Heart Failure Pts Research Articles

Cardiac Reverse Remodeling and Recovery in Dilated Cardiomyopathy Medication-Naive Patients Requiring Durable Left Ventricular Assist Device Support

Purpose Occasionally new onset cardiomyopathy patients (pts) present late, in such advanced disease stage that they cannot tolerate heart failure (HF) drug therapy. We investigated the cardiac recovery (CR) potential following a combination of left ventricular assist device (LVAD) and guideline-directed HF drug therapy in this medication-naive population. Methods Chronic advanced HF pts requiring durable continuous-flow LVAD were prospectively evaluated. Pts with acute HF (myocarditis etc) or post LVAD follow up Results Univariate analysis showed that “med-naive” pts were younger, more likely to be on intravenous vasoactive agents, temporary MCS and with lower INTERMACS profile before LVAD implantation. Interestingly, no differences were seen in HF symptoms duration or other comorbidities. Baseline and follow up hemodynamics were similar in both groups, besides higher right atrial pressure pre-LVAD in the “meds-naive” group (16 vs 11 mmHg; p=0.04). Baseline echocardiographic (including LV dilation) and biochemical parameters revealed no differences between the groups, besides lower LVEF and higher BNP in the “meds-naive” group (14 vs 19 %; p=0.03 and 2352 vs 1270; p=0.03, respectively). CR rates were significantly higher on “meds-naive” versus “meds-failed” group (50.0 vs 13.8 %; p=0.005). Despite higher cardiac recovery rates in the “meds-naive” group the time course and magnitude of the favorable functional and structural response was similar among the CR responders of each of the 2 groups. Conclusion Young pts with new onset dilated cardiomyopathy sometimes present late, with advanced disease stage, unable to tolerate HF medications and requiring durable LVAD support. This patient population appears to have a potential for CR up to 50% and this could be factored in decisions surrounding their long-term therapeutic options.

OPTIMAL MEDICAL THERAPY USE AND LONG-TERM OUTCOMES IN CABG-ELIGIBLE HEART FAILURE PATIENTS: INSIGHTS FROM THE STICH TRIAL

Coronary Artery Bypass Grafting (CABG) reduces mortality in Heart Failure (HF) and coronary artery disease (CAD) patients (pts). There is a paucity of data on the utilization of optimal medical therapy (OMT) in HF and CAD pts after revascularization and the impact on long term outcomes. We evaluate

Abstract 16697: Predictive Value of Cardiopulmonary Exercise Testing Parameters for 1-Year Adverse Outcomes in Ambulatory Advanced Heart Failure

Introduction: Maximal and submaximal cardiopulmonary exercise (CPX) parameters predict heart failure (HF) outcomes, yet the best predictors in advanced ambulatory HF are not known. Hypothesis: We examined the discriminative value of maximal CPX parameters including peak oxygen consumption (peak VO2), VO2 pulse, circulatory power (CP, peak systolic BP x peak VO2), and end tidal pressure CO2 (PetCO2), as well as submaximal parameters of ventilatory efficiency (VE/VCO2 slope), VO2 at anaerobic threshold (VO2AT) and oxygen uptake efficiency slope (OUES) on the combined outcome of LVAD, UNOS 1 transplant or death at 1 year. Methods: REVIVAL enrolled systolic HF pts in INTERMACS profiles 4-7 despite optimal medical therapy and CRT, of whom 273 performed CPX; 64 did not exercise (26 too ill, 38 for non-cardiac issues). ROC curves display the discriminative power of each parameter using censored c-statistics. The best multivariable model was identified by Cox regression. Results: At 1 year, there were 53 events (10 transplants,19 deaths; 24 LVADs). Pts with and without events were comparable for age (61 vs 60 yrs), LVEF (27 vs 29%), and BMI (31 vs 32 kg/m 2 ).) Peak VO2, VO2AT, OUES, PetCO2, and CP were higher in the no event group (all p <0.001), whereas VE/VCO2 slope was lower (p<0.0001); respiratory exchange ratio was not different. Among the 26 pts too sick for exercise, the event rate was 15/26 (58%) compared to 38/273 (14%) in those exercising (HR=6.7, p<0.0001). Figure displays ROC curves and c-indices for CPX parameters. VO2 pulse (HR 1.18, p=0.017), CP (HR 0.86, p=0.005) and VE/VCO2 slope (HR 1.1, p=0.0001) were significant predictors in the multivariable analysis (model c-statistic=0.80). Conclusions: In ambulatory advanced HF, the inability to perform exercise due to being too ill predicts adverse outcome and for those who can exercise, VE/VCO2 slope is the most robust submaximal CPX parameter, while CP was the strongest maximal parameter to predict death, transplant or LVAD at 1 year.

