Hospitalization For Failure Research Articles

Transcatheter edge-to-edge mitral valve repair in atrial functional mitral regurgitation: insights from the multi-center MITRA-TUNE registry

BackgroundA-FMR is considered a specific sub-type of secondary MR in patients with atrial fibrillation (AF) and preserved left ventricle ejection fraction (LVEF). Aim of the study was to investigate the acute and mid-term outcomes of transcatheter edge-to-edge mitral valve repair (TMVr) with the MitraClip in atrial functional mitral regurgitation (A-FMR). MethodsThe study included patients with A-FMR and concomitant AF who underwent to the MitraClip at 7 Italian Centers. Aim of the study was to assess the safety, efficacy and mid-term cardiovascular outcomes. ResultsAfter reviewing 1153 patients with FMR treated with TMVr from 2009 to 2021, 87 patients (median age 81 years, 61% female) with A-FMR were identified. Technical success was achieved in 97%, 30-day device success in 83% and 30-day procedural success in 80%. All-cause death at 30-day was 5%. Estimated two-year freedom from all-cause death and cardiac death was 60% and 77%, respectively, whereas freedom from all-cause death/heart failure hospitalization was 55%. Residual MR ≤ 2+ was encountered in 89% (n = 47/53) and improvement in NYHA class I/II in 79% (n = 48/61). Post-procedural MR ≥ 2+ (HR 5.400, CI 1.371–21.268) and inter-commissural annular diameter ≥ 35 mm (HR 4.159, CI 1.057–16.363) were independent predictors of all-cause death/heart failure hospitalization during the follow-up. Positive reverse remodeling of left atrium and mitral annular dimensions occurred after TMVr during the follow-up. ConclusionsMitraClip resulted to be a safe and effective option to treat A-FMR in elderly patients.

Abstract 10044: Efficacy of Sacubitril-Valsartan in Patients with Reduced Left Ventricular Ejection Fraction

Introduction: Angiotensin receptor-neprilysin inhibitor (ARNI) reduces death and heart failure (HF) hospitalization in patients with HF and reduced ejection fraction (HFrEF). In addition to the PARADIGM-HF, PARADISE-MI and LIFE trial has recently tested the safety and efficacy of ARNI in subgroups of patients with reduced left ventricular ejection fraction (LVEF) such as those patients at risk for HFrEF after myocardial infarction (without prior HF) and advanced HF patients. Methods: We performed a random-effects model meta-analysis of three randomized controlled trails investigating the effect of ARNI in patients with reduced LVEF. The main endpoints were the composite of cardiovascular death and HF hospitalization, and HF hospitalization. Results: A total of 14,395 patients were included in our analysis. The characteristics of the included studies are demonstrated on Table 1. The composite endpoint and HF hospitalization were non-significantly reduced with ARNI compared with angiotensin-converting enzyme inhibitor or angiotensin II receptor blockers (composite endpoint adjusted hazard ratio [HR] 0.9, 95% confidence intervals 0.75-1.08 and HF hospitalizations: HR 0.87, 0.72-1.04, Figure 1). The heterogeneity among trials was high (I 2 >50%). Conclusions: In line with the recently reported trials, our findings support the use of ARNI in patients with HFrEF that meet the inclusion criteria of PARADIGM-HF trial. It is important to tailor medical therapy by matching individual patient profiles to inclusion criteria of the published randomized clinical trials.

Abstract 10811: Hemodynamic Optimization of Left Ventricular Assist Devices During Right Heart Catheterization Ramp Studies

Background: Studies have shown that hemodynamic LVAD ramp studies can be used to optimize speeds and improve clinical outcomes, yet these studies lack external validation. Methods: 470 LVAD patients, including 3 LVAD subtypes, were retrospectively analyzed and 53 ramp studies were identified. Measurements (RA, mean PA, PCWP, and CI) were taken at speeds +/- 20% of the manufacturer recommended set speed for HM2, HM3, and HVAD devices. Primary outcomes were all-cause and heart failure (HF) hospitalizations in the 6-month period pre- and post-ramp study. Secondary outcomes included final LVAD speed and hemodynamic measurements following ramp study. Time to first hospitalization and cumulative incidence rate of all-cause and HF hospitalization were reported. Results: Baseline characteristics of 53 studies included: mean age of 60.1 (+/- 10.9), 84.9% male, 56.6% ischemic etiology, 71.7% destination therapy, and average NYHA class and INTERMACS of 2.5 (+/- 0.7) and 5.9 (+/- 1), respectively. 38 of 53 studies (71.7%) showed PCWP decompression >20%, with average PCWP decompression of 51.2% (+/- 21.0%), and CI increase of 22.5% (+/- 18.7%). Optimal LVAD speeds were chosen to maintain CI > 2.2, PCWP < 15 and minimize RAP, in the absence of suction events. 31 (58.5%) of studies resulted in an LVAD speed change and 16 (30.2%) of studies resulted in diuretic change. All-cause and HF hospitalizations were significantly decreased in the 6-months following ramp studies compared the 6-months pre-ramp (total days hospitalized for all causes: 12.0 vs 26.6, p=0.0002; total days hospitalized for HF, 4.8 vs 22.1, p=0.00003). Speed changes were associated with a nonsignificant improvement in time to first hospitalization. Conclusion: This externally validates previous data suggesting that LVAD hemodynamic ramp studies decrease hospitalizations. Larger, prospective studies may elucidate specific hemodynamic targets to improve mortality and reduce rehospitalizations.

