Higher Ejection Fraction Research Articles

Dietary vitamin D interacts with high phosphate-induced cardiac remodeling in rats with normal renal function.

Vitamin D (VD) and phosphate (Pi) load are considered as contributors to cardiovascular disease in chronic kidney disease and the general population, but interactive effects of VD and Pi intake on the heart are not clearly illustrated. We fed normal male rats with three levels of dietary VD (100, 1100 or 5000 IU/kg chow) and Pi (0.2, 0.6 or 1.6%) (3X3 design) for 8 weeks and examined renal and cardiac function and histology. High dietary Pi decreased plasma and renal Klotho and plasma 25-hydroxyvitamin D, and increased plasma Pi, fibroblast growth factor 23 and parathyroid hormone without affecting renal function, while low Pi increased plasma and renal Klotho. Both low and high VD diets enhanced high Pi-reduced Klotho expression. Low dietary VD reduced-plasma Klotho was rescued by a low Pi diet. High dietary Pi reduced-cardiac ejection fraction was not modified by a low or high VD diet, but the dietary VD effects on cardiac pathologic changes were more complex. High dietary Pi-induced cardiac hypertrophy was attenuated by a low VD and exacerbated by a high VD diet. In contrast, high dietary Pi -induced cardiac fibrosis was magnified by a low VD and attenuated by a high VD diet. High Pi diet induces hypertrophy and fibrosis in left ventricles, a low VD diet accelerates high Pi-induced fibrosis, and a high VD diet exacerbated high Pi -induced hypertrophy. Therefore, cardiac phosphotoxicity is exacerbated by either high or low dietary VD in rats with normal kidney function.

Clinical predictors of antitachycardia pacing response in implantable cardioverter defibrillator patients.

Antitachycardia pacing (ATP) provides safe and painless termination of reentrant ventricular arrhythmias in patients with implantable cardioverter defibrillator (ICDs), improving their quality of life. Established predictors of ATP responsiveness are not well known; only longer ventricular tachycardia (VT) cycle length and higher ejection fraction have been found to predict ATP success. To investigate clinical and ECG predictors of ATP response in ICD patients with monomorphic VT. The ICD clinic database was searched for monomorphic VT events requiring ICD therapy in patients with ischemic or non-ischemic cardiomyopathy. Each patient's first ICD encounter for VT was assessed. Patient demographics, clinical characteristics, VT rate, and ATP responsiveness (always, sometimes, and never successful) were recorded. An ECG was analyzed for QRS morphology and duration. Data was assessed for predictors of ATP responsiveness. In 527 patients, characteristics associated with always successful ATP included ACE-I/ARB therapy and slower VT rate (never successful ATP 197±28bpm, sometimes successful ATP 190±27bpm, always successful ATP 183±22bpm, P<.0001). Secondary prevention indication, amiodarone therapy, and longer QRS duration were associated with ATP failure. After multivariate analysis, only faster VT rate and amiodarone therapy were predictive of ATP failure. Neither QRS morphology nor duration was predictive of ATP success. Slower VT rate was predictive of repeated ATP responsiveness. Amiodarone therapy, which is known to increase VT cycle length, interestingly was associated with ATP failure for unclear reasons. More individualized and possibly more aggressive ATP programming may be warranted in patients on amiodarone.

Exploratory Analysis of Low PEACE Heart Failure Risk Score with Elevated NTproBNP: Insights from the MESA Study

Introduction PEACE heart failure (HF) score is a validated risk prediction score exclusive of NTproBNP. NTproBNP is a sensitive but non-specific biomarker with independent prognostic value for incident HF. We explore discordance between the two using data from the MESA study which enrolled patients devoid of existing cardio-cerebro-vascular disease. Hypothesis Patients with low risk PEACE score but elevated NTproBNP levels would be at elevated risk for incident HF. Methods PEACE HF score was calculated for visit 1 of the MESA study. NTproBNP > 125 pg/mL and eGFR Results 3,294 patients had low PEACE HF score, of which 484 had elevated NTproBNP. Elevated NTproBNP group was older with higher prevalence of hypertension, higher ejection fraction and comparable left ventricle mass index. KM curves showed higher incident HF in the elevated NTproBNP group. NTproBNP retained its incremental value after adjusting for age, race and gender (HR 9.2 [4.9-17.6]) (p Conclusion Among an ambulatory population free of clinical cardio-cerebrovascular disease and preserved renal function, 14% of patients at low risk of incident HF calculated using PEACE HF score had elevated NTproBNP levels which translated to higher risk of incident HF. Cost analysis studies are needed to assess its viability in risk assessment in low-risk PEACE patients.

