥ 10% after 2 years from baseline. Seventy-one patients met the inclusion criteria for this study. Forty-four patients (61.9%) achieved recovered EF. Logistic regression analysis showed that the native T1 value (OR: 0.98; 95% CI: 0.96-0.99; P = 0.014) and the native T1 high region (OR: 0.17; 95% CI: 0.05-0.55; P = 0.002), but not late gadolinium enhancement, were independent predictors of recovered EF. Compared with native T1 value alone, combined native T1 high region and native T1 value improved the area under the curve from 0.703 to 0.788 for predicting recovered EF. Myocardial damage, which was quantified using native T1 mapping and the native T1 high region were independently associated with recovered EF in patients with newly diagnosed DCM.

Role of RA-LV pacing in patients with symptomatic left bundle branch block with CRT - a single centre experience

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiac Resynchronisation Therapy(CRT) is considered as the cornerstone of treatment for patients with heart failure and left ventricular conduction delay ( left bundle branch block) who remain symptomatic despite optimal medical therapy. However, it has been well documented that the responder and success rates of this therapy are highly variable. Contemporary response rates from clinical trials as well as real world data demonstrate non-response rates of between 30–50%. Suboptimal AV delay timing is the most prevalent modifiable factor on follow up for improving response rates. AV Fusion pacing describes the delivery of CRT pacing with a programming strategy to preserve intrinsic atrioventricular (AV) conduction and ventricular activation via the right bundle branch. This concept is utilised in the RA- LV pacing strategies, which have been described in literature. However, RA-LV only pacing raises certain practical , moral and ethical concerns as it has never been a part of contemporary guidelines nor a part of large randomised control trial. Purpose The purpose of this study was to study the clinical as well as hemodynamic effects of RA-LV pacing in patients with a conventional CRT device with a programmed subthreshold RV lead. Methods All patients with a convention CRT indication ( CRT-P as well as CRT-D), with acceptable intrinsic AV conduction, non pacing dependent and normal Right Ventricular function were enrolled into the study. A total of 60 consecutive patients between 2016-2021 were enlisted from after the implant and followed up in the Device clinic of the institution. The baseline as well as follow-up LV function, Battery life and QRS duration was recorded and analysed. Results Total of 60 patients were enlisted of which 30 were males and 30 females. There were 16 patients were with Ischemic Cardiomyopathy in this group. The average follow-up period was 3 year from implant. The mean baseline Left Ventricular Ejection Fraction was 29% while the mean follow-up Left Ventricular Ejection Fraction was 46.5%. The mean QRS duration at implant was 155msec and the mean follow-up QRS was 123 msec. The subset analysis of ischemic vs the nonischaemic cardiomyopathy groups revealed that both groups had a similar response rates to improvement of clinical as well as Echocardiographic parameters including LVEF. The mean follow up LVEF in the ischemic and nonischaemic groups were 44.5 &amp; 46.5% respectively. This finding suggests that the advantage of AV fusion pacing is not significantly impacted with underlying aetiology of the Cardiomyopathy. Conclusion RA-LV with RV subthreshold CRT is a reasonable strategy for achieving traditional response rates of CRT in patients with a good intrinsic AV conduction. This modality overcomes a large number of procedural as well as ethical roadblocks in the use of fusion pacing for CRT therapy optimisation.

Physiological stimulation in preserved ejection fraction: A randomized trial

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Right ventricular stimulation in the apex (RVAS) produce dysynchrony, leading to left ventricle systolic dysfunction (LVSD) in some cases. Circumstances that can worsen the LVSD are a high burden of RVAS, and the presence of previous LVSD and/or intraventricular conduction disease (IVCD). Direct activation of the specialized conduction system with physiological stimulation (PS) can preserve this physiological pattern and shorten de QRS when the impairment is proximal to the pacing site. Most of the studies with PS has been focused on patients with LVSD, with few and scarce evidences regarding pacients without LVSD. Objectives and methods This is a parallel, single blinded, unicentric, randomized trial of patients with preserved of mild reduced left ventricular ejection fraction (LVEF) submitted to a pacemaker implantation due to atrioventricular block (AVB), with previous IVCD (wide QRS) an anticipated high rate of ventricular pacing. Patients were randomized 1:1 to RVAS vs PS and followed for 6 months. Clinical, ECG, echocardiography and analytic parameters were compared. The primary endpoint was the change in the LVEF at 6 months in each group. The secondary endpoints were the changes in the left ventricular end-diastolic diameter (LVEDD), the QRS duration, the pro–B-type natriuretic peptide (NT-proBNP), the NYHA class, and the Minnesota Living with Heart Failure Questionnaire (MLWHFQ) in each group. Results The study included 57 patients of 77±9,6 years. Of all patients, 53% were treated with RVAS and 47% with PS. There were 2 patients with crossover to RVAS for technical difficulties and 1 patient with crossover to PS due to apical scar. There were no differences in the basal QRS duration (142.08±20,2 ms), LVEF (58.87±7,2%), NT-proBNP (3336,03±7258,68 pg/ml), or MLWHFQ (22,19±14,68), between both groups (Table 1). Acutely significant differences were observed in the change of QRS duration among groups (+16±29 ms in the RVAS group vs -17±25 ms in the PS group, p&amp;lt;0,001). At 6 months follow-up LVEF showed a non-significant reduction of 0.8±1.1% in the PS group compared to a significant reduction of 5.1±1.7% in the RVAS group (difference 4,26% IC 0,1-8,43 p=0,022). No differences were observed regarding the values of the NT-ProBNP and the MLWHFQ between groups at 6 months (Table 2). Conclusions In patients with preserved LVEF requiring pacemaker implantation for AVB, PS shorten the QTS duration and preserves the LVEF compared to RVAS.