Abstract 10633: Deep Learning Model Accurately Quantifies LA Volumes on Routine Non-Contrast Chest CTs and Predicts Adverse Outcomes

Introduction/Hypothesis: To develop and validate a deep learning model to automatically segment and measure left atrial (LA) volumes from routine noncontrast chest CTs and evaluate for outcomes prognosis. Methods: A prototype AI algorithm, with a conditional variational auto-encoder architecture, was initially developed and trained using training data from 1313 patients (paired CTA and non-contrasted exams; “training group”). Left atrium contours from contrasted cases were used to train the model on corresponding non-contrasted dataset. We then retrospectively evaluated 274 patients (mean age 67.9 years, 54.6% male, 57.2% caucasian) who underwent a routine non ECG-gated, noncontrast chest CT for coronary artery calcium or lung cancer screening for validation of the AI model (“validation group”). Outcomes included heart failure (HF) hospitalization and new-onset atrial fibrillation within 5 years. Simple logistic regressions with appropriate univariate statistics were used for modelling outcomes. Results: In the validation group, there was excellent correlation between AI and expert results with a LA volume index (LAVi) intraclass correlation coefficient of 0.950 (0.936-0.960). Bland-Altman plot demonstrated that the AI underestimated LAVi by a mean 5.86 mL/m2. AI-LAVi independently predicted new-onset atrial fibrillation (AUC = 0.855, OR = 1.12, 95% CI 1.08 - 1.18; p<0.0001). AI-LAVi was independently associated with HF hospitalization (AUC = 0.903, OR = 1.08, 95% CI 1.04 - 1.13, p = 0.0009). Conclusion: In this large validation cohort, AI for automated measurement of LA volume on routine noncontrast chest CTs had excellent agreement with manual quantification. AI-LAVi is independently predictive for new-onset atrial fibrillation and HF hospitalization within 5 years.

Abstract 10402: H 2 FPEF Score as a Prognostic Tool to Predict Mortality and Hospitalization in Adults with Normal Left Ventricular Ejection Fraction and Dyspnea: A Systematic Review and Meta-Analysis

Introduction: The score “H2FPEF’’ has been described as a tool to predict heart Failure with Preserved Ejection fraction (HFpEF). The scoring criteria and interpretation are as follows: 0 or 1, exclude HFpEF; 2-5, further examination is needed to confirm the diagnosis; and 6-9, high probability of HFpEF diagnosis. However, predicting the prognosis of patients by using this scoring system is an ongoing topic of interest. Hypothesis: H2FPEF score can be used to predict mortality and heart failure (HF) hospitalization in adults with normal left ventricular ejection fraction (LVEF) and dyspnea. Methods: We systematically searched Pubmed, Embase, and Scopus for abstracts and full-text articles from inception to May 2021. Studies were included if they evaluated the relationship between a high H2FPEF score (defined as ≥6) and mortality or hospitalization due to HF in adults with normal LVEF and/or dyspnea. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using the random-effects model by DerSimonian and Laird. Results: A total of 4 studies were included that had a total of 8071 patients (mean age: 72 years, 49% were females) with an overall mortality of 35%. The relationship between a high H2FPEF score between survivors and non-survivors demonstrated an association with mortality (OR:1.73 CI:1.41-2.11 p<0.01. Figure 1.). The association to mortality persisted in the subgroup analysis of patients who already had the diagnosis of HFpEF and in patients evaluated with unexplained dyspnea, (OR:1.55 CI:1.22-1.96 p<0.01. Figure 2.), (OR:2.02 CI:1.49-2.74 p<0.01 Figure 3.) respectively. In addition, a high H2FPEP was associated with HF related hospitalizations (OR:1.70 CI:1.26-2.29 p<0.01. Figure 4.). Conclusions: A high H2FPEF score is associated with mortality and HF hospitalization irrespective of the presence of a known HFpEF diagnosis. This could help identify a population that may warrant more aggressive monitoring and management strategies.

Abstract 11671: Inpatient Cardiac Rehabilitation After Hospitalization for Acute Decompensated Heart Failure is Associated With Reduced Cardiovascular Events

Introduction: The effects of cardiac rehabilitation during acute decompensated heart failure (HF) hospitalization remain to be elucidated. This study sought to determine whether inpatient cardiac rehabilitation after HF hospitalization could improve outcomes in HF patients. Methods: We analyzed HF patients enrolled in the Japanese Registry Of Acute Decompensated Heart Failure (JROAD-HF), a national database of HF. Eligible patients were divided into two groups according to the inpatient cardiac rehabilitation. The primary outcome was the composite of cardiovascular death or re-hospitalization due to cardiovascular event after discharge. The secondary outcomes were cardiovascular death and re-hospitalization due to cardiovascular event. Results: Out of 10,473 eligible patients, 3,210 patients underwent cardiac rehabilitation. Propensity score matching yielded 2,635 pairs. The mean age was 77.2 years and 2,927 (55.5%) was male. Ischemic heart disease was accounted for 28.8% and the mean left ventricular ejection fraction was 45.2 ± 17.1. During a mean follow-up of 2.8 years, the cardiac rehabilitation group had a lower incidence rate of the composite of cardiovascular death or re-hospitalization due to cardiovascular event (284.0 vs. 311.7 events per 1000 patient-years; rate ratio [RR] 0.89; 95% confidence interval [CI] 0.83-0.96; P = 0.003), and re-hospitalization due to cardiovascular event (255.4 vs. 283.9 events per 1000 patient-years; RR 0.90; 95% CI 0.83-0.97; P = 0.007) than the no cardiac rehabilitation group. Cardiovascular death was not different between groups (71.0 vs. 75.5 events per 1000 patient-years; RR 0.94; 95% CI 0.83-1.06; P = 0.31). Cubic spline analysis showed that patients with lower Barthel index were benefited by cardiac rehabilitation. Conclusions: The implementation of cardiac rehabilitation during HF hospitalization was associated with better long-term outcomes in patients with HF.