Recent Diagnosis and Undefined Etiology Delay Initiation of Mineralocorticoid Receptor Antagonism in Heart Failure

Introduction ACC/AHA guidelines recommend all patients with heart failure (HF), both reduced and preserved ejection fraction (HFrEF and HFpEF), be prescribed a mineralocorticoid antagonist (MRA). National data suggest as few as 16-33% of patients admitted for acute HF are prescribed MRAs. We performed a retrospective analysis from an urban academic quaternary care center to elucidate why some individuals are prescribed MRA while others are not. Methods We analyzed all patients admitted for acute HF in 2017. Eligibility for MRA was determined by serum potassium less than 5 mEq/dL and estimated glomerular filtration rate (eGFR) greater than 30 mL/min/1.73m2. Patients were divided into those newly prescribed MRA on discharge, and those eligible for MRA but not prescribed. Variables included comorbidities, medications, etiology, ejection fraction (EF), potassium, eGFR, and new HF diagnosis. Students’ t-test for continuous and chi-square analysis for categorical variables were completed. Results There were 802 admissions for acute HF representing 570 unique patients. Prior to admission, 101 (18%) were on MRA. Two hundred-eighteen others were eligible for MRA, of which 87 (40%) were newly prescribed (Rx) after discharge, and 131 (60%) were not prescribed (NRx). A total of 188 (33%) were on MRA at discharge. Rx patients had a mean EF of 30% compared to 38% for NRx (p = 0.002). Similarly, 70% of Rx patients had a reduced EF compared to 46% for NRx patients (p Discussion Lack of MRA prescription was associated with greater EF, newly diagnosed HF, and unclear HF etiology. This data suggests that prescribers hesitate to follow guideline directed medical therapy for those with higher EF, even if the patients fit within the recommendations. Similarly, physicians delay MRA after an initial diagnosis. Awareness of these influences may inform future decision making when prescribing MRAs.

Curative effect of β-blocker on various ejection fractions of patients with atrial fibrillation.

The aim of this study was to retrospectively determine the effects of metoprolol on patients presenting with persistent atrial fibrillation (AF), but either with or without a reduced ejection fraction (EF). All patients meeting the inclusion criteria were treated for 2 years with metoprolol. Blood pressure, heart rate and echocardiography parameters were measured and analysed in patients before and after treatment. The patients were divided into 2 cohorts as follows: Those presenting with a low EF (<50%) and those with normal EF values (≥50%). In total, 151 patients enrolled were 136; however, of these 15 were lost to mortality during the follow-up period, thus leaving a total of 136 patients. In total, 42 patients presented EF values <50%, while the remaining 94 presented with normal EF values. Treatment with metoprolol controlled blood pressure (both diastolic and systolic) and heart rate in patients with both low and normal EF values. EF values in the low EF group significantly increased following treatment. In addition, the echocardiography data revealed a statistically significant decrease in left atrial and ventricular diameters in the low EF group. On the whole, the findings of this study demonstrate that patients with AF and low EF values who were treated with metoprolol presented with improved cardiac function parameters. However, metoprolol should be contraindicated for patients with high EF values (i.e., absence of heart failure) as it seemed to increase their risk of heart failure based on the N-terminal pro b-type natriuretic peptide (NT-pro BNP) results.

The effect of nicorandil in patients with acute myocardial infarction undergoing percutaneous coronary intervention: a systematic review and meta-analysis.

To study the effect of nicorandil on prognosis of patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). We retrieved literatures from Web of Science, Pubmed, Embase, and Cochrane Library. The retrieval time was limited from inception to December 2018. Nineteen randomized controlled trials involving 2176 patients were finally selected for this study. Meta-analysis showed that nicorandil can significantly reduce corrected TIMI frame count (cTFC) (WMD = - 5.27; 95% CI (- 6.61, - 3.93); P < 0.00001) and improve the no-reflow or slow-reflow phenomenon of coronary arteries (thrombolysis in myocardial infarction (TIMI) ≤ 2) (RR = 0.52; 95% CI (0.40, 0.68); P < 0.001). Compared with control group, nicorandil group has higher left ventricular ejection fraction (LVEF) (WMD = 3.42; 95% CI (1.32, 5.51); P = 0.001), and subgroup analysis showed that sex ratio was one source of heterogeneity (male/female ratio < 4 for low M/F group, M/F > 4 for high M/F group). In the low M/F group, LVEF in nicorandil group was increased significantly (WMD = 4.61; 95% CI (3.03, 6.20); P < 0.001), while there was no significant difference in LVEF between two groups in the high M/F group (WMD = 1.00; 95% CI (- 1.09, 3.09); P = 0.350). In addition, the incidence of in-hospital reperfusion arrhythmia (RR = 0.47; 95% CI (0.36, 0.63); P < 0.00001) and major adverse cardiovascular events (MACEs) (RR = 0.49; 95% CI (0.35, 0.69); P < 0.001) were significantly lower in the nicorandil group than that in control group. Nicorandil can improve coronary microcirculation and left ventricular function of patients with AMI after PCI. Interestingly, female patients may benefit more from nicorandil than male patients in improving heart function.