Big Endothelin-1 as a Predictor of Reverse Remodeling and Prognosis in Dilated Cardiomyopathy

This study aimed to investigate the predictive value of Big endothelin-1(ET-1) for left ventricular reverse remodeling (LVRR) and prognosis in patients with dilated cardiomyopathy (DCM). Patients with DCM and a left ventricular ejection fraction (LVEF) ≤ 50% from 2008 to 2017 were included. LVRR was defined as the LVEF increased by at least 10% or follow-up LVEF increased to at least 50% with a minimum improvement of 5%; meanwhile, the index of left ventricular end-diastolic diameter (LVEDDi) decreased by at least 10% or LVEDDi decreased to ≤33 mm/m2. The composite outcome for prognostic analysis consisted of death and heart transplantations. Of the 375 patients included (median age 47 years, 21.1% female), 135 patients (36%) had LVRR after a median of 14 months of treatment. An independent association was found between Big ET-1 at baseline and LVRR in the multivariate model (OR 0.70, 95% CI 0.55-0.89, p = 0.003, per log increase). Big ET-1, body mass index, systolic blood pressure, diagnosis of type 2 diabetes mellitus (T2DM) and treatment with ACEI/ARB were significant predictors for LVRR after stepwise selection. Adding Big ET-1 to the model improved the discrimination (∆AUC = 0.037, p = 0.042 and reclassification (IDI, 3.29%; p = 0.002; NRI, 35%; p = 0.002) for identifying patients with LVRR. During a median follow-up of 39 (27-68) months, Big ET-1 was also independently associated with the composite outcome of death and heart transplantations (HR 1.45, 95% CI 1.13-1.85, p = 0.003, per log increase). In conclusion, Big ET-1 was an independent predictor for LVRR and had prognostic implications, which might help to improve the risk stratification of patients with DCM.

Intermediate Follow-Up of Balloon-Expandable Versus Self-Expanding Transcatheter Aortic Valve Implantation in Patients With Small Aortic Annuli

The clinical impact of prosthesis-patient mismatch (PPM) in patients with small aortic annuli who underwent transcatheter aortic valve (AV) implantation with either balloon-expandable (BE) or self-expanding (SE) valves remains controversial. We assessed in-hospital and intermediate clinical outcomes in 573 patients with transfemoral transcatheter AV implantation with a small AV annulus, defined as an AV annulus area ≤430mm2. A total of 337 patients treated with a 23-mm BE valve (SAPIEN 3, Ultra) were compared with 236 patients treated with a 26-mm SE valve (Evolut series). Valve-in-valve cases were excluded, and late echo follow-up (mean 674 ± 438days) was assessed in a subset of 292 patients (51.0%). Well-matched BE and SE cohorts did not differ with respect to major in-hospital outcomes, other than a borderline increase in vascular complications and composite bleeding in patients with SE. Patients with BE had a higher incidence of severe PPM on discharge echocardiography (16.9% vs 6.8%, p <0.002). The mean AV gradient at 30days was higher for patients with BE (12.2 ± 4.2 vs 6.2 ± 7.9mm Hg, p <0.001) and at late follow-up (14.0 ± 8.2 vs 7.2 ± 3.5mm Hg, p <0.001). The follow-up left ventricular ejection fraction and incidence of >mild aortic insufficiency were similar. All-cause mortality for the 2 cohorts was similar, with an overall mean (95% confidence interval) survival time of 61.2months (57.8 to 64.5; p=0.98). There were no significant survival differences between combined patients with BE and SE with no, moderate, or severe PPM, with an overall mean (95% confidence interval) survival time of 32.5 (30.5 to 34.5)months combining valve types (p=0.23). In conclusion, despite an increased incidence of PPM with higher mean AV gradients that persist on late echocardiography in the BE cohort, patients with BE and SE with small aortic annuli have similar clinical outcomes at intermediate follow-up. Moderate and severe PPM had no impact on survival at a mean follow-up of 32.5months.