Prediction of long-term hospitalisation and all-cause mortality in patients with chronic heart failure on Dutch claims data: a machine learning approach

BackgroundAccurately predicting which patients with chronic heart failure (CHF) are particularly vulnerable for adverse outcomes is of crucial importance to support clinical decision making. The goal of the current study was to examine the predictive value on long term heart failure (HF) hospitalisation and all-cause mortality in CHF patients, by exploring and exploiting machine learning (ML) and traditional statistical techniques on a Dutch health insurance claims database.MethodsOur study population consisted of 25,776 patients with a CHF diagnosis code between 2012 and 2014 and one year and three years follow-up HF hospitalisation (1446 and 3220 patients respectively) and all-cause mortality (2434 and 7882 patients respectively) were measured from 2015 to 2018. The area under the receiver operating characteristic (ROC) curve (AUC) was calculated after modelling the data using Logistic Regression, Random Forest, Elastic Net regression and Neural Networks.ResultsAUC rates ranged from 0.710 to 0.732 for 1-year HF hospitalisation, 0.705–0.733 for 3-years HF hospitalisation, 0.765–0.787 for 1-year mortality and 0.764–0.791 for 3-years mortality. Elastic Net performed best for all endpoints. Differences between techniques were small and only statistically significant between Elastic Net and Logistic Regression compared with Random Forest for 3-years HF hospitalisation.ConclusionIn this study based on a health insurance claims database we found clear predictive value for predicting long-term HF hospitalisation and mortality of CHF patients by using ML techniques compared to traditional statistics.

Prognostic impact of percentage of ventricular pacing in patients requiring pacemaker implantation after transcatheter aortic valve replacement

Abstract Background Despite the continuous developments of transcatheter aortic valve implantation (TAVI), around 15% of the patients (P) who undergo this procedure require permanent pacemaker (PM). Right ventricular pacing (RVP), particularly with a cumulative percentage of ventricular pacing (CVp) above 40%, has been associated with detrimental effects on ventricular function and an increased risk of cardiovascular events in non-TAVI patients. Aim To evaluate the long-term prognostic significance of RVP, regarding overall mortality and the combined endpoint of overall mortality/heart failure hospitalization in P requiring a PM after TAVI. Methods We retrospectively examined P who underwent TAVI with a self-expanding valve from 2009 to 2020 at our institution. All P had pre-procedural clinical evaluation, cardiac computed tomographic angiography, transthoracic echocardiography and electrocardiography performed. CVp was determined from stored PM data. P with previous PM were excluded. Post-TAVI PM implantation was defined as a device implantation during hospital stay or during the first month after discharge. Results 474P, 57% male, mean age 81.7±6.5 years with a mean left ventricular ejection fraction of 51.5±14.6% were analysed. Mean follow-up was 18.7 months. Mean STS score and mean Euroscore II were, respectively, 6.89% and 5.76%. Mean gradient was 51.67 mmHg and mean aortic valve area 0.71 cm2. After TAVI, 104P (21.9%) required PM implantation, with a mean CVp of 65.3±43.4%. Post-TAVI PM was not associated with a worse outcome - overall mortality: HR 1.13, 95% CI 0.72 – 1.78, p=0.57; combined mortality/heart failure hospitalization: HR 1.22, 95% CI 0.87 – 1.70, p=0.24. The follow-up Kaplan-Meier curves according to the need for PM post-TAVI were similar: log rank p=0.24. A CVp cut-off of 40% was not associated with any of the study endpoints - overall mortality: HR 1.72, 95% CI 0.38–7.86, p=0.48; combined mortality/heart failure hospitalization: HR 1.32, 95% CI 0.45–3.91, p=0.61. Also, a CVp cut-off of 40% did not provide an accurate risk stratification as survival free of events was similar between these P and those below this cut-off (log rank p=0.11) and in comparison, with P without PM (log rank p=0.65). Conclusions In P submitted to TAVI with a self-expanding valve, the need for PM implantation is common, but not associated with increased risk of total mortality or heart failure hospitalization during a 18 months follow-up period. A CVp cut-off of 40% showed poor discriminative ability regarding long-term events in this population. Funding Acknowledgement Type of funding sources: None.