MON-587 Thyroid Hormones within the Normal Range and Cardiac Function in the General Population: The Epiporto Study

Introduction: Thyroid hormones have a central role in cardiovascular homeostasis. Both hypothyroidism and hyperthyroidism are associated with specific cardiovascular changes. However, the association of thyroid hormone levels within the normal range with cardiac function in general population remains largely unknown. Methods: 835 subjects with ≥45 years from EPIPorto population-based cohort study were analyzed. We excluded participants with TSH, FT4 or FT3 outside the reference range and participants with history of myocardial infarction, coronary revascularization, cardiac surgery, valvular heart disease, history of thyroid disease or treatment with drugs that interfere with thyroid function. All participants were submitted to detailed echocardiographic evaluation. The association of TSH, FT4 and FT3 with heart rate, blood pressure (BP), cardiac structure and cardiac function was evaluated with linear regression models unadjusted and adjusted for sex and age (model 1), and for sex, age, BMI, diabetes and hypertension (model 2). We assessed nonlinear associations using restricted cubic splines (3 knots). Results: The mean age of the population was 61.5±10.5 years, with 61.1% female participants. Eleven percent had diabetes, 47.8% dyslipidemia and 54.8% hypertension. Heart rate was positively associated with FT3 levels (model 2: β=1.78 [0.04 to 3.51], p=0.045). Diastolic BP was positively associated with TSH levels (model 2: β=1.50 [0.10 to 2.89], p=0.035). Regarding left ventricle (LV) structure, there was a nonlinear association of FT4 with posterior wall thickness, with lower thickness in the middle of the reference range. Both LV end-diastolic and end-systolic diameters were inversely associated with TSH (β=-3.62 (-5.89 to -1.35), p=0.002; and β=-2.03 (-3.31 to -0.77), p=0.002 in model 2). FT3 was nonlinearly associated with ejection fraction, with higher ejection fractions near the extremes of the normal range of FT3. Concerning diastolic function, FT3 was positively associated with E', and FT4 was negatively associated with E', although these associations were no longer significant in the adjusted models. Conclusions: Variations of thyroid function within the reference range are associated with heart rate, blood pressure, cardiac structure and cardiac function in the general population. Our results suggest that increasing thyroid function (lower TSH, higher FT4 or higher FT3) is associated with higher heart rate, lower diastolic BP and larger LV cavity volumes. On the other hand, both LV wall thickness and LV ejection fraction are non-linearly associated with thyroid hormones, with greater wall thickness and higher ejection fraction near the extremes of normal range of thyroid hormones concentration.

A human‐origin probiotics cocktail exhibit cardio‐protective effects independent of GLP‐1 receptor signaling