Subclinical hypothyroidism and its relationship with therapy failure in patients underwent cardiac resynchronization therapy.

Cardiac resynchronization therapy (CRT) is used in patients with heart failure (HF), an important problem in cardiology practice, with reduced left ventricular systolic dysfunctions and left ventricular dyssynchrony to improve morbidity and mortality. Thyroid diseases have undeniable effects on cardiac functions. So, we aimed to evaluate the effect of subclinical hypothyroidism on CRT response in HF patients in this study. After the exclusion, 386 consecutive patients who received first-time CRT-defibrillator (CRT-D) or CRT-pacemaker (CRT-P) were retrospectively included. Known overt hypothyroidism or hyperthyroidism patients were excluded. The response of CRT was defined as a relative increase (≥15%) or absolute increase (≥10%) in left ventricular ejection fraction (LVEF) from implantation to one-year after follow-up. Diabetes mellitus, atrial fibrillation and coronary artery disease ratios were similar between responder vs. non-responder groups. Thyroid stimulating hormone (TSH) levels were higher (p <0.005) in non-responder group. Responder group had higher baseline LVEF (p <0.001), and follow-up LVEF (p <0.001) and longer baseline QRS interval (p =0.004), but similar post-implant QRS interval duration (p >0.005) with non-responder group. Baseline QRS interval (p =0.002), baseline LVEF (p <0.001) and the presence of subclinical hypothyroidism (SCH) (p =0.001) were independent predictors of CRT response. Adding SCH as a risk factor to our baseline risk modelling has an independent prognostic impact to predict non-responder patients (p =0.01). Presence of the SCH may be an important predictor of non-response in patients undergoing CRT. Evaluating the risk factors associated with non-response to CRT may be logical in identifying patients who obtain maximum benefit from CRT treatment.

Left atrial strain quantified after myocardial infarction is associated with early left ventricular remodeling.

Left ventricular remodeling (LVR) is common and associated with adverse outcome after ST-elevation myocardial infarction (STEMI). We aimed to investigate the association between left atrial (LA) mechanical function using speckle tracking imaging and early LVR at follow-up in STEMI patients. Baseline 3D thoracic echocardiograms were performed within 48h following admission and at a median follow-up of 7 months after STEMI. A>20% increase in the left ventricular (LV) end-diastolic volume compared to baseline at follow-up was defined as LVR. LA global longitudinal strain was evaluated for the reservoir, conduit, and contraction (LASct) phases. A total of 121 patients without clinical heart failure (HF) were prospectively included, between June 2015 and October 2018 (age 58.3±12.5 years, male 98 (81%)). Baseline and follow-up LV ejection fraction (LVEF) were 46.8% [41.0, 52.9] and 52.1% [45.8, 57.0] respectively (p<.001). Compared to other patients, those with LVR had significantly lower values of LASct at baseline(-7.4% [-10.1, -6.5] vs. -9.9% [-12.8, -8.1], p<.01), both on univariate and baseline LV volumes-adjusted analyses. Baseline LA strain for reservoir and conduit phases were not associated with significant LVR at follow-up. Intra- and interobserver analysis showed good reproducibility of LA strain. Baseline LASct may help identifying patients without HF after STEMI who are at higher risk of further early LVR and subsequent HF and who may benefit from more intensive management.

Abstract 10149: Clinical Predictors of Medical Therapy-Induced Improvement in Left Ventricular Function in Patients Diagnosed With Heart Failure With Reduced Ejection Fraction (HFrEF): The Intermountain Healthcare Experience

Introduction: When patients (pts) are diagnosed with HFrEF, it is hoped that medical therapy will improve their left ventricular ejection fraction (LVEF). However, which baseline clinical characteristics may predict an improvement in LVEF after medical treatment remains unclear. Methods: Pts with a baseline LVEF ≤35% and a follow-up LVEF ≥180 days later were categorized according to the change in LVEF identified between the baseline and follow-up LVEF’s (Increased [ΔLVEF ≥+10%]; No change [ΔLVEF=-9% to +9%]; Decreased [ΔLVEF ≥-10%]). Baseline characteristics and follow-up death rates were collected. Independent predictors of an improved LVEF were determined by logistic regression. Results: Qualifying HFrEF pts totaled 5,632 and were categorized by ΔLVEF as follows: Increased = 3,074 (54.6%); No change = 2,193 (38.9%); Decreased = 365 (6.5%). Baseline characteristics and independent predictors of an increase in LVEF are shown in the figure. During a median follow-up of 6.2 years, the death rate was 35.3%, 60.0%, and 72.6% (p&lt;0.0001) in patients with an increase, no change, or decrease in LVEF, respectively. Conclusions: In patients diagnosed with HFrEF and initiated on medical therapy, an increase in LVEF predicted a lower death rate. The strongest predictors of an increase in LVEF included female gender, the absence of ASCVD, a low initial BNP, a narrow QRS duration, and the presence of atrial fibrillation, pulmonary hypertension, and statin use. Explanations for these findings remain to be determined.