“A Sure Thing” - Connecting Heart Failure Patients through the inpatient Heart Failure Navigator to the Outpatient Care Coordination Team: A Highly Successful Strategy to Reduce Readmissions

Introduction Heart Failure (HF) readmissions remain a critical issue for health care systems. HF Navigators (HFN) can streamline care transitions. Thus, we used an inpatient HFN to establish early follow up and “hand off” HF pts to an OP Care Coordinator (CC). Methods At our hospital, HF pts can be admitted to multiple IP units. A HF Unit (HFU) primarily admits higher risk pts. A single HFN was recruited to staff the HFU M-F. The HFN linked HF pts to a CC to at discharge. Most HF pts were referred to the OP CC although some pts received only HFN services and no CC due to difficulty identifying HF pts prior to discharge. Over the 14-month period, the HFN established early follow-up and the CC made regular telephone contact post discharge. The incremental contributions of the HFN and CC were evaluated to test the independent impact of each of these roles based on the serial implementation of these roles in distinct hospital units and based on whether or not a particular HF pt was cared for by the HFN and/or the CC. Results Thirty (30) day readmission rates were measured for pts admitted between October 17, 2016 and December 31, 2017. Patients with a primary, discharge diagnosis of HF were analyzed. HFN services were provided on the dedicated HF unit (HFU) as part of a pilot program and were not available on other IP units during this period. Concurrent 30-day all-cause readmission data were stratified and reported based on admitting unit, involvement of the HFN with or without CC. Of the 757 pts (non LVAD or Transplant) who were admitted to units other than the HFU, there were 160 pts readmitted (21.1%). There were 254 high risk (Includes LVAD and transplant pts) HF pts admitted to the HFU, and there were 75 pts readmitted (29.5%) in this cohort. There were 33 (non LVAD or transplant) pts admitted to the HFU with care provided by HFN but who did not receive a referral to CC, and 6 pts were readmitted (18.9%). Finally, of the 169 HF pts were admitted to the HFU and had access to a HFN and CC, with only 9 pts readmitted (5.33%). Conclusions In this analysis, there was a synergistic effect noted to drastically reduce HF readmission rates when an IP HFN and OP CC were involved in the care of hospitalized HF pts. The 5.33% 30 day all cause readmission rates noted is significantly better than rates reported in the literature and reflects the critical role of combining HFN care with care coordination in the OP setting. These data have solidified an interest to expand access to HFN and CC to all IP units and can serve as a model for care delivery to improve readmission rates for this high-risk population.

Ballistocardiography for Ambulatory Detection and Prediction of Heart Failure Decompensation

Background Ambulatory home monitoring of heart failure (HF) patients (pts) to assess clinical status remotely and adjust therapies accordingly could potentially decrease the costs associated with hospitalizations and improve pts quality of life. Our group has been investigating the use of non-invasive ballistocardiogram (BCG) measurements (the measurement of body vibrations due to cardiac ejection of blood) using a modified weighing scale for monitoring hemodynamics and cardiac timing intervals from HF pts. BCG waveforms from HF pts in a decompensated state will show, on average, a higher variability in signal structure than corresponding waveforms from pts in a compensated state. Methods For each of the 36 HF pts included in the study, we recorded simultaneously daily 30-second measurements of electrocardiogram (ECG) and BCG signals using a modified weighing scale ( Fig. 1 a). Recordings were processed for data quality and some of the waveforms were discarded if data quality was insufficient (e.g. missing R-peaks in ECG signals). We developed a metric from the BCG signal that quantifies the variability of the BCG heartbeat waveforms ( Fig. 1 b). Results Of the 36 pts (83% men, 58 ± 13 years, left ventricular ejection fraction 0.31 ± 0.12, New York Heart Association functional class I/ II 36% and III 64%), 18 pts were recorded only when hospitalized for a HF exacerbation, 11 were recorded in the outpatient setting, and 7 were recorded both during a hospitalization for HF exacerbation and in the outpatient setting. Pts were considered decompensated (day of hospital admission) or compensated (day of hospital discharge or outpatient visit) based on the clinician assessment. We found that the BCG variability was significantly different between the groups based on pts state: compensated (n=648 recordings) 0.46 ± 0.013 and decompensated (n=223 recordings) 0.54 ± 0.026, p=0.002 ( Fig. 1 c). Conclusion BCG variability, a metric of consistency defined quantitatively based on the shape of BCG signals, can be captured using a modified weighing scale. BCG variability is significantly different between decompensated and compensated HF pts. This metric may be used in future studies for detection of HF worsening in ambulatory pts at home.