Use of echocardiography and heart failure mortality from registry data in Japan

Abstract Background There are several recommendations for the use of echocardiography in acute hospitalized HF. Echocardiography requires a high degree of skill on the part of the examiner, and the skill may be more improved in larger volume centers. Purpose In this study, we investigated whether the use and volume of echocardiography is associated with in-hospital mortality from the real world registry database of heart failure (HF) hospitalizations. Methods This study was based on the Diagnosis Procedure Combination database in the Japanese Registry of All Cardiac and Vascular Datasets (JROAD-DPC). We categorized the 739 hospitals into 3 groups according to the number of echocardiographic studies performed annually (first tertile: <2500 cases, second tertile: 2500–4500 cases, third tertile: >4500 cases) and compared the groups of patients who were first admitted to the categorized hospitals with heart failure between April 2015 and March 2016. We estimated the odds ratios and their 95% confidence interval for in-hospital mortality using multivariable models. The variables of multivariable analysis were selected by stepwise method. Results A total of 80,496 HF patients were hospitalized, and 73.2% were examined for echocardiography. We found that the use and volume of echocardiography exams were associated with significantly lower odds of all-cause hospital mortality in heart failure (adjusted OR: 0.48 for use of echocardiography and 0.78 for the third tertile; both P<0.001). Conclusions The use of echocardiography was associated with decreased odds of hospital mortality in HF. The volumes of echocardiographic examinations were also associated with hospital mortality; thus, this study suggests that the skill of echocardiography may be improved in the large volume center and provide good outcomes in HF. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Japan Society for the Promotion of Science (JSPS) Flowchart of this studyOdds ratio of in-hospital mortality

Right ventricular remodeling and prognostic relevance after ST-segment elevation myocardial infarction in patients treated with primary percutaneous coronary intervention

Abstract Background ST-segment elevation myocardial infarction (STEMI) often involves changes in right ventricular (RV) function and size over time. However, the prognostic implications of RV remodeling after STEMI are unknown. The aim of current study was to characterize RV remodeling in post-STEMI patients and to investigate it's prognostic relevance. Methods RV remodeling in post-STEMI patients who underwent primary percutaneous coronary intervention (PCI) was defined by RV end-systolic area (RV ESA) change at 6 months after STEMI, compared to baseline. The optimal threshold of RV ESA change (≥40%) to define RV remodeling was derived from spline curve analysis (Figure 1A). The primary endpoint was the composite of all-cause mortality and heart failure (HF) hospitalization. Long term outcomes were compared between patients with and without RV remodeling by means of a log rank test. Results A total of 2280 patients were analyzed (mean age 60±11 years, 76% male) and RV remodeling was present in 320 patients (14%). After a median follow-up of 75 months (interquartile range 50–106 months), the composite endpoint of all-cause mortality and HF hospitalization occurred in 292 patients (13%). After adjustment for various risk factors, including tricuspid annular plane systolic excursion (TAPSE), post-STEMI RV remodeling was independently associated with a higher risk of all-cause mortality and HF hospitalization (HR=1.37, 95% CI 1.00–1.87, p=0.049. Finally, patients with RV remodeling were had a significantly lower event-free survival rate compared with patients without RV remodeling during follow-up (log-rank test p=0.009) (Figure 1B). Conclusion RV post-infarct remodeling is associated with mortality and HF hospitalization, independent of RV systolic function. Funding Acknowledgement Type of funding sources: None. Figure 1. A) Spline and B) Kaplan-Meier curve

Association of neighbourhood-level poverty with outcomes and clinical care following atrial fibrillation diagnosis in a universal healthcare system

Abstract Background There are limited data on the association of poverty with outcomes and care patterns after an atrial fibrillation (AF) diagnosis in jurisdictions with universal healthcare. The Canadian province of Ontario provides publicly funded healthcare and prohibits private payment for medically necessary physician and in-hospital care. It also covers prescription medications for residents aged >65 years. Purpose Determine the association of neighbourhood-level poverty with outcomes and processes of care after AF diagnosis in older people within a universal healthcare system. Methods Using linked administrative databases, we conducted a population-based cohort study of community-dwelling adults aged ≥66 years who were newly diagnosed with AF in Ontario between April 1, 2007 and March 31, 2019. The primary exposure was material deprivation of patients' neighborhood of residence. This metric is derived using Canadian census data to estimate inability to access and attain basic material needs. Neighborhoods were categorized by quintile of material deprivation from Q1 (wealthiest) to Q5 (poorest). We used cause-specific hazards regression models to study the association of deprivation quintile with time to the following outcomes over one year from AF diagnosis: death, ischemic stroke, bleeding, heart failure (HF) hospitalization, cardiology services, and AF-specific treatments. Models accounted for clustering by region of residence and adjusted for age, sex, diabetes, HF, stroke/transient ischemic attack, vascular disease, hypertension, bleeding history, rural residence, renal function, and setting of AF diagnosis (hospital, emergency department [ED] or outpatient). Results We studied 350,353 patients with AF (median age 78 years, 48.9% female). People from neighborhoods in higher deprivation quintiles (poorer) were more likely to be diagnosed in hospital/ED than outpatient settings. Relative to people from the wealthiest neighbourhoods (Q1), patients in the poorest neighbourhoods (Q5) had higher prevalence of baseline hypertension, diabetes, HF, vascular disease and other comorbidities. In adjusted analyses (Figure), higher quintiles of neighborhood poverty were associated with greater rates of death, ischemic stroke, bleeding, and HF hospitalization, but lower rates of cardiology visits, cardiac testing, anticoagulation, anti-arrhythmic medications, cardioversion, or AF ablation. Conclusions In a setting of universal healthcare and prescription medication coverage, people living in poorer neighbourhoods had worse baseline health and higher rates of adverse outcomes after an AF diagnosis. Despite this, people in poorer neighbourhoods had less cardiology visits and diagnostic tests and were less likely to receive anticoagulation and rhythm control interventions. This shows that universal healthcare and medication coverage are insufficient to achieve equitable health care and outcomes for people with AF. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): This research was funded by a Canadian Institutes of Health Research Foundation grant; and is supported by ICES (formerly the Institute for Clinical Evaluative Sciences), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).