The emerging role of the gut microbiome in cardiovascular diseases is posited to be mediated by the microbial metabolites, some of which yield beneficial effects while others may accelerate the heart diseases. The beneficial metabolites like short‐chain fatty acids, particularly butyrate, exhibit several beneficial effects on metabolic diseases including cardiovascular functions. We have previously demonstrated that butyrate promotes the production of glucagon‐like protein‐1 (GLP‐1). GLP‐1 and its therapeutic agonists are known to promote cardiovascular functions. Herein, we investigated the role of systemic deletion of GLP‐1 receptor (using GLP1R KO) on cardiac functions in 16 weeks high‐fat diet (HFD)‐fed obese mice and assessed the impact of feeding a butyrate‐producing probiotic cocktail (consisting 5 Lactobacillus and 5 Enterococcus strains isolated from infant's gut) on cardiac functions, using the non‐invasive high‐frequency ultrasound echocardiography system (VEVO, VisualSonics, Toronto, Ontario, Canada). GLP1R‐KO mice show reduced cardiac output and stroke volume, and higher ejection fraction and fractional shortening of the left ventricle compared GLP1R‐WT mice. In addition, the GLP1R‐KO mice also exhibited significantly reduced systolic and diastolic diameter and volume, along with higher ratio of aortic acceleration and ejection time. Interestingly, feeding of probiotic cocktail protected from such dysfunctions in GLP‐KO mice, and also all these measures remain unchanged in GLP‐WT mice with and without probiotics treatments. No significant differences in body weight and diet intake was observed, however, glucose and insulin tolerance tests were improved in both probiotic‐fed groups. Results indicate that GLP1‐receptor depletion causes cardiovascular dysfunctions and feeding of the human‐origin probiotic cocktail ameliorates such dysfunctions, and probiotics effects are independent of GLP‐1 receptor signaling. Further analyses to better understand the mechanisms of actions of probiotics cocktail contributing these effects, are directed to establish a new cardioprotective probiotic biotherapy in obesity and type 2 diabetes.Support or Funding InformationWe thank the support provide by Center of Cardiovascular Sciences Center, Wake Forest School of Medicine, and the Department of Defense funding PR170446, as well funds and services provided from Center for Diabetes, Obesity and Metabolism, Wake Forest Baptist Medical Center and National Center for Advancing Translational Sciences (NCATS), National Institutes of Health funded Wake Forest Clinical and Translational Science Institute (WF CTSI) through Grant Award Number UL1TR001420.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Prognosis of Severe Asymptomatic Aortic Stenosis With and Without Surgery

This study sought to determine outcomes in patients with severe, asymptomatic aortic stenosis (AS), stratified by treatment recommendation. Between January 2005 and December 2013, 4,998 patients had severe AS by echocardiography, of whom 308 were identified as asymptomatic by medical record review. Five patients were deemed inoperable, and 38 were lost to follow-up. Of the remaining 265 patients, aortic valve replacement (AVR) was recommended in 104, and watchful waiting (WW) was recommended in 161. Probabilities of undergoing surgery and of death from recommendation date were estimated using a multistate model. Cox regression analysis was used to determine independent risk factors for death. Probability of death at 1 year after recommendation was 5.2% in the WW group and 4.7% in the AVR group. At 2 years after recommendation, survival in the AVR-recommended group was 92.5% versus 83.9% in the WW group (p= 0.044). In the WW group, the probability of dying or undergoing surgery was 43.9% by 2 years. Undergoing surgery was independently associated with higher survival in the AVR-recommended group (hazard ratio [HR], 0.17; p= 0.038) and in the WW group (HR, 0.39; p= 0.044). A higher ejection fraction (HR, 0.58; p<0.001) was associated with better survival, whereas renal failure (HR, 2.81; p= 0.009) was associated with worse survival. The strategy of early AVR is associated with improved survival in asymptomatic patients.

Cardiac Resynchronization Therapy in Congenital Heart Disease and Pediatric Patients with Heart Failure is Associated with Improved Survival

Purpose Cardiac resynchronization therapy (CRT) has been shown to shorten QRS duration (QRSd) and improve ejection fraction (EF) in adults with congenital heart disease (ACHD) and children with heart failure with reduced ejection fraction (HFrEF). It is not known whether CRT confers a survival benefit. We sought to determine whether CRT is associated with longer transplant-free survival after adjusting for patient factors. Methods All eligible patients ( 3) who received CRT were compared to a propensity score (PS)-matched cohort with similar characteristics at a single center between 2004 and 2017. Controls were identified from non-selective echocardiographic and ECG databases, with enrollment timed to first out-patient visit where all criteria were achieved (no CRT, EF 3). Primary endpoint was transplant-free survival. Results Of 128 patients who underwent CRT, 74 met all study inclusion criteria. 123 non-CRT controls met all inclusion criteria. Controls were younger with higher EF, but fewer had biventricular circulation. For the PS-matched cohorts (n=58 pairs), there were no differences in baseline characteristics (Table 1). Median follow-up was 2.3 years; risk of death or transplant was higher in the control group (HR 0.26 (95% CI 0.15-0.46), p Conclusion For ACHD patients and children with HFrEF, those receiving CRT had longer transplant-free survival and greater freedom from HF rehospitalization.

