Impaired LVEF Research Articles

Mechanical and electrical dysfunction of Riata implantable cardioverter-defibrillator leads.

Riata implantable cardioverter-defibrillator leads are prone to failure by conductor externalization and/or electrical dysfunction. The objectives of this study were to determine the predictors of the Riata lead failure, to assess the association of conductor externalization and electrical lead failure, and to analyse the rates of lead failure over time. Of 273 implanted Riata leads in our centre, 197 were investigated according to the Riata recall protocol, including electrical measurements by device interrogation and annually fluoroscopy. During a mean follow-up period of 5.6 ± 1.4 years, Riata lead failure was 18.8% (37 of 197) for externalization and 17.3% (34 of 197) for electrical lead failure. Electrical lead failure was correlated with time after implant. Externalization and electrical dysfunction co-existed in only 6 of 197 (3%) patients and were not related (Phi's coefficient -0.013, P = 0.85). During the second annual screening, 145 (73.6%) patients underwent fluoroscopy and 9 patients had novel externalizations resulting in an incidence of 6.72%/patient/year which was higher than expected based on cross-sectional analysis. Besides, there was a significant increase in the extent of externalization (17.65 ± 11.14 mm vs. 21.77 ± 11.95 mm, P = 0.001). In multivariate Cox regression analysis, non-ischaemic cardiomyopathy and impaired LVEF were independent predictors of externalization, and 7 Fr lead was a predictor of electrical lead failure. Riata leads show progressive and high externalization rates without correlation between externalization and electrical lead failure. Non-ischaemic cardiomyopathy and impaired LVEF are independent predictors of structural lead failure in cross-sectional analysis, whereas 7 Fr lead is a predictor of electrical lead failure.

Detection of intracardiac masses in patients with coronary artery disease using cardiac magnetic resonance imaging: A comparison with transthoracic echocardiography

We sought to evaluate the diagnostic accuracy of contrast-enhanced cardiac magnetic resonance (CMR) imaging for the detection of intracardiac masses and thrombus formation in patients with history of coronary artery disease (CAD) in comparison to transthoracic echocardiography (TTE) under clinical routine conditions. 171 patients with history of CAD (89 male, aged 34-89 years, median 63 ± 11) underwent TTE and CMR during routine clinical examinations. TTE and CMR were independently analysed regarding the presence of intracardiac thrombus formation, masses and related size, dimensions, shape and signal characteristics. TTE depicted intracavitary thrombus formation in 40/171 patients (23.4 %) and intracardiac mass in 12/171 patients (7.0 %). All masses revealed in TTE were correctly detected on CMR and confirmed by histology. However, CMR showed 15 additional thrombi and 3 additional intracardiac masses (p = 0.001) that were not seen in TTE. Patients with poor systolic function (LVEF 30 %, whereas CMR was superior when the LVEF was <30 %. Routine TTE in patients with CAD leads to lower detection rates of intracardiac masses and thrombus formation in patients with severely impaired EF. Consequently we are missing a significant amount of clinically relevant diagnosis when only assessing patients with TTE. In patients with CAD and severely impaired LVEF, CMR should be considered as first line imaging tool to detect or rule out intracardiac masses and thrombi.

Effect of renal denervation on left ventricular mass and function in patients with resistant hypertension: data from a multi-centre cardiovascular magnetic resonance imaging trial

Sympathetic stimulation induces left ventricular hypertrophy and is associated with increased cardiovascular risk. Catheter-based renal denervation (RDN) has been shown to reduce sympathetic outflow and blood pressure (BP). The present multi-centre study aimed to investigate the effect of RDN on anatomic and functional myocardial parameters, assessed by cardiac magnetic resonance (CMR), in patients with resistant hypertension. Cardiac magnetic resonance was performed in 72 patients (mean age 66 ± 10 years) with resistant hypertension (55 patients underwent RDN, 17 served as controls) at baseline and after 6 months. Clinical data and CMR results were analysed blindly. Renal denervation significantly reduced systolic and diastolic BP by 22/8 mm Hg and left ventricular mass index (LVMI) by 7.1% (46.3 ± 13.6 g/m(1.7) vs. 43.0 ± 12.6 g/m(1.7), P < 0.001) without changes in the control group (41.9 ± 10.8 g/m(1.7) vs. 42.0 ± 9.7 g/m(1.7), P = 0.653). Ejection fraction (LVEF) in patients with impaired LVEF at baseline (<50%) significantly increased after RDN (43% vs. 50%, P < 0.001). Left ventricular circumferential strain as a surrogate of diastolic function in the subgroup of patients with reduced strain at baseline increased by 21% only in the RDN group (-14.8 vs. -17.9; P = 0.001) and not in control patients (-15.5 vs. -16.4, P = 0.508). Catheter-based RDN significantly reduced BP and LVMI and improved EF and circumferential strain in patients with resistant hypertension, occurring partly BP independently.