Association of low total cholesterol level with clinical outcomes in patients with atrial fibrillation: the Fushimi AF registry

Abstract Background Hyperlipidemia is a well-established risk factor for cardiovascular disease. However, low cholesterol is also reported to be associated with poor outcome in patients with chronic disease, which is called “cholesterol paradox”, and the association of cholesterol level with the incidence of clinical outcomes in patients with atrial fibrillation (AF) remains unclear. Methods In the Fushimi AF Registry, a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto, Japan, follow-up data and baseline total cholesterol levels were available in 3,054 patients. We excluded 767 patients who were taking statins, and 2,267 patients were included in the analyses. We defined low cholesterol as total cholesterol <150 mg/dl, and examined the incidence of all-cause death, stroke/systemic embolism (SE), heart failure (HF) hospitalization, and major bleeding. Results Patients with low cholesterol (N=464 (20.4%)) were older, more often male, and had higher prevalence of low body weight (<50 kg), permanent/persistent AF, prior stroke/SE, HF, chronic kidney disease, and anemia (hemoglobin <11 g/dl). CHA2DS2-VASc score was higher in patients with low cholesterol (low cholesterol vs others; 3.6±1.6 vs 3.2±1.7: P<0.001). Prescription of oral anti-coagulants was comparable between the groups (50.0% vs 54.5%: P=0.09). During the median follow-up of 1,805 days, the incidence of all-cause death, stroke/SE, HF hospitalization, and major bleeding was significantly higher in patients with low cholesterol (all-cause death, 10.9 vs 3.8 /100 person-years; stroke/SE, 3.4 vs 1.9 /100 person-years; HF hospitalization, 4.7 vs 2.5 /100 person-years; major bleeding, 2.7 vs 1.4 /100 person-years) (Figure 1). After adjustment for the components of CHA2DS2-VASc score, low body weight, permanent/persistent AF, chronic kidney disease, anemia, and prescription of oral anti-coagulants, low cholesterol was significantly associated with the incidence of all-cause death and stroke/SE, but not with that of HF hospitalization or major bleeding (Figure 2, model 3). Total cholesterol levels were still significantly and inversely associated with the incidence of all-cause death (hazard ratio, 0.94; 95% confidence interval, 0.92–0.96 for 10 mg/dl increase) and stroke/SE (hazard ratio, 0.96; 95% confidence interval, 0.92–0.999 for 10 mg/dl increase), when analyzed as continuous variables. Subgroup analysis revealed that the risk of low cholesterol for all-cause death was more pronounced in female (interaction P, 0.049), patient without prior stroke/SE (interaction P, 0.01), those without HF (interaction P, 0.01), and those without vascular disease (interaction P, 0.001). The risk for stroke/SE was more pronounced in patients without vascular disease (interaction P, 0.01). Conclusion Low total cholesterol level was significantly associated with the incidence of all-cause and stroke/SE in AF patients not taking statins, suggesting the existence of cholesterol paradox in AF. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi-Sankyo, Novartis Pharma, MSD, Sanofi-Avent

Left ventricular noncompaction: the importance of identifying high-risk patients within the scope of left ventricular hypertrabeculation

Abstract Introduction Prominent left ventricular (LV) trabeculation is frequently encountered, however LV noncompaction (LVNC) criteria are not always fulfilled. The clinical and prognostic significance of these findings remains unclear. Objectives To characterize the patients (P) with echocardiographic suspicion of LVNC and to assess clinical outcomes. Methods Retrospective single-centre study that included all echocardiograms between January 2018 and June 2020 perceiving LV hypertrabeculation. The cohort underwent diagnostic assessment for LVNC by Chin and Jenni criteria. Baseline characteristics were evaluated. Composite endpoint of cardiovascular death, heart failure (HF) hospitalization, ventricular arrythmias (VA) and nonfatal stroke was considered. Results 51P, 75% male, mean age 50±18 years. 35P (69%) had associated heart conditions, of which 57% had other known cardiomyopathy (mainly dilated cardiomyopathy), 14% congenital, 26% ischemic and 3% valvular heart disease. 2P were in postpartum period and 1P was an athlete. Family history of cardiomyopathy was present in 8P (16%). 12P underwent genetic testing, with TTN and MYH7 mutations being the most frequently detected. Prior clinical HF was reported in 53%, previous stroke in 14%, and non-sustained and sustained VA in 24% and 4%, respectively. Mean NYHA classification was 1.8±0.7, with 31% being asymptomatic. The prevalence of LVNC by Chin criteria was 31% and by Jenni criteria was 55%. 32P (63%) met at least one LVNC criteria. This group was younger (45±18 vs 59±15, p=0.004), had higher NT-proBNP levels (3644±2819 vs 389±640, p=0.048) and QRS fragmentation (59% vs 21%, p=0.027). Significantly higher LV end-diastolic volume (84 (41) vs 64 (28)ml/m2, p=0.008) and end-systolic volume (51 (37) vs 35 (20)ml/m2, p=0.004), along with lower LV ejection fraction (39±12 vs 49±13%, p=0.009) and global longitudinal strain (−11±5 vs −17±4%, p=0.003) were noticed. P who met LVNC criteria also had higher number of affected LV segments (6.4±1.8 vs 4.2±1.6, p<0.001). Over a mean follow-up of 18±9 months, the incidence of composite endpoint was 35%. Univariate Cox analysis showed a significant association between the presence of LVNC criteria and adverse outcomes (HR: 5.108, 95% CI: 1.682–11.236, p=0.030) (Fig. 1). Conclusion LV hypertrabeculation can be encountered in a variety of clinical scenarios and often overlaps with other heart diseases. P satisfying criteria for LVNC had more impairment in LV performance and worse clinical outcomes. Funding Acknowledgement Type of funding sources: None. Figure 1