The Relation Between Monocyte to High-Density Lipoprotein Cholesterol Ratio and Short Term Outcome in Patients with Acute ST Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

AbstractBackground: Ischemic heart disease is considered the most common cause of death worldwide. Inflammation and oxidative stress play an important role in the pathogenesis of all phases of atherosclerosis and atherosclerotic plaque rupture which are the main mechanisms in the pathophysiology of acute ST-segment elevation myocardial infarction (STEMI). Monocyte to HDL ratio (MHR) was defined as a novel potential marker to determine inflammation and used to predict clinical outcome in patients with STEMI.Objectives: To study the relation between monocyte to high-density lipoprotein cholesterol ratio and short-term outcome in patients with acute ST-segment elevation myocar-dial infarction undergoing primary percutaneous coronary intervention (PCI).Methods: This study was conducted on a number of 100 patients diagnosed with STEMI and underwent primary PCI in Tanta University Hospitals, Cardiovascular Department, from June 2017 to December 2017. The primary end points were all cause mortality and major adverse cardiovascular events (MACE) including a composite of death, nonfatal re-infarction, target vessel re-vascularization, or new onset congestive heart failure during hospitalization and during the 3-months clinical follow-up.Patients were divided into 3 tertiles according to the monocyte to high- density lipoprotein cholesterol ratio (MHR); Tertile 1: MHR20 (number of patients=23).Results: Patients in the high MHR tertile showed signif-icantly lower systolic blood pressure, higher Killip class II-IV, lower final angiographic TIMI flow, higher WBCs, neu-trophils and monocytes count, higher serum LDL level and lower HDL levels, higher ejection fraction, higher all the composite endpoints of MACE including death, reinfarction and CHF. The study showed that MHR level >12.3 predicted the overall MACE following STEMI with a sensitivity and specificity above 75%. Conclusion: Monocyte to high-density lipoprotein cho-lesterol ratio is an independent prognostic factor for both in-hospital adverse outcomes, as well as, short-term adverse outcomes among STEMI patients who underwent primary PCI.

Association between left ventricular outflow tract opening and successful resuscitation after cardiac arrest

BackgroundSurvival after cardiac arrest depends on adequate cardiopulmonary resuscitation (CPR). Manual or mechanical external chest compression may be ineffective to restore circulation: structures subjected to external chest compression may differ in forces transfer to intrathoracic structures due to anatomic characteristics and physiological changes.This clinical study aims to assess the association of trans-oesophageal findings during CPR and successful resuscitation. MethodsRetrospective cohort study. Trans-oesophageal assessment of right ventricular fractional area change, right ventricular outflow tract fractional shortening, left ventricular volumes, ejection fraction, and aortic diameters were performed in refractory out-of-hospital cardiac arrest patients admitted to emergency department for extracorporeal CPR. Results19 patients were analyzed. 15 of 19 patients (79%) received venous-arterial extracorporeal membrane oxygenation support. Resuscitation was successful with return of spontaneous circulation or electromechanical activity in 7 patients (group-SUXX) and failed in 12 patients (group-FAIL). 6 patients (32%) were alive at 24 h from the cardiac arrest, one patient (5%) survived to hospital discharge. Left ventricular outflow tract (LVOT) was open during CPR in all patients in group-SUXX and in 1 patient in group-FAIL (p 0.0002). None of the patients with closed LVOT had successful resuscitation. Patients in group-SUXX had a higher ejection fraction (p 0.03), ascending aortic diameter (p 0.04), and survival rate than those in group-FAIL (p 0.015). In a multiple variable Cox’s proportional model LVOT opening was the only variable associated with successful resuscitation. ConclusionsTrans-oesophageal echocardiography can be useful in the emergency setting of cardiopulmonary arrest for discriminating between successful and failing resuscitation.

Sex-Related Differences in Patients Undergoing Thoracic Aortic Surgery.