Factors associated with biventricular dysfunction in patients with repaired tetralogy of Fallot.

Impaired right ventricular (RV) mechanics is a common problem in patients after repair of tetralogy of Fallot (TOF). Moreover, also impaired left ventricular (LV) systolic function has been demonstrated in this population. There are no studies evaluating patients after TOF repair with impaired both RV and LV ejection fractions (RVEF, LVEF). We hypothesized that a considerable group of patients with repaired TOF would demonstrate both RV and LV systolic function impairment. Accordingly, the purpose of our study was to characterize patients with biventricular dysfunction after TOF repair. Consecutive patients with repaired TOF undergoing cardiac magnetic resonance (n=146, mean age 26.4±8.2 years, age range: 13.6-51.3 years, 60.3% males, 54 patients [37.0%] with early correction and 92 [63.0%] with late correction). There were 31 patients (21.2% of the study population; 90.3% males) with biventricular dysfunction. Normal both RVEF and LVEF were observed in 65 individuals (44.5%). Neither the presence nor the extent of late gadolinium enhancement differed between patients with normal both RVEF and LVEF vs low both RVEF and LVEF. There were no differences in pulmonary regurgitation (PR) fraction, peak right ventricular outflow tract (RVOT) gradient, and the incidences of significant PR and RVOT obstruction between these groups (P=NS for all comparisons). Multivariate logistic regression revealed that the male sex and RVOT aneurysm/akinesia (only in patients repaired early) were associated with the presence of biventricular dysfunction. In patients with repaired TOF, : Male sex and RVOT aneurysm/akinesia were independently associated with biventricular dysfunction. Impaired both RVEF and LVEF were common in patients with repaired TOF, with the vast majority of males.

Detection of intracardiac masses in patients with coronary artery disease using cardiac magnetic resonance imaging: a comparison with transthoracic echocardiography

We sought to evaluate the diagnostic accuracy of contrast-enhanced cardiac magnetic resonance (CMR) imaging for the detection of intracardiac masses and thrombus formation in patients with history of coronary artery disease (CAD) in comparison to transthoracic echocardiography (TTE) under clinical routine conditions. 171 patients with history of CAD (89 male, aged 34-89 years, median 63 ± 11) underwent TTE and CMR during routine clinical examinations. TTE and CMR were independently analysed regarding the presence of intracardiac thrombus formation, masses and related size, dimensions, shape and signal characteristics. TTE depicted intracavitary thrombus formation in 40/171 patients (23.4 %) and intracardiac mass in 12/171 patients (7.0 %). All masses revealed in TTE were correctly detected on CMR and confirmed by histology. However, CMR showed 15 additional thrombi and 3 additional intracardiac masses (p = 0.001) that were not seen in TTE. Patients with poor systolic function (LVEF <30 %) had misleading results when referred to TTE (19 vs. 27 thrombi detected, p < 0.01). The detection of intracardiac masses or thrombi was not significantly different in patient with LVEF >30 %, whereas CMR was superior when the LVEF was <30 %. Routine TTE in patients with CAD leads to lower detection rates of intracardiac masses and thrombus formation in patients with severely impaired EF. Consequently we are missing a significant amount of clinically relevant diagnosis when only assessing patients with TTE. In patients with CAD and severely impaired LVEF, CMR should be considered as first line imaging tool to detect or rule out intracardiac masses and thrombi.