Use of Echocardiography and Heart Failure In-Hospital Mortality from Registry Data in Japan.

Background: Echocardiography requires a high degree of skill on the part of the examiner, and the skill may be more improved in larger volume centers. This study investigated trends and outcomes associated with the use and volume of echocardiographic exams from a real-world registry database of heart failure (HF) hospitalizations. Methods: This study was based on the Diagnosis Procedure Combination database in the Japanese Registry of All Cardiac and Vascular Datasets (JROAD-DPC). A first analysis was performed to assess the trend of echocardiographic examinations between 2012 and 2016. A secondary analysis was performed to assess whether echocardiographic use was associated with in-hospital mortality in 2015. Results: During this period, the use of echocardiography grew at an average annual rate of 6%. Patients with echocardiography had declining rates of hospital mortality, and these trends were associated with high hospitalization costs. In the 2015 sample, a total of 52,832 echocardiograms were examined, corresponding to 65.6% of all HF hospital admissions for that year. We found that the use and volume of echocardiography exams were associated with significantly lower odds of all-cause hospital mortality in heart failure (adjusted odds ratio (OR): 0.48 for use of echocardiography and 0.78 for the third tertile; both p < 0.001). Conclusions: The use of echocardiography was associated with decreased odds of hospital mortality in HF. The volumes of echocardiographic examinations were also associated with hospital mortality.

Examining the association of social risk with heart failure readmission in the Veterans Health Administration

BackgroundPrevious research has found that social risk factors are associated with an increased risk of 30-day readmission. We aimed to assess the association of 5 social risk factors (living alone, lack of social support, marginal housing, substance abuse, and low income) with 30-day Heart Failure (HF) hospital readmissions within the Veterans Health Affairs (VA) and the impact of their inclusion on hospital readmission model performance.MethodsWe performed a retrospective cohort study using chart review and VA and Centers for Medicare and Medicaid Services (CMS) administrative data from a random sample of 1,500 elderly (≥ 65 years) Veterans hospitalized for HF in 2012. Using logistic regression, we examined whether any of the social risk factors were associated with 30-day readmission after adjusting for age alone and clinical variables used by CMS in its 30-day risk stratified readmission model. The impact of these five social risk factors on readmission model performance was assessed by comparing c-statistics, likelihood ratio tests, and the Hosmer-Lemeshow goodness-of-fit statistic.ResultsThe prevalence varied among the 5 risk factors; low income (47 % vs. 47 %), lives alone (18 % vs. 19 %), substance abuse (14 % vs. 16 %), lacks social support (2 % vs. <1 %), and marginal housing (< 1 % vs. 3 %) among readmitted and non-readmitted patients, respectively. Controlling for clinical factors contained in CMS readmission models, a lack of social support was found to be associated with an increased risk of 30-day readmission (OR 4.8, 95 %CI 1.35–17.88), while marginal housing was noted to decrease readmission risk (OR 0.21, 95 %CI 0.03–0.87). Living alone (OR: 0.9, 95 %CI 0.64–1.26), substance abuse (OR 0.91, 95 %CI 0.67–1.22), and having low income (OR 1.01, 95 %CI 0.77–1.31) had no association with HF readmissions. Adding the five social risk factors to a CMS-based model (age and comorbid conditions; c-statistic 0.62) did not improve model performance (c-statistic: 0.62).ConclusionsWhile a lack of social support was associated with 30-day readmission in the VA, its prevalence was low. Moreover, the inclusion of some social risk factors did not improve readmission model performance. In an integrated healthcare system like the VA, social risk factors may have a limited effect on 30-day readmission outcomes.

Initiation and long-term use of tolvaptan for patients with worsening heart failure through hospital and clinic cooperation.