Contemporary outcomes after surgical management of thoracic aortic disease have improved; however, the impact of sex-related differences is poorly understood. A total of 1653 patients (498 [30.1%] female) underwent thoracic aortic surgery with hypothermic circulatory arrest between 2002 and 2017 in 10 institutions of the Canadian Thoracic Aortic Collaborative. Outcomes of interest were in-hospital death, stroke, and a modified Society of Thoracic Surgeons-defined composite for mortality or major morbidity (stroke, renal failure, deep sternal wound infection, reoperation, prolonged ventilation). Multivariable logistic regression was used to determine independent predictors of these outcomes. Women were older (mean±SD, 66±13 years versus 61±13 years; P<0.001), with more hypertension and renal failure, but had less coronary disease, less previous cardiac surgery, and higher ejection fraction than men. Rates of aortic dissection were similar between women and men. Rates of hemiarch, and total arch repair were similar between the sexes; however, women underwent less aortic root reconstruction including aortic root replacement, Ross, or valve-sparing root operations (29% versus 45%; P<0.001). Men experienced longer cross-clamp and cardiopulmonary bypass times, but similar durations of circulatory arrest, methods of cerebral perfusion, and nadir temperatures. Women experienced a higher rate of mortality (11% versus 7.4%; P=0.02), stroke (8.8% versus 5.5%; P=0.01), and Society of Thoracic Surgeons-defined composite end point for mortality or major morbidity (31% versus 27%; P=0.04). On multivariable analyses, female sex was an independent predictor of mortality (odds ratio, 1.81; P<0.001), stroke (odds ratio, 1.90; P<0.001), and Society of Thoracic Surgeons-defined composite end point for mortality or major morbidity (odds ratio, 1.40; P<0.001). Women experience worse outcomes after thoracic aortic surgery with hypothermic circulatory arrest. Further investigation is required to better delineate which measures may reduce sex-related outcome differences after complex aortic surgery.

Sex Differences in Heart Failure With Preserved Ejection Fraction Pathophysiology: A Detailed Invasive Hemodynamic and Echocardiographic Analysis

ObjectivesThis study sought to identify sex differences in central and peripheral factors that contribute to the pathophysiology of heart failure with preserved ejection fraction (HFpEF) by using complementary invasive hemodynamic and echocardiographic approaches. BackgroundWomen are overrepresented among patients with HFpEF, and there are established sex differences in myocardial structure and function. Exercise intolerance is a fundamental feature of HFpEF; however, sex differences in the physiological determinants of exercise capacity in HFpEF are yet to be established. MethodsPatients with exertional intolerance with confirmed HFpEF were included in this study. Evaluation of the subjects included resting and exercise hemodynamics, echocardiography, and mixed venous blood gas sampling. ResultsA total of 161 subjects included 114 females (71%). Compared to males, females had a higher pulmonary capillary wedge pressure (PCWP) indexed to peak exercise workload (0.8 [0.5 to 1.2] mm Hg/W vs. 0.6 [0.4 to 1] mm Hg/W, respectively; p = 0.001) and lower systemic (1.1 [0.9 to 1.5] ml/mm Hg vs. 1 [0.7 to 1.2] ml/mm Hg, respectively; p = 0.019) and pulmonary (2.9 [2.2 to 4.2] ml/mm Hg vs. 2.4 [1.9 to 3] ml/mm Hg, respectively; p = 0.032) arterial compliance at exercise. Mixed venous blood gas analysis demonstrated a greater rise in lactate indexed to peak workload (0.05 [0.04 to 0.09] mmol/l/W vs. 0.04 [0.03 to 0.06] mmol/l/W, respectively; p = 0.007) in women compared to men. Women had higher mitral inflow velocity to diastolic mitral annular velocity at early filling (E/e′) ratios at rest and peak exercise, along with a higher ejection fraction and smaller ventricular dimensions. ConclusionsWomen with HFpEF demonstrate poorer diastolic reserve with higher echocardiographic and invasive measurements of left ventricular filling pressures at exercise, accompanied by lower systemic and pulmonary arterial compliance and poorer peripheral oxygen kinetics.

Effects of left atrium on intraventricular flow in numerical simulations

With the aid of cardiac imaging techniques, recent numerical simulations of left ventricular flow can be patient-specific to better mimic physiological conditions. However, studies with a dynamic mitral valve (MV) remain extremely limited. Even so, the left atrium (LA) is usually simplified to be tubular regardless of its complex structure. Studies on the effect of this simplification are limited and observations are controversial. In this study, both tubular and generic atriums were incorporated in patient-specific simulations with and without the MV to qualitatively and quantitatively estimate the effects of the atrial model on downstream ventricular flow. The patient-specific model was generated based on cardiac magnetic resonance (CMR) images of a healthy volunteer, and the dynamic motion of the MV was defined by the contours acquired along long-axis images. Based on the simulations, the influence of the atrial vortices on ventricular flow was significant in the valveless models in terms of flow structure, kinetic energy (KE) and circulation. Although these effects were suppressed in the presence of the MV, the atrial vortices that survived the passage were not trivial, which was evidenced by reduced strength of circulation and undesired flow pattern in the apical region. The flow structure in the generic atrium also dominated the development of ventricular flow in the valveless model. After the MV was incorporated, its effects on the downstream ventricular flow were considerably reduced but not eliminated. Therefore, a proper modelling of atrial flow is necessary, especially for subjects with high ejection fraction (EF).