TCT-445 Patients with 3-vessel Coronary Artery Disease and Impaired LVEF undergoing PCI with Impella 2.5 Hemodynamic Support Have Improved 90-Day Outcomes Compared to Intra-Aortic Balloon Pump: A Substudy of The PROTECT II Trial

PROTECT II demonstrated a trend of improved outcomes in patients with impaired LVEF and left main or 3-vessel disease (3VD) undergoing PCI with hemodynamic support using Impella 2.5 (IR2.5) or intra-aortic balloon pump (IABP). However, it is unclear if this trend was due to a specific benefit in a

TCT-216 Predictors Of Patient-Oriented And Device-Oriented Outcomes Among Patients Undergoing Primary Percutaneous Coronary Intervention

Background: Treatment of STEMI has considerably evolved over the past 2 decades. However, predictors of adverse events after STEMI are mostly based on early studies without consistent use of reperfusion therapy, P2Y12 inhibitors, and drug-eluting stent implantation. We aimed to identify predictors of adverse events among patients with ST-elevation myocardial infarction (STEMI) undergoing contemporary primary percutaneous coronary intervention (PCI). Methods: Individual data of 2655 patients from 2 primary PCI trials (EXAMINATION, N=1504; COMFORTABLE-AMI, N=1161) with identical endpoint definition and event adjudication were pooled. Predictors of patient-oriented (death or reinfarction) and device-oriented (definite stent thrombosis [ST] and target-lesion revascularization [TLR]) outcomes at 1 year were identified by multivariable Cox regressions analysis. Results: Killip class III/IV was the strongest predictor of death or reinfarction (OR5.11, 95%CI2.48-10.52), ST (OR7.74, 95%CI2.87-20.93), and any TLR (OR2.88, 95%CI1.17-7.06). Impaired LVEF (OR4.77, 95%CI2.10-10.82), final TIMI flow 0-2 (OR1.93, 95%CI1.05-3.54), hypertension (OR1.69, 95%CI1.11-2.59), age (OR1.68, 95%CI1.41-2.01), and peak CK (OR1.25, 95%CI1.02-1.54) were independent predictors of death or reinfarction. Allocation to treatment with DES was an independent predictor of a lower risk of ST (OR0.35, 95%CI0.16-0.74) and any TLR (OR0.34, 95%CI0.21-0.54). Conclusions: Killip class remains the strongest predictor of death or reinfarction among STEMI patients undergoing primary PCI. Noteworthy, DES use independently predicts a lower risk of TLR and definite ST.

Abstract 486: Increased Afterload In Sub-acute Phase Of Myocardial Infarction Exacerbates Heart Failure

Background: Hypertension (HT) increases cardiac afterload and is one of the risk factors of poor prognosis after myocardial infarction (MI). However, there is little information on how HT impacts the healing processes during sub-acute phase MI. We investigated the role of an increased afterload on left ventricular (LV) performance and remodeling shortly after MI. Methods: Anterior MIs were created in 15 Yorkshire pigs via percutaneous access. To mimic HT condition, 7 pigs (Banding, n=7) underwent surgical banding of the ascending aorta 10 days after the MI, and were compared to the remaining pigs (Control, n=8). LV remodeling and function were assessed one month after MI using 3-D echocardiography and invasive hemodynamic measurements. Results: Echocardiographic assessment at day 10 revealed no significant differences in LV ejection fraction (EF) or LV volumes. One month after MI, aortic banding increased the systemic vascular resistance index, but was not statistically significant (1658±282 dyn/s/cm5/m 2 vs 1153±658 dyn/s/cm5/m 2 , P=0.08). Banding group presented with significantly impaired LVEF (Figure, P=0.002), larger end systolic volume (Figure, P=0.045), lower cardiac index (3.1±0.9 L/min/m 2 vs 4.4±0.6 L/min/m 2 , P=0.01), and elevated LV end diastolic pressure (22.4±5.0 mmHg vs 14.4±7.5 mmHg: P=0.04, Banding vs Control, respectively). Reduced EF was associated with remote myocardial dysfunction and histological analysis revealed increased interstitial fibrosis in this area. Conclusion: Increased afterload in sub-acute phase of MI induces more severely impaired cardiac function and LV remodeling, and was associated with worse heart failure status.