Abstract 11588: Multicenter Development and Validation of a Machine Learning Model to Predict Myocardial Recovery During LVAD Support: The UCAR Score

Introduction: Although significant cardiac reverse remodeling is a prerequisite for a left ventricular (LV) assist device (LVAD) patient to be considered for device weaning, multiple factors including patient goals, physician comfort, and center experience, weigh in on this complex decision. Existing predictive models defining recovery as device removal may under detect patients that could benefit from a targeted bridge to recovery strategy. We sought to derive and validate a predictive tool to identify patients prone to reverse remodel, independent of the complex decision of device explant. Methods: Heart failure patients (N=782) requiring LVAD were enrolled at the Utah Transplant Affiliated Hospitals (n=537) and 5 US programs (n=245). Baseline characteristics were recorded. The primary outcome was ‘responder’ incidence, defined as follow-up LV ejection fraction (LVEF) ≥40% and LV end-diastolic diameter (LVEDD) ≤6 cm within one year on LVAD support. Bootstrap imputation and lasso variable selection techniques were used to derive a predictive model which was then validated. A predictive calculator was developed and patients were classified into groups with varying potential for reverse remodeling. Results: Patients were predominantly white (84%), males (82%), aged 56±1 years. Overall, 14.8% patients were identified as responders. A subset of 10 pre-operative variables associated with reverse remodeling were included in the multivariate model achieving an optimism-corrected C-statistic of 0.75 (95% CI: 0.73-0.84) (Figure) . Conclusions: The UCAR calculator is a machine learning-based multicenter and validated risk tool, implementing routine pre-operative clinical data, effectively stratifying patients into groups with varying potential for reverse remodeling. This tool can be useful in selecting patients to implement diagnostic and therapeutic protocols to promote reverse remodeling and myocardial recovery.

Left bundle branch pacing after transcatheter aortic valve implantation. Initial experience of a center

Abstract Introduction Permanent pacing is often needed in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) due to new onset conduction disorders. Nevertheless, continuous right ventricular pacing may deteriorate left ventricular ejection fraction (LVEF) and lead to poor outcomes. Thus, in last years, more physiological forms of pacing, such as left bundle branch pacing (LBBP) have been developed to prevent pacing induced cardiomyopathy. Purpose The aim of our study is to describe the initial experience in our center, evaluate the safety and feasibility of LBBP after TAVI and describe electrophysiological outcomes in the first months of follow-up. Methods We designed a prospective registry that collected all patients from the TAVI program of our center who developed conduction abnormalities in the immediate postoperative and received LBBP. We analyzed baseline characteristics, complications and procedure time, electrophysiological parameters after the procedure and final QRS interval. During follow-up LVEF, electrophysiological parameters and adverse clinical events (readmissions for heart failure, cardiovascular mortality and all-cause of mortality) were also evaluated at 3rd, 6th and 12th month. Results Between January 2020 and January 2022, twenty patients who developed conduction abnormalities after TAVI underwent LBBP. Seven patients (35%) had a complete atrioventricular block, two patients (10%) alternating bundle branch block and 11 (55%) had a new left bundle branch block. HV electrophysiology study was performed in 8 patients, with a median value of 68ms (66–72). Of the 20 patients, 3 out of 4 patients were male and had history of hypertension. 40% had previous ischemic heart disease and one patient had transthyretin cardiac amyloidosis. Median age was 79 years-old (76–83.5). Balloon-expandable prosthesis was implanted in 11 patients while 9 received a self-expandable prosthesis. Median basal LVEF was 59% (41.5–60) and median NTproBNP was 1722pg/ml (535–5848). LBBP was successful in all of the 20 patients. The median time of the procedure was 60 minutes (45–80) without suffering any complications. The median QRS interval before the procedure was 155ms (140–158) and 116ms (105–125) post-implant. To date, two patients have died of non-cardiac cause 3 and 8 months after LBBP. There have been no readmissions for heart failure. LVEF (pre and post-LBBP) and electrophysiological parameters post-implant and three-month follow-up are shown in Table 1. Conclusions In our experience, LBBP after TAVI is a safe and feasible procedure. Despite the small sample size and short follow-up period, our first results indicate stability of LVEF and pacemaker parameters. Funding Acknowledgement Type of funding sources: None.