Technical Feasibility and Design of a Shape Memory Alloy Support Device to Increase Ejection Fraction in Patients with Heart Failure

PurposeHeart failure is increasingly prevalent in the elderly. Treatment of patients with heart failure aims at improving their clinical condition, quality of life, prevent hospital (re)admissions and reduce mortality. Unfortunately, only a select group of heart failure patients with reduced ejection fraction are eligible for Cardiac Resynchronization Therapy where 30–40% remain non-responders and need left ventricular support. The aim of this study is to investigate if a shape memory alloy (SMA) is able to increase the ejection fraction of a mono-chamber static heart model by 5%.MethodsA pediatric ventilation balloon was used as a heart model (mono-chamber). Flexinol®, a SMA, was placed around the heart model in multiple configurations and activated using pulse width modulation techniques to determine influence of diameter and configuration on volume displacement. Furthermore, pressure within the heart model was measured with a custom-made pressure sensor.ResultsSMA with a diameter of 0.38 mm, placed in a spiral shape and activated with a duty cycle of 80% and a frequency of 50/min gave the highest ejection fraction increase of 3.5%.ConclusionsThis study demonstrated the feasibility of volume displacement in a static heart model by activation of SMA-wires. Configuration, duty cycle, frequency, pulse intervals and diameter were identified as important factors affecting the activation of SMA-wires on volume displacement. Future research should include the use of parallel SMA-wires, prototype testing in dynamic or ex vivo bench models.

Increased Mortality of High versus Normal Ejection Fraction – Insights from Big Echo Data

Mortality with impaired left ventricular ejection fraction (LVEF) has been demonstrated. However, the prevalence and significance of increased LVEF in the community is unclear. We used the National Echo Database Australia (NEDA) to compare mortality in patients with normal and high LVEF. Methods: 331,344 individuals aged >18 years (52% men, age = 60.8 ± 18.0 years) had a mean follow up of 5.4 person-years and 63,142 fatal events. LVEF using Method of Discs could be calculated in 116,544 individuals. We compared mortality in those with normal LVEF compared with high LVEF for males and females. Results: Mortality was 11% higher in females with high LVEF vs normal LVEF. On multivariable logistic regression, high ejection fraction remained an independent predictor of mortality after correction for age, gender and body mass index. High LVEF was associated with female gender, age and diastolic dysfunction. Of 96,033 individuals in the study population, 44,282 males had normal LVEF (52–72%) as opposed to 2,594 with high LVEF (>72%). In females, 46,186 had normal LVEF (54–74%) and 2,971 had high LVEF. In Cox proportional hazard models, the hazard ratio (HR) for mortality in males with normal EF was 1.105 for age (95% CI 1.102 to 1.07) and 1.074 (95% CI 0.988 to 1.167) for high LVEF (p < 0.001 for all outputs). In females, the corresponding adjusted HR was 1.107 for age (95% CI 1.105 to 1.110) and 1.140 for high LVEF (95% CI 1.057 to 1.230). Conclusion: High LVEF, particularly in older women, is associated with increased mortality compared with normal LVEF.

Ischemic postconditioning reduces infarct size and microvascular obstruction zone in acute ST-elevation myocardial infarction - a randomized study.

IntroductionIschemic postconditiong (postcon) has been reported to reduce infarct size in ST-segment myocardial infarction (STEMI). However, recently a few other studies did not show any effect of postcon or suggested that it may even be harmful.AimWe sought to assess whether postcon could reduce infarct size (IS) and the microvascular obstruction (MVO) zone in early presenters with STEMI.Material and methodsSeventy-four STEMI patients treated with primary coronary intervention (PCI) < 4 h from symptoms onset were randomly assigned to the postcon group (n = 37) or standard PCI group (n = 37). Postcon was performed immediately after obtaining reperfusion with 4 balloon occlusions, each lasting 60 s, followed by 60 seconds of reperfusion. Cardiac magnetic resonance was performed in all subjects within 48 to 96 h after admission. To evaluate the infarct size and MVO, the late gadolinium enhancement (LGE) technique was used. Infarct size was defined as an area greater than 50% of the maximal signal intensity within LGE. MVO was defined as the area of the absence or hypoenhancement of contrast surrounded by LGE. Infarct size and MVO were determined by planimetry and the summation of discs method.ResultsPostcon was associated with significantly smaller IS (16.42 ±9.6 vs. 31.2 ±22.2 g; p = 0.007) and higher ejection fraction (59.8 ±9.2% vs. 52.3 ±10.2%). The extent of MVO was significantly lower in the postcon group in comparison to the control group (0.76 ±1.4 g vs. 2.2 ±3.2 g; p = 0.03).ConclusionsIn early presenters with STEMI postcon could significantly reduce infarct size and limit reperfusion injury.