LRP5 modulates the Wnt signalling pathway to protect cardiac cells

Background and Purpose: LDL receptor-related protein 5 (LRP5) triggers the canonical Wnt pathway which participates in cell function regulation, spanning from tissue regeneration to lipid metabolism. However there is little understanding on the role of LRP5 in the heart. The aim of this study was to investigate the expression and function of LRP5 and the canonical Wnt signalling pathway in cardiac pathology. Methods: LRP5 and Wnt signalling proteins expression levels were measured in in vivo myocardial infarction (MI) models in LRP5 KO mice and hypercholesterolemic (HC) pigs, in cultured cardiomyocytes and in human dyslipidemic hearts from heart transplants. Results: We show that LRP5 KO mice have an increased infarct size after MI with respect to WT mice, indicating a protective role of LRP5 in injured myocardium. An in vivo HC porcine model of MI showed upregulation of LRP5 in the ischemic reperfused myocardium of HC-animals that directly correlated with an impaired LVEF. Proteins members and targets of the canonical Wnt signalling pathway were correspondingly upregulated in the ischemic reperfused HC-porcine myocardium. LRP5 overexpression/silencing experiments in isolated cardiomyocytes induced Wnt pathway activation in lipid-loaded hypoxic cardiomyocytes whereas LRP5-silencing blocked the pathway. Finally, an increased LRP5 and Wnt regulated gene expression in human ischemic failing hearts of dyslipidemic patients, was observed. Conclusions: Our results demonstrate that the modulation of LRP5 and the canonical Wnt pathway in hypoxic cardiomyocytes and in porcine and human ischemic myocardium is a defensive pro-survival process of the damaged myocardium triggered to restore cell viability. Therapeutic interventions targeting LRP5 may favour cardiac healing post-MI.

Abstract 9207: Zofenopril and Ramipril Plus ASA in Post-myocardial Infarction Patients With Left Ventricular Systolic Dysfunction: A Post-hoc Analysis in Preserved or Impaired Left Ventricular Fraction at Entry

Introduction: in the randomized, double-blind, parallel-group, multicenter, international SMILE-4 Study zofenopril 60 mg plus acetyl salicylic acid (ASA) was more effective than ramipril 10 mg plus ASA 100 mg in reducing 1-year occurrence of major cardiovascular (CV) events in patients with acute myocardial infarction (AMI) complicated by left ventricular dysfunction (LVD). Objective: to compare zofenopril and ramipril efficacy in combination with ASA in a subgroup of patients of the SMILE-4 with preserved (&gt;40%) or impaired (≤40%) left ventricular ejection fraction at the time of enrolment in the study. Methods: the SMILE-4 was a phase IIIb, randomized, double-blind, parallel-group, multicenter, European study comparing the safety and efficacy of zofenopril 60 mg/day and ramipril 10 mg/day plus ASA 100 mg/day, in patients with LVD (clinical signs of heart failure or a left ventricular ejection fraction or LVEF &lt;45%) following AMI. We analyzed the 1-year combined occurrence of death or hospitalization for CV causes. Information on LVEF at baseline was available in 710 out of the 716 patients of the intention-to-treat population. Results: in the main study population the primary outcome was significantly reduced by zofenopril vs. ramipril (odds ratio, OR and 95% confidence interval, CI: 0.70, 0.51-0.96; p=0.028). Overall, 448 (63.1%) patients had preserved and 262 (36.9%) impaired LVEF at baseline. In the first group, the rate of major CV events was significantly lower under zofenopril than under ramipril (22.5% vs. 32.8%; OR: 0.60, 0.39-0.91; p=0.016). This was the case also for the group of patients with impaired LVEF, though between-group difference was not statistically significant (37.7% zofenopril vs. 44.4% ramipril; OR: 0.77, 0.47-1.26; p=0.297). The reduction in the risk of major CV events was significantly larger (p=0.019) in patients with preserved LVEF at baseline. Conclusions: this retrospective analysis of the SMILE-4 Study confirmed the superiority of zofenopril plus ASA as compared to ramipril plus ASA in the prevention of long-term CV outcomes. The benefit was particularly evident in subjects with preserved left ventricular function at study entry.

Abstract 18476: Are Cardiac Magnetic Resonance Patterns Associated with Adverse 18-Month Outcome in Patients with Acute Myocarditis?