Sustaining Quality of Life of the Aged: Transplant or Mechanical Support: Baseline Cognitive Dysfunction

Introduction Cognitive dysfunction (CD), a risk factor for poor outcomes, is common in older patients (pts) with advanced heart failure (HF). Given these pts may be candidates for heart transplantation (HT) or mechanical circulatory support as destination therapy (DT MCS), we compared CD in older advanced HF pts prior to HT and DT MCS. Methods A total of 263 advanced HF pts from 11 U.S. sites either listed for HT (n=164; 75 HT-MCS and 89 HT-non-MCS) or scheduled for DT MCS (n=99) were enrolled between 10/1/15-1/1/18 and completed the Montreal Cognitive Assessment (MoCA), a 10-minute screening instrument (worst-to-best total score range=0-30), including 7 cognitive domains, to detect CD (MoCA total score less than 26). Risk-unadjusted statistical analyses included descriptive statistics, ANOVA, and chi-square tests. To risk-adjust for baseline age differences, we used linear regression and polytomous logistic regression models. Results The majority of advanced HF pts were white males. DT MCS candidates were older than HT candidates and had more co-morbidities (DT = 4.6±2.1 vs HT-MCS = 3.9±2.0 vs HT-non-MCS =3.7±1.7, p=0.008). More DT MCS candidates had CD than HT candidates. DT MCS candidates had lower total MoCA scores and lower scores in all domains except naming, abstraction and orientation (strong trend), compared with HT-MCS and HT-non-MCS candidates. See table. The same conclusions were reached after baseline age-adjustment. See table. Conclusions CD exists in older pts with advanced HF who are candidates for DT MCS and HT. DT MCS pts may be at highest risk. Baseline CD in these pts may inform shared decision making discussions about remaining on medical therapy vs choosing these surgical treatment options.

Seismocardiography Can Assess Cardiopulmonary Exercise Test Parameters in Patients with Heart Failure

Background Cardiopulmonary exercise testing (CPET) is an important risk stratification tool in patients (pts) with heart failure (HF) and measures such as peak VO 2 , VE/VCO 2 slope, Oxygen uptake efficiency slope (OUES) have prognostic value in HF pts. In our previous studies, we have shown that wearable chest patch based seismocardiogram (SCG) signals - the local body vibrations of the chest wall in response to cardiac ejection - can accurately quantify cardiac contractility changes [pre-ejection period (PEP)], which can be used to differentiate between compensated and decompensated HF pts following exercise (six-minute walk test). Hypothesis We hypothesized that CPET variables can be assessed using changes in PEP from simultaneously recorded SCG. The degree of impairment in myocardial contractility should reflect the severity of HF and it could be used for risk stratification. Methods CPET was performed using a modified Naughton protocol. SCG and ECG signals were simultaneously recorded using our custom built wearable chest patch ( Fig. 1 A). We segmented these signals into heart beats and averaged the beats over 30 seconds window and compared the PEP (normalized to the resting values) with corresponding CPET variables. We compared changes in PEP (percentage change from baseline value) following exercise with CPET variables. Results We enrolled 8 patients with HF and reduced ejection fraction (age 61 ± 11, 50% women, ejection fraction 0.25 ± 0.08). We found that normalized PEP at anaerobic threshold (AT) correlated with VO 2 at AT (R 2 = 0.56), while normalized PEP at VO 2 max correlated with OUES (R 2 =0.64) and O 2 pulse at VO 2 max (R 2 =0.43). Percentage change in PEP following exercise correlated with VO 2 at AT (R 2 = 0.61) and VO 2 max (R 2 = 0.48). Conclusions Using SCG and simultaneous ECG we can assess corresponding CPET variables for patients with HF. This wearable device can potentially provide value in stratifying risk in patients with HF by tracking hemodynamic parameters during daily activities.