ABSTRACTWorsening heart failure (WHF) has a negative impact on the prognosis of patients with heart failure. Adequate management of non-hospitalized episodes of WHF, regarded as “outpatient WHF”, may reduce the frequency of emergent/urgent hospitalization for acute heart failure; thus, the patients’ cardiac parameters return to their clinical baseline. This study aimed to investigate the efficacy of tolvaptan initiation during planned hospitalization of patients with “outpatient WHF” through hospital and clinic cooperation. The data from 28 patients with outpatient WHF referred by general practitioners to hospital were assessed. Tolvaptan administration was initiated during planned hospitalization and continued in the clinics. Patients were followed-up for 12 months. None of the patients required withdrawal of tolvaptan due to adverse effects. During the follow-up period, the loop diuretic dosage significantly decreased. There were significant favorable changes in the levels of serum creatinine, estimated glomerular filtration rate, natriuretic peptide and body weight. Kaplan-Meier survival analysis revealed that the cardiac death- and HF-related hospitalization-free survival rates were significantly higher among the patients who were administered tolvaptan for the outpatient WHF than the propensity score-matched patients who were administered tolvaptan for acute heart failure requiring emergent/urgent hospitalization. In conclusion, tolvaptan may be safe and effective for the long-term management of outpatient WHF through hospital and clinic cooperation.

CLINICAL EVALUATION OF TENCKHOFF CATHETER INSERTION IN PAEDIATRIC PERITONEAL DIALYSIS : A SINGLE CENTER STUDY

Objective: This study aimed to evaluate the clinical outcome of Tenckhoff catheter insertion at Sardjito General Hospital for pediatric renal failure. Material &amp; Methods: Data were collected from January 2014 to December 2018 at Sardjito General Hospital. All patient records were collected retrospectively such as patient characteristics, underlying diseases of kidney failure, congenital abnormalities, surgical technique, complications that occur after Tenckhoff catheter insertion. Results: 45 patients meet the inclusion criteria. A total of 7 patients with acute kidney failure (15.5%) and 38 patients with chronic kidney failure (84.5%). Glomerulonephritis is the most common cause of kidney failure (21 patients, 46.7%). The insertion technique used was open surgery in 34 patients (76%) and laparoscopic insertion in 11 patients (24%). Complications reported were catheter dysfunction, leakage of dialysate, surgical site infection, and peritonitis. Conclusion: Tenckhoff catheter insertion for peritoneal dialysis (PD) in pediatric patients with acute and chronic renal failure performed in our center is effective and safe. The most common cause of renal failure in pediatric is glomerulonephritis. Open surgery and laparoscopic insertion of Tenckhoff catheter both have a low complication rate. Catheter dysfunction due to mechanical catheter obstruction is one of the main problems in the placement of Tenckhoff catheter.

Cardiac Magnetic Resonance Predicting Outcomes Among Patients at Risk for Cardiac AL Amyloidosis.

Introduction: Patients with systemic AL amyloidosis (AL) should be evaluated for cardiac amyloidosis (CA), as prognosis is strongly related to cardiac involvement. We assessed the characteristics of patients referred to cardiac magnetic resonance (CMR) with suspected CA from a cancer center and determine predictors of mortality/heart failure hospitalizations (HFH).Methods: Forty-four consecutive patients referred for CMR with suspected CA were retrospectively included. Variables collected included cardiac biomarkers, in addition to echocardiographic and CMR variables. Survival analyses were performed to determine which variables were more predictive of mortality and HFH.Results: Of the 44 patients included, 55% were females. 73% of patients were diagnosed with CA by CMR; 56% of them had an established diagnosis of AL. Patients with CA by CMR had higher native T1, higher extracellular volume (ECV) fraction, higher T2, less negative GLS by Echo, and higher troponin I and B-type natriuretic peptide (BNP). Kaplan-Meier survival analysis revealed that the following were predictive of mortality: an ECV ≥ 0.50 (p = 0.0098), CMR LVEF < 50% (p = 0.0010), T2/ECV ≤ 100 (p = 0.0001), and troponin I > 0.03 (p = 0.0025). In a stepwise conditional Cox logistic regression model, the only variable predictive of a composite of mortality and HFH was ECV (HR: 1.17, 95% CI = 1.02–1.34 p = 0.030).Conclusion: ECV seems to be an important biomarker that could be a predictor of outcomes in cardiac AL amyloidosis. In combination, CMR and serum cardiac biomarkers might help to establish prognosis in patients with CA.

1000-P: Plasma Water T2 Monitors Cardiometabolic Health and Improves with Lifestyle Modification