Introduction: Cardiac Magnetic Resonance (CMR) is a fundamental tool in the diagnosis of Acute Myocarditis (AM). However, its prognostic value is not well established. Hypothesis: CMR findings in patients with AM may predict functional/clinical outcome. Methods: We studied consecutive pts diagnosed with AM by CMR between 2008 and 2011. All pts underwent initial clinical assessment and CMR was performed at a mean of 11±12 days after acute clinical presentation. Black-blood T2-CMR was used for myocardial edema assessment and contrast-enhanced CMR was performed 3 (early gadolinium enhancement, EGE) and 10 (late gadolinium enhancement, LGE) min after gadolinium chelates. Images were analysed dividing the myocardium into 17 segments and 3 myocardial sectors (subepicardium, midwall, and subendocardium), allowing quantification of lesions extent as percent of LV myocardium. Presence of pericardial effusion and LV segmental wall motion was assessed. Adverse cardiac events including recurrence of symptoms, congestive heart failure, ventricular arrhythmias, heart transplantation, or death, were carefully recorded at clinical follow-up (FU) performed 19±8 months after indexed CMR. Results: The patient population comprised 203 pts (43±17 year-old, 76% males) with AM. A total of 22/203 patients (10.8% of the whole population) experienced adverse cardiac events. By univariate analysis, the extent of EGE was inversely correlated with the presence of clinical events at FU (2.2±4.1 vs. 5.1±6.0% of LV myocardial mass, for pts with and without adverse cardiac events, respectively, p=0.005). Additionally, pts with altered EF on initial CMR examination had worse myocardial function at FU. In contrast, presence of hyper-T2 signal (p=0.68), extent (p=0.72) and distribution (p=0.09) of LGE, presence of pericardial effusion p=0.18), were not associated with adverse clinical outcome. Multivariate analysis showed no CMR predictors of adverse clinical outcome. Conclusions: In this large cohort of patients with AM, there were no CMR predictors of adverse clinical outcome. A significant association was found between initial LV function and impaired LVEF at FU, as well as between EGE and adverse clinical events.

ANALYSIS OF PREDICTORS OF ATRIAL FIBRILLATION AFTER PACEMAKER IMPLANTATION

ObjectivesMany patients post pacemaker implantation developed into atrial fibrillation (AF). The factors that can lead a greater risk of AF post implantation from different researches are controversial. As the first...

Severe autonomic failure in moderate to severe aortic stenosis: prevalence and association with hemodynamics and biomarkers

Severe autonomic failure (SAF) refers to combined abnormalities in reflex and tonic autonomic function. SAF indicates increased risk of death in post-infarction and heart failure patients, but has not been studied in aortic stenosis (AS). Here, we investigated SAF in patients with AS and tested its correlation with hemodynamic and biochemical markers. We prospectively enrolled 174 patients with moderate to severe AS in sinus rhythm (age 76 ± 9 years; mean aortic valve area 0.9 ± 0.3 cm(2)). Heart rate turbulence (as marker of autonomic reflex activity) and deceleration capacity (as marker of autonomic tonic activity) were calculated from 24-h Holter recordings. According to the previously published technology, SAF was considered present if both factors were abnormal. 44 (25.3%) of the 174 patients had signs of SAF. Patients with SAF had lower left ventricular ejection fraction (LVEF: 48.1 vs. 54.8%; p = 0.002), lower mean aortic gradients (28 vs. 34 mmHg, p = 0.019), higher systolic pulmonary artery pressures (46.8 vs. 40.9 mmHg, p = 0.028), higher levels of brain natriuretic peptide (905 vs. 407 ng/l; p = 0.003) and higher levels of high sensitive troponin I (0.65 vs. 0.24 μg/l; p = 0.013). Impaired LVEF (≤50%) was the only independent factor associated with SAF, but only explained autonomic abnormalities in less than half of the patients. In patients with moderate to severe AS prevalence of SAF is high. SAF correlates with hemodynamic and biochemical markers indicating increased risk. Future studies should evaluate the prognostic value of SAF in patients with AS.

The left heart after pulmonary valve replacement in adults late after tetralogy of Fallot repair