Abstract 166: End-of-Life Situations in Cardiology: A Qualitative Study of Physicians and Nurses’ Experience in a Large University Hospital in France

Introduction: With advances in medication and device therapy for heart failure pts, the number of end-of-life situations encountered in cardiology is rising. We aimed to understand perceptions and attitudes of medical and paramedical staff regarding end-of-life situations using a qualitative approach. Methods: Single-centre, qualitative study using semi-directive interviews with physicians, nurses and nurses’ aides in a university hospital cardiology unit. Participants were invited to describe experiences and feelings about end-of-life situations. Interviews were transcribed in full and analyzed using thematic analysis. Results: 13 physicians, 16 nurses and 5 nurses’ aides were interviewed. The main themes that arose in the discourse were the frequency, the type of death (emergency vs chronic disease), the value of the pt’s life, the positive effect of communication, and the rarity of advance directives (AD). The majority felt that end-of-life situations are increasingly frequent, and their management has improved. Cardiology was felt to be a highly technical discipline where death is generally rapid; otherwise, for pts with end-stage heart failure, the course of disease allows time to anticipate end of life issues. Nurses tend to engage in a degree of “coaxing” to persuade physicians to move from a curative to a palliative frame of mind, particularly in the cardiac intensive care unit. The perceived value of the pt’s life plays a role in the level of therapeutic engagement, with younger patients receiving more intensive resuscitation manoeuvers, whereas oldest-old patients are more rapidly labelled as “end of life” cases. Communication was felt to be key to ensuring that pt, family and healthcare workers (HCW) are all in agreement regarding clinical status and likely outcome. Nurses in particular can suffer considerable distress when their opinions regarding the pt’s status or wishes are not taken into account by the physicians, or when they are asked to continue invasive therapies for a pt they consider to be at the end-of-life. Poor communication was felt to engender suffering both among HCW and families; and lack of time was cited as a frequent cause. AD were not unanimously considered useful; some felt that discussing end-of-life may be more harmful than helpful, and overall, AD remain infrequent in our unit. The pt’s wishes are taken into account if possible, but some believe the pt is not qualified to know what can be done, and in such cases, their wishes may be disregarded as inappropriate to the clinical situation. Conclusions: Most participants felt that management of end-of-life has greatly improved in terms of pain relief and communication. Poor communication remains prevalent and can be a source of suffering for patients, families and caregivers, especially nurses.

PRIOR HEART FAILURE HOSPITALIZATION AMONG PATIENTS HOSPITALIZED FOR WORSENING CHRONIC HEART FAILURE: FROM THE ASCEND-HF TRIAL

Among chronic heart failure (HF) patients (pts), hospitalization for HF is associated with increased risk of death. The degree to which hospitalization for HF is a distinct biologic entity mediating poor outcomes versus a marker of higher risk chronic HF pts is unclear. Among 4,205 pts hospitalized

GW28-e1237 Feasibility of His Bundle Pacing to Correct Left Bundle Branch Block in Heart Failure Patients

Heart failure (HF) patients (pts) with left bundle branch block (LBBB) are indicated for cardiac resynchronization therapy (CRT) that paces left and right ventricles almost at the same time. This study explored the feasibility of correction of LBBB by His bundle pacing (HBP) in HF pts. A total of

Shear wave elastography of peripheral muscle stiffness in patients with congestive heart failure – A new diagnostic ultrasound method to detect muscular deficits

It is well established that patients (pts) with chronic heart failure often suffer from severe peripheral muscular weakness resulting in difficulties performing daily life tasks. Reduced oxygen delivery, lowered lactate turnover and -mitochondrial capacity are thought be responsible for a diminished contractility of peripheral muscles in heart failure pts. To date, only invasive muscle biopsies are suitable to diagnose this condition.

Differences in biochemical and genetic biomarkers in patients with heart failure of various etiologies