Paradoxical low-flow aortic stenosis - baseline characteristics, impact on mortality.

IntroductionParadoxical low-flow, low-gradient aortic stenosis (pLF-LGAS) constitutes an important part of the population undergoing transcatheter aortic valve implantation (TAVI). However, it remains the least defined subtype of aortic stenosis (AS).AimTo investigate baseline characteristics and impact on mortality of pLF-LGAS in patients treated with TAVI.Material and methodsTwo-hundred and thirty-one consecutive patients (mean aortic valve area: 0.76 ±0.41 cm2) who underwent TAVI in our centre during the period of 6 years were included in the study. Based on echocardiographic examination, patients with pLF-LGAS were identified, analysed and compared to a population with high-gradient AS (HGAS) and low-flow, low-gradient AS with reduced ejection fraction (classical, cLF-LGAS). The primary endpoints of the study were all-cause mortality after 30 days and 1 year.ResultspLF-LGAS was diagnosed in 42 (18.2%) patients, whereas 40 (17.3%) had cLF-LGAS and 149 (64.5%) had HGAS. The pLF-LGAS population was younger, had higher prevalence of hypertension, and had higher ejection fraction (EF) than the HGAS population, and had a smaller proportion of heavily symptomatic patients than the cLF-LGAS population. Overall, 46 (19.9%) patients died within 12 months after TAVI. The 30-day and 1-year survival was comparable between AS subtypes. Multivariate analysis identified severe renal failure as an independent predictor of mortality among all patients.ConclusionspLF-LGAS is common among subjects undergoing TAVI. Patients with paradoxical AS are younger, more often burdened with hypertension and have higher EF than the HGAS population, while being less symptomatic than the cLF-LGAS group. Presence of pLF-LGAS does not seem to affect short- and mid-term survival. Severe renal failure is an independent predictor of mortality after TAVI.

Association Between the Lipid Profile and Renal Dysfunction in the Heart Failure Patients

Background/Aims: In heart failure patients with high prevalence of chronic renal disease (CKD), hospitalization and mortality, whether the lipid profile was associated with renal dysfunction remained unknown. The present study intended to clarify the association between the lipid profile and renal dysfunction in the heart failure patients. Methods: 336 hospitalized heart failure patients with left ventricle ejection fraction (LVEF) ≤45% and New York Heart Association (NYHA) class II-IV were enrolled. The estimated glomerular filtration rate (eGFR) < 90 mL/min·1.73 m² was defined as renal dysfunction. The demographic, clinical data, blood samples and echocardiography were documented. The Pearson simple linear correlation was performed to evaluate the confounding factors correlated with eGFR. The significantly correlated factors were enrolled in Logistic regression as confounding factors to determine the association between the lipid profile and renal dysfunction in the heart failure patients. Results: 182 patients (54.2%) had renal dysfunction and 154 patients (45.8%) did not have renal dysfunction. The waist circumference, platelet counts, platelet distribution width (PDW), high density lipoprotein-cholesterol (HDL-C), apolipoprotein A1 (apoA1), albumin and left ventricular ejection fraction (LVEF) are positively correlated with eGFR (all P< 0.05). Meanwhile, the age, mean platelet volume (MPV), neutrophilic granulocyte percentage (NEUT%), urea nitrogen (BUN), creatinine and total bilirubin (TBIL) are negatively correlated with eGFR (all P< 0.05). The total cholesterol (TC), triglyceride, low density lipoprotein-cholesterol (LDL-C) and apolipoprotein B (apoB) show no correlation with eGFR. After the adjustment of sex, hypertension, diabetes mellitus, age, waist circumference, platelet counts, MPV, PDW, NEUT%, TBIL, albumin and LVEF, HDL-C is the only lipid factor still significantly associated with renal dysfunction in hospitalized heart failure patients (OR=0.119, P=0.003). Conclusion: Among the lipid profile of TC, triglyceride, LDL-C, HDL-C, apo A1 and apo B, the HDL-C is the only lipid factor significantly associated with renal dysfunction in hospitalized heart failure patients.