BackgroundAdverse ventricular-ventricular interactions have been recognized in those with repaired tetralogy of Fallot (TOF) and severe pulmonary regurgitation. ObjectiveWe aimed to examine the impact of pulmonary valve replacement (PVR) on the left heart late after TOF repair. Methods and resultsLeft ventricular (LV) volumes and ejection fractions (EF) were analyzed in adults with severe pulmonary regurgitation after TOF repair with cardiac magnetic resonance imaging (CMR) before and after PVR. Thirty-nine patients (median age 33[20–65] years) were reviewed. Post-PVR, LVEF improved significantly in the entire cohort (50±9%→54±7%, p<0.001) and in those with moderately impaired (defined as LVEF ≤45%) preoperative LVEF (38±5%→47±6%, p<0.0001), but was not statistically different in those with relatively preserved (defined as LVEF >45%) preoperative LVEF. By multivariate linear regression analysis to evaluate independent CMR predictors of improved LVEF post-PVR for the entire cohort, the only CMR variable to emerge was preoperative LVEF (p=0.012, regression coefficient −0.54, SE 0.13). Whereas PVR resulted in increased LV filling in patients with relatively preserved preoperative LVEF reflected by an increase in LV end-diastolic volumes (77±10→82±16mL/m2, p=0.05), LV end-systolic volumes decreased after PVR in patients with impaired preoperative LVEF (65±12→54±10mL/m2, p=0.001) but LV end-diastolic volumes were not significantly changed. ConclusionWhen LVEF is decreased after TOF repair, PVR appears to have a salutary effect on postoperative LVEF, thereby supporting the concept of recovery of adverse right–left heart interactions. Mechanisms of left heart improvement post-PVR differ depending on degree of preoperative LV systolic dysfunction.

Sudden death risk in type 2 diabetic patients post-myocardial infarction: A “sweet” opportunity?

Sudden death risk in type 2 diabetic patients post-myocardial infarction: A “sweet” opportunity?

Long-Term (4-Year) Outcomes and Predictors of Adverse Cardiac Events After Sirolimus-Eluting Stent Implantation in Unprotected Left Main Coronary Artery

The long-term safety and efficiency of sirolimus-eluting stent (SES) treatment in unprotected left main coronary artery (ULMCA) have not yet been ascertained.From 2003 to 2006, 126 consecutive patients with de novo lesions in ULMCA who underwent SES were retrospectively analyzed in a single center in China. During 4-year follow-up, major adverse cardiovascular event (MACE)-free survival was 74.6%. Cardiac death occurred in 5 (4.0%), and target lesion revascularization (TLR) and target vessel revascularization (TVR) occurred in 15 (11.9%) and 24 (19.0%) patients, respectively. One (0.8%) experienced probable stent thrombosis while 1 (0.8%) presented possible stent thrombosis. Impaired LVEF (< 40%) and high surgical risk (Euro score > 6) were the independent predictors of MACEs.PCI with SES for de novo lesions in ULMCA is feasible with a low procedural risk. However, SES was associated with a relatively higher rate of TLR and TVR. Impaired LVEF and high surgical risk were important predictors of MACEs.

121 Longitudinal Global Strain by Speckle Tracking is an Independent Predictor of Outcome in Heart Failure Patients with Impaired Left Ventricular Function

To assess the predictive value of peak global longitudinal strain (e) and e rate by speckle tracking to predict outcome in heart failure (HF) patients. The study included 112 consecutive patients admitted for HF (64±13 years, 81% male, 52% ischemia) with reduced left ventricular ejection fraction (LVEF<50%, mean =31±10%, range 10-49]. Longitudinal global-ɛ and ɛ rate by speckle tracking were curves computed from apical views and compared to the occurrence of major cardiac events (death, heart transplantation, and recurrent HF). On the whole, peak systolic longitudinal global-ɛ and ɛ rate averaged -8± 3% [range -3 to -18] and -0.34±0.20s-1 [range -1.6 to -0.1], respectively. During the follow up period (208±149 days), major cardiac adverse events occurred in 40 (36%) patients (11 death, 23 recurrent HF and 4 heart transplantation). Univariable analysis using Cox model shown that global-ɛ, ɛ rate, LVEF, tricuspid annular plane systolic excursion, NYHA class and BNP level were associated with cardiac adverse event. However, only global-ɛ (OR1.2, p=0.025) and BNP level (OR1.3, p=0.024) were predictive of outcome by multivariable analysis. In patients admitted for heart failure with impaired LVEF, peak global strain by speckle tracking appears to be the only echocardiography predictor of adverse outcome.