Background/objectivesTo evaluate whether biomarkers reflecting pathophysiological pathways and selected single nucleotide polymorphisms differ between patients (pts) with heart failure (HF). Methods110 pts with were involved, including HF pts with preserved ejection fraction (HFpEF, n=51) with hypertensive origin, HF pts with reduced ejection fraction (HFrEF) with ischemic aetiology (ICM) (n=32) and HFrEF with dilated cardiomyopathy (DCM) (n=27). We assessed selected HF biomarkers, echocardiographic examinations and functional polymorphisms selected from six candidate genes: CYP27B1, NOS3, IL-6, TGF beta, TNF alpha, and PPAR gamma. ResultsHigher concentrations of TNF alpha were observed in pts with hypertensive HFpEF compared to pts with DCM (p=0.008). Pts with HFpEF had higher concentrations of TGF beta 1 compared to DCM and ICM (p=0.0001 and p=0.0003, respectively). For the NOS3 −786 C/T rs2070744 polymorphism in DCM there were significantly more CT heterozygotes than in ICM and HFpEF. In multivariate analysis TGF beta 1 (p=0.001) and syndecan 4 (p=0.001) were the only factors distinguishing HFrEF pts with DCM vs HFpEF and also TGF beta 1 (p=0.001) and syndecan 4 (p=0.023) were the only factors distinguishing HFrEF pts with ICM vs HFpEF pts. ConclusionsInflammation mediated through TNF alpha and TGF beta 1 may represent an important component of an inflammatory response that partially drives the pathophysiology of HFpEF. NOS3 −786 C/T rs2070744 polymorphism in DCM may serve as a marker for more rapid progression of heart failure. The only biomarkers independently distinguishing HFpEF and HFrEF are syndecan 4 and TGF beta 1.

Inspiratory work capacity is more severely depressed than inspiratory muscle strength in patients with heart failure: Novel applications for inspiratory muscle training

BackgroundWe hypothesized that the ability to sustain maximal inspiratory pressure (SPImax) over time as a measure of work capacity may be more severely affected than inspiratory muscle strength (PImax) in patients with heart failure (HF). MethodsWe retrospectively investigated eighty patients with HF, NYHA II/III/ ambulatoryIV and a (mean±SD) LVEF 27±8%, and compared them to 25 healthy subjects (HS). During a maximal inspiratory manoeuvre from residual volume (RV) to total lung capacity, PImax was measured as the maximum mouth pressure at RV, inspiratory contraction time (ICT) as the time from RV to end of inspiration and SPImax as the area under a pressure-time curve using an electronic pressure manometer with designed-purpose software (Trainair®, Project Electronics Ltd., London, UK). Exercise capacity was assessed with cardiopulmonary exercise testing and the 6-minute walk test (6MWT). ResultsPatients achieved a (mean±SD) peak VO2=15.7±3.4ml/kg/min and 6MWT=338±88m. PImax, ICT and SPImax were reduced in HF pts at 75%***, 61%*** and 52%*** of HS, and correlated with NYHA (r=−0.485***), (r=−0.507**), (r=−0.500***), peakVO2 (r=0.501***), (r=0.655***), (r=0.508***) and 6MWT (r=0.477***), (r=0.345**), (r=0.530***), respectively (*p<0.05, **p<0.01, ***p<0.001). ConclusionPImax, ICT and SPImax were impaired in HF patients compared to HS and may be important determinants of exercise capacity. SPImax was severely depressed even in patients with relatively preserved PImax and should be considered as an additional target index for inspiratory muscle training. Equations are provided to predict SPImax in relation to age and exercise capacity in HF.

Abstract 13502: Statins Buffer the Vasoconstricting, Pro-Inflammatory and Pro-Oxidant Effects of Experimental Venous Congestion in Patients With Systolic Heart Failure on Stable Medical Regimen

Background: In heart failure (HF), statins decrease hospitalizations for acute decompensation, which are primarily due to venous congestion (VC). The reason is unknown. We tested whether statins buffer the vasoconstricting, pro-inflammatory and pro-oxidant effects of VC in an established human model of this condition. Methods: We studied 41 pts, NYHA class II-III, LVEF &lt;40%, euvolemic and on stable medical therapy. To experimentally model VC, venous arm pressure was increased to 30 mmHg above baseline by inflating a pressure cuff around the dominant arm. Blood was sampled from test and control arm (lacking an inflated cuff) before and after 90 minutes of VC. Plasma endothelin-1 (ET-1), interleukin-6 (IL-6), and vascular cell adhesion molecule 1 (VCAM-1) were measured by ELISA; isoprostane by LC-MS. Results: Age was 53±2 years, 32% were female, 29% had an ischemic etiology, LVEF was 22±1%, 56% were treated with a statin. Experimental VC increased plasma isoprostane, ET-1, VCAM-1 and IL-6. However, the use of a statin greatly influenced the rate of this response: the increase in isoprostane (marker of oxidative stress) was four-fold higher among nonstatin vs statin users (62.3±11 vs 15.4±11.2 pg/ml, p=0.01); ET-1 (marker of vasoconstriction and inflammation) increased 50% more among nonstatin users (1.83±0.23 vs 1.21±0.21 pg/ml, p=0.05); VCAM-1 (marker of endothelial activation) increased 80% more among non-statin users (62.5±15.1 vs 33.6±13.3 pg/ml, p=0.16). Changes in IL-6 (marker of inflammation) did not differ in the two groups (1.2±.08 vs 1.1±0.08 pg/ml, p=0.78). Of note, the effects of statins on ET-1 was dose-dependent. Conclusions: We provide the first evidence that statins (particularly at high dose) partially buffer the vasoconstricting, pro-inflammatory and pro-oxidant effects of experimental VC. Future studies are warranted to address whether short-term high dose statins have an adjunctive role in the treatment of acute decompensation in HF pts.