Plasma water T2 is a screening tool for cardiometabolic health. It detects hidden insulin resistance, dyslipidemia and inflammation. To assess the response of T2 to lifestyle changes, we are conducting an ancillary study of PREMIER. The parent PREMIER trial evaluated the effect of lifestyle interventions on blood pressure. Many subjects had insulin resistance, prediabetes and/or metabolic syndrome. The interventions included physical activity, weight loss, ↓sodium and alcohol, and the DASH diet. Hypothesis: Plasma water T2 increases (improves) with PREMIER interventions. Methods: Subjects (n=810) were randomized into 3 arms: established, established+DASH and advice only. The subjects were 62% female, 34% black, age 50.0±8.9 years. Inclusion criteria were age ≥25, ↑BP and BMI 18.5-45.0 kg/m2. Exclusion criteria were diabetes, prior CV event, heart failure, cancer or psychiatric hospitalization within 2 yrs. In the ancillary study, mixed effects models were used to assess T2 values at 6- and 18-months post-intervention, after adjusting for baseline T2 and other co-variates. Multiple means comparisons used Dunnett’s test. Results: Model 1 adjusted for baseline T2, BMI, visit and treatment group as fixed effects, with nested subject ID-recruitment site as random effects. All three arms showed progressive increases in T2 at 6 and 18 mo, but were significant at 18 mo. Mean T2 at 18 mo for the established+DASH and advice-only arms were 792.8 ms (95% CI: 782.7, 802.8; p=0.0027) and 794.4 ms (95% CI: 784.5, 804.3; p=0.0006), respectively, compared with 767.5 ms (95% CI: 757.9, 777.0) for baseline controls. Similar results were seen in Model 2, which adjusted for fitness level measured by treadmill. Conclusion: Plasma water T2 values detected global improvement in cardiometabolic health after 18 months of PREMIER interventions, even after adjusting for BMI and fitness. Early T2 screening and monitoring, paired with a simple lifestyle change, is effective for improving cardiometabolic health. Disclosure D. P. Cistola: None. R. Patel: None. E. Campbell: None. V. Patel: None. A. K. Dwivedi: None. Funding National Heart, Lung, and Blood Institute (R21HL143030)

FC 021EFFICACY OF INTRAVENOUS FERRIC CARBOXYMALTOSE IN PATIENTS WITH IRON DEFICIENCY FOLLOWING ACUTE HEART FAILURE, ACCORDING TO BASELINE EGFR: A SUBGROUP ANALYSIS OF THE AFFIRM-AHF TRIAL

Abstract Background and Aims In the AFFIRM-AHF trial, treatment with intravenous (IV) ferric carboxymaltose (FCM) reduced the risk of heart failure (HF) hospitalisations vs placebo in patients with iron deficiency after an episode of acute HF. Of these patients, 41% had a medical history of chronic kidney disease (CKD). This prespecified subanalysis of AFFIRM-AHF data was performed to investigate the effect of renal function on FCM efficacy. Methods In AFFIRM-AHF, patients stabilised following hospitalisation for acute HF with concomitant iron deficiency (defined as ferritin &amp;lt;100 μg/L, or 100–299 μg/L with transferrin saturation &amp;lt;20%) were randomised to receive either IV FCM or placebo before discharge for the index hospitalisation. In this analysis, patients who had received at least one dose of the study drug, and who had at least one post-randomisation data point and a baseline value for estimated glomerular filtration rate (eGFR; calculated using the CKD-EPI formula and baseline creatinine value), were stratified into tertiles according to baseline eGFR. The primary outcome was a composite of total HF hospitalisations and CV death. Secondary outcomes included total HF hospitalisations, CV death, time to first HF hospitalisation or CV death, composite of total CV hospitalisations and CV death, and days lost due to HF hospitalisations or CV death. All outcomes were evaluated up to 52 weeks post-randomisation. Results Of the 1,108 patients included in primary AFFIRM-AHF analyses, 967 (FCM: 487; placebo: 480) had a baseline eGFR value and were included in this analysis. In both groups, 60% of patients had an eGFR &amp;lt;60 mL/min/1.73 m2 following the index acute HF episode. Patients were divided into eGFR tertiles 1, 2 and 3, with corresponding respective baseline eGFR values of &amp;lt;42.96, 42.96 to &amp;lt;64.32, and ≥64.32 mL/min/1.73 m2. At baseline, the mean age, proportion of females, and proportions of patients with ischaemic HF aetiology, a documented history of HF, and a medical history of percutaneous coronary intervention, coronary artery bypass graft and/or cardiac resynchronisation therapy, were highest in eGFR tertile 1 and lowest in eGFR tertile 3. In eGFR tertiles 1, 2 and 3, the number of total HF hospitalisations and CV deaths in the FCM group vs placebo group were, respectively, 115 vs 152, 76 vs 83, and 56 vs 79, with respective annualised rate ratios (95% confidence interval [CI]) of 0.76 (0.50, 1.16), 0.76 (0.48, 1.22) and 0.69 (0.42, 1.12) (Figure). In eGFR tertile 3, the total number of CV hospitalisations and CV deaths was significantly lower in the FCM group vs the placebo group (69 vs 107; rate ratio [95% CI] 0.60 [0.39, 0.93]), with a nominally lower number of total HF hospitalisations with FCM vs placebo (44 vs 66; rate ratio [95% CI] 0.62 [0.38, 1.01]). In the time to first event analysis, FCM significantly reduced HF hospitalisation or CV death vs placebo in eGFR tertile 3 (hazard ratio [95% CI] 0.64 [0.42, 0.98]). In eGFR tertiles 1 and 2, differences between FCM and placebo arms for secondary endpoints did not reach statistical significance. The p-trend for treatment by baseline eGFR subgroup was non-significant for the primary outcome (0.941) and also for the secondary outcomes specified here. Conclusion In patients with iron deficiency who were stabilised after an episode of acute HF, numerically fewer primary and secondary events, endpoints or outcomes were consistently observed with FCM vs placebo across the eGFR tertiles. In addition, no significant interaction between kidney function and FCM efficacy was noted. Given that this analysis was limited by small patient numbers following subgroup stratification, further studies in larger cohorts with CKD may help to clarify the effect of IV FCM in this patient population.