Risk prediction by heart rate turbulence and deceleration capacity in postinfarction patients with preserved left ventricular function retrospective analysis of 4 independent trials

Background and aim In the Improved Stratification of Autonomic Regulation–Risk trial, postinfarction patients with severe autonomic failure (SAF)—defined as abnormal heart rate turbulence in the presence of abnormal deceleration capacity (DC)—were at high risk of subsequent death, even if left ventricular function was not particularly compromised. The aim of this study was to investigate SAF as a risk predictor in independent postinfarction cohorts. Methods and results The data of 3 postinfarction trials (ie, St George's Hospital Medical School Postinfarction Survey, Holter substudy of the European Myocardial Infarction Amiodarone Trial with both the placebo and the amiodarone arms, and Multiple Risk Factor Analysis Trial) were reanalyzed in a blinded fashion. The populations included a total of 2534 postinfarction patients. Heart rate turbulence and DC were obtained from 24-hour Holter recordings. Patients with both abnormal heart rate turbulence (slope ≤2.5 ms/R-R and onset ≥0%) and abnormal DC (≤4.5 milliseconds) were considered suffering from SAF and prospectively classified as high risk. Primary end point was all-cause mortality. During follow-up, 291 of 2534 patients died. In all populations, SAF was a highly significant predictor of death in the subgroups of patients with preserved left ventricular ejection fraction (LVEF; >30%). The mortality risk of these patients was not statistically different from that of patients with impaired LVEF (≤30%). The combined use of the criteria, LVEF of 30% or less and LVEF of more than 30% as well as SAF lead to a significant increase of sensitivity in all populations, whereas the positive predictive accuracies were preserved. Conclusion In postinfarction patients with preserved left ventricular function, SAF identifies a subgroup with increased mortality risk equivalent to patients with LVEF of 30% or less.

Survival After Isolated Coronary Artery Bypass Grafting in Patients With Severe Left Ventricular Dysfunction

The number of patients with severe left ventricular dysfunction referred for coronary artery bypass graft surgery (CABG) continues to increase. The aim of this study was to document the long-term survival in this group. The 30-day mortality and long-term survival outcome of 162 patients with severely depressed left ventricular ejection fraction (LVEF [< or = 30%]) who had consecutive isolated CABG between 1996 and 2005 were compared with 661 patients who had impaired LVEF (31% to 59%) and 1,231 patients with normal LVEF (> or = 60%). The 30-day mortality for patients with severely depressed LVEF was 5.6%. The median survival for deceased patients was 3.4 years (interquartile range, 1.3 to 5.9). The risk of all-cause mortality attributable to severe left ventricular dysfunction was increased twofold compared with having normal LVEF (hazard ratio = 2.28; 95% confidence interval: 1.64 to 3.18; p < 0.001). Among the covariates, older age, emergency surgery, mitral incompetence, smoking history, respiratory disease, diabetes mellitus, cerebrovascular disease, intensive care unit intubation for 24 hours or more, postoperative renal failure, postoperative pleural effusion, and nonuse of left internal mammary artery were detected as significant predictors of increased mortality risk. The mortality rate among CABG patients with severely depressed LVEF was comparable to that reported in other series. Severe left ventricular dysfunction carried more than a twofold increased mortality risk compared with patients who had an impaired LVEF, adjusted for traditional risk factors. These data suggest that LVEF has an impact on long-term patient survival even after preoperative covariates and postoperative morbidity outcomes are considered.

Relationship between Plasma Norepinephrine at Peak Exercise and 123I-MIBG Imaging of the Heart and Lower Limbs in Heart Failure

Past studies suggested that plasma norepinephrine during exercise originates in sympathetic nerve endings and that the main origin differs among pathophysiological conditions. This study investigated the most important site of sympathetic terminals as an origin of plasma norepinephrine during exercise in patients with heart failure using (123)I- metaiodobenzylguanidine (MIBG) scintigraphy. Twenty patients with organic heart disease underwent exercise testing and (123)I-MIBG scintigraphy. Systemic (123)I-MIBG uptake was measured 4 hours after (123)I-MIBG injection, and the heart-to-brain (H/B) and lower limb-to-brain ratios (L/B) were calculated. Plasma norepinephrine concentration was measured at rest and at peak exercise. Subjects were divided into two groups: those with preserved left ventricular ejection fraction (LVEF> or =45%, n=8) and those with reduced LVEF (<45%, n=12). Plasma norepinephrine at rest did not correlate with H/B or L/B. In the preserved LVEF group, plasma norepinephrine at peak exercise was correlated with H/B (r=0.722), but not with L/B. In the reduced LVEF group, the norepinephrine response to peak exercise correlated with L/B (r=0.642), but not with H/B. The present findings suggest that norepinephrine concentration is regulated by sympathetic terminal function of working muscles in patients with impaired LVEF and by that of the heart in patients with preserved LVEF.