Abstract 18639: Implantable Cardioverter-defibrillator Use is Associated With Improved Survival on the Waitlist for Heart Transplantation: A UNOS/ OPTN Registry Analysis of 36,397 Patients

Background: Current guidelines do not support routine use of implantable cardioverter-defibrillators (ICDs) in patients (pts) with end-stage heart failure (HF), unless these pts are awaiting advanced HF therapies such as left ventricular assist devices (LVADs) or a heart transplantation (HT). Whether ICDs improve survival in end-stage HF pts awaiting HT has not been previously examined in a large, multicenter cohort. Hypothesis: Presence of ICDs at time of listing for HT is associated with lower waitlist mortality. Methods: The United Network for Organ Sharing registry was used to identify adults (≥18 years) listed for HT between January 4, 1999 &amp; September 30, 2014. Pts with congenital heart disease, total artificial heart, restrictive cardiomyopathy, prior HT, or missing covariates were excluded. Cox regression analysis was used to assess the impact of an ICD at the time of listing on waitlist mortality. Results: The analysis included 36,397 pts (mean age 53±12; 77% males) listed for HT. The prevalence of ICDs at listing has steadily increased over time before reaching a plateau in 2006 (27% in 1999, and range 76-82% between 2006-2014). In the unadjusted model, ICD use was associated with a 36% reduction in waitlist mortality (HR 0.64, 95% CI 0.60-0.68, p&lt;0.001). After adjustment for covariates such as age, sex, race, creatinine, ischemic cardiomyopathy, and listing status, this association was nearly unchanged (HR 0.67, 95% CI 0.62-0.72, p&lt;0.001). Test for interaction by listing era (pre- and post-2006) was non-significant (p=0.28). In the final adjusted model, that included listing era and LVAD status in addition to the above listed covariates, ICD use continued to remain associated with a mortality benefit on the waitlist for HT (HR 0.84, 95% CI 0.78-0.91, p&lt;0.001). Conclusion: ICDs are increasingly prevalent in pts listed for HT; however many pts are still listed for HT without these devices. The presence of an ICD at the time of listing is associated with lower mortality on the waitlist. Although the magnitude of ICD efficacy diminishes slightly, its benefit continues to remain significant even after adjustment for listing era and LVAD use. Further analyses are required to identify specific sub-groups of pts where ICD use is most beneficial and appropriate.

Abstract 242: Impact of Hospitalists on Heart Failure Outcomes in Hawaii

Background: Hospital Medicine is the fastest growing subspecialty in the US. However, limited data compare care provided by Hospitalists (H) with Non-Hospitalists (NH) (ie, internal medicine, family practice). Because much of heart failure (HF) care is provided by non-cardiologists, we examined HF outcomes among pts treated by H and NH. Methods: All pts discharged with primary dx of HF from 2009-11 were identified from a statewide all-payer database in Hawaii (n=6,581). We categorized pts by specialty of discharging physician and examined length of stay (LOS), 30-day readmission and inhospital mortality comparing H and NH. Because pts discharged by cardiologists accounted for a minority of cases (345/6,581 or 5.2%) and may substantially differ from other pts, they were excluded from our study. Results: There were slight differences between pts cared by H and NH, while disease severity (Charlson Index) was similar. Readmissions were similar for H and NH, although inhospital mortality was significantly lower for H. These differences persisted after adjusting for potential confounders (readmission: OR=1.08, 95% CI: 0.96-1.20; mortality: OR=0.59, 95% CI: 0.46-0.75). Conclusions: In a statewide, all-payer hospital discharge database H care for the majority of HF pts. Compared with NH, 30-day readmission was similar but inhospital mortality was lower. Further research is needed to study the impact of cardiologists, who often serve as consultants for this population.

0122: Peritoneal dialysis and heart failure: designing of the heart module in the French speaking peritoneal dialysis registry (RDPLF)

Heart failure (HF) is a frequent and severe comorbidity in dialysis patients (pts); conversely, 30% of pts in the large Acute Decompensated Heart Failure National Registry had moderate to severe chronic kidney disease and 5% were receiving dialysis therapy. Refractory HF is a not uncommon indication for peritoneal ultrafiltration although its benefits have been unconsistently reported through mainly retrospective or monocentric studies. The main objectives of the “heart module” are to prospectively collect data related to cardiac status in PD pts and to allow longitudinal follow-up of cardiac- and dialysisrelated parameters in HF pts The RDPLF constitutes the largest recruiting observational cohort of French speaking PD pts, with coverage estimated at 98,3% of PD in France in 2013. All centers complete a set of core modules covering sociodemographics and basic clinical information, peritonitis episodes, and outcomes. Optional specialized modules are available. The heart module consists of baseline followed by quarterly collection of information related to cardiac disease, hospitalization rate, and dialysis-related parameters. 14 centers volunteered to participate since the heart module was launched in February 2013, now totalizing 75 pts. PD was initiated because of HF in 73%. Mean eGFR was 22±14 ml/mn/1.73m 2 with GFR>15 ml/mn/ 1.73m 2 in 69%. Half of the pts had echocardiographic Left Ventricular Ejection Fraction (LVEF)<30% and 71% pts had NYHA III-IV status. Mean rate of hospitalization the previous year was 30.8 days/pts/yr. Follow-up data were obtained in 38 pts at 3 months. Hospitalization rate decreased from 8.4 days/ 100 days to 4.7 days/100 days. LVEF increased by more than 10% in 13/ 23 pts. Mortality rate was 15.6% among the 32 pts with 1-year follow-up. Expanding this cohort will give the unique opportunity to define features of HF requiring PD and clarify which pts take most benefit from the strategy. The rapid decrease of hospitalization rate is confirmatory of previous studies.

Abstract 13259: Electrophysiologic Mapping Identifies Stable Organized Tachyarrhythmias ("Rotors") in Both Atria during Spontaneous Atrial Fibrillation with Systolic Heart Failure

Introduction: Stable organized atrial tachyarrhythmias (ATs) /"rotors" that maintain AF have been identified in patients (pts) with paroxysmal atrial fibrillation (PAF) &amp; persistent AF (PRAF) with no or minimal heart disease. Hypothesis: Biatrial ATs occur in AF pts with systolic heart failure (HF). Methods: We performed simultaneous contact catheter mapping of the RA &amp; LA using 3 D non-contact mapping ) in 83 refractory AF pts during spontaneous AF episodes.Spontaneous atrial premature beats (APBs) &amp; triggered ATs were analyzed. We also compared regional distribution of ATs &amp; activation patterns in pts with &amp; without HF. Results: 24 HF pts, mean age of 62±9 years, 75% male with mean left ventricular ejection fraction (LVEF) 45.5±9% and mean left atrial (LA) size 4.35±0.8 cm were mapped. They had 42 APBs that triggered 26 distinct organized stable ATs/"rotors". Each pt had 1 to 4 RA or LA regions showing triggering APBs (mean 1.75/pt) initiating AT. APBs arose predominantly from the RA or LA septum (45%) &amp; superior LA/PV (24%) regions (Fig 1a). A biatrial distribution of the stable ATs/"rotors" occcurred in HF pts (Fig 1b) with few focal ATs. Compared to pts without HF (n=59), HF pts (n=24) trended to have more PRAF (83% vs 66%, p=0.18). 78 organized stable ATs/"rotors" were compared for regional distribution in PRAF pts with HF (n=16) &amp; without HF (n=32). Stable ATs with focal LA/PV origin were uncommon in both groups (7% vs. 15%). LA ATs/"rotors" were similar (26% vs. 17%; p=0.58) as were typical RA flutter and atypical RA ATs/"rotors" in both groups (Fig 1c). Conclusions: 1. A majority of APBs initiating AF in HF pts originated from the septal and superior LA/PV regions. 2. While triggers are still frequently present with the LA/PV origin in HF pts, stable ATs/"rotors" had biatrial distribution &amp; a lesser frequency of focal LA/PV ATs. 3. This spectrum of ATs/"rotors" was similar to PRAF pts without HF, potentially supporting similar ablative interventions in both pt groups.

Abstract 16255: Wearable Cardioverter Defibrillator Treatment Characteristics and Outcomes in Recent Myocardial Infarction Patients With Heart Failure

Introduction: Previous studies report patients (pts) with acute myocardial infarction (MI) complicated by heart failure (HF) have poorer outcomes than non-ischemic HF pts. We determined the clinical and arrhythmia characteristics and outcomes in recent (&lt; 40 days) MI pts with HF versus non-ischemic (NICM) HF pts treated by the wearable cardioverter defibrillator (WCD). Methods: WCD pts with a medical history of HF treated for VT or VF between 1/2007 and 11/2013 were identified from the manufacturer-maintained registry. Pts were classified as recent MI if they were identified as having a “recent MI with ejection fraction (EF) ≤ 35%” or given an ICD-9 diagnostic code of 410.xx (acute MI). Pts were classified as non-ischemic if they had no epicardial coronary vessels with ≥ 75% stenosis, no history of myocardial infarction, and no coronary revascularization. Data were reviewed for demographics, ECG recordings, and 24-hour survival. Electrical storm was defined as 3 or more unique VT/VF events requiring WCD therapy over a 24-hour time period. Results: Total of 346 pts met the study criteria, with 56% classified as recent MI with HF (MI-HF). MI-HF group was more likely to have risk factors for ischemic disease such as being older, male, hypertensive, diabetic, etc. (Table). The mean difference in EF between the two groups was less than 5%. MI-HF pts were 1.7 times more likely to be in VT versus VF at initial shock and 2.1 times more likely to have an electrical storm. Conversion of VT/VF events to slower rhythms by WCD treatment shock was 98% or greater in both groups. 24-hour post-treatment survival was 92% for all pts, with no difference between the two groups. CONCLUSIONS: Recent MI pts with HF who were treated by the WCD were likely to be older and male, with risk factors for ischemic disease. In addition, MI-HF pts exhibited increased incidence of VT versus VF events and electrical storm. The WCD was effective in terminating arrhythmic events with a high post-treatment survival in both groups.

Abstract 18714: Role of 123 Iodine Metaiodobenzylguanidine Imaging in Prediction of Arrhythmic Events in Heart Failure Patients Candidate to ICD

Background: According to guidelines, implantable cardioverter defibrillator (ICD) is recommended in prevention of sudden cardiac death (SCD) in heart failure (HF) patients (pts). Guidelines have several limitations because ICD indication is based mainly on left ventricular ejection fraction (EF). Recent data showed that, independently from EF, 123-iodine metaiodobenzylguanidine imaging (123-I MIBG) could help to identify HF pts at high risk of SCD [heart/ mediastinum (H/M) ratio ≤1.6 and a summed score (SS) &gt; 26], who may benefit of ICD. Aim: Our aim is to assess, in a real world registry, the role of 123-I MIBG for the prediction of ventricular tachyarrhythmia (VT) causing appropriate ICD therapy in HF pts. Methods: We consecutively enrolled 97 patients admitted to our hospital with diagnosis of HF, left ventricular ejection fraction (LVEF) ≤35% and indication to ICD. All patients underwent MIBG imaging. The patients were classified into two groups: Group 1 with H/M≤1.6 , SS&gt; 26; Group2 with H/M&gt;1.6, SS &lt;26. All patients underwent 1 year follow-up. Results: 65 pts were included in group 1 and 32 pts in group 2. All baseline characteristics were similar in 2 groups apart from the etiology (table 1). In group 1, H/M ratio was 1.37±0.3 vs 1.8 ± 0.2 in group 2 (p=0.0002); SS was 37.5± 9.7 vs 16 ±6 in group 2 (p = 0.0001). At 1 year follow-up VTs causing appropriate ICD therapy in group 1 were 13.4% vs 1.28% in group 2(p=0.02); overall cardiac events were in group 1 16.4 % vs 1.92% in group 2 (p=0.02). Conclusion: Our results suggest that 123 I-MIBG can identify patients at increased risk for arrhythmic death and can be useful in the decision-making of ICD implantation independently from ejection fraction.