Improvement In EF Research Articles

Epidemiology, clinical characterization, and outcomes for heart failure with improved ejection fraction

Abstract Background Contemporary guidelines propose a new classification of heart failure with improved ejection fraction (HFimpEF). The prevalence of HFimpEF is expected to increase with the implementation of guideline-directed medical therapy (GDMT); however, there are limited data on the epidemiology of and outcomes for this novel clinical entity. Purpose We describe the prevalence, GDMT use and outcomes among patients with HFimpEF within a large, integrated healthcare delivery system. Methods We identified adults ≥18 years with incident HF with reduced EF (HFrEF ≤40%) between January 2013 and December 2018 from a large, integrated healthcare system serving >4.5 million members. HFimpEF was defined as known HFrEF with a follow-up EF measurement >40% within 12 months after incident HFrEF. Among HFimpEF patients, we examined GDMT use at discharge after incident HFrEF, incident HFimpEF, and at 6- and 12-months post-HFimpEF. From 12 months post initial HFrEF diagnosis, we calculated incidence rates of subsequent worsening HF (WHF) events (i.e., HF-related hospitalization, emergency department or urgent outpatient visits adjudicated using validated natural language processing-based algorithms) and all-cause death through December 31, 2019. We compared rates between patients with HFimpEF and those with persistent HFrEF (i.e., having all LVEF measurements within 12 months of incident HFrEF ≤40%) using Cox proportional hazards models adjusted for the EF value at incident HFrEF. Results Among 12,639 patients with incident HFrEF, 4,124 (33%) experienced HFimpEF within 12 months. Among patients with HFimpEF, use of β-blockers (82%) and angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers (86%) was high, while angiotensin receptor-neprilysin inhibitor (1.2%) or mineralocorticoid receptor antagonist (28.2%) use was low. β-blockers, ACEi/ARB, and MRA use declined after incident HFimpEF (Figure, Panel A). Rates of WHF were 19.7 (95% Confidence Interval [CI]: 18.7 to 20.6) per 100 person-years among patients with HFimpEF vs. 40.0 (95% CI: 38.5 to 41.5) among patients with persistent HFrEF (hazard ratio [HR]: 0.55, 95% CI: 0.49 to 0.62; Figure, Panel B). Rates of death were 5.2 (95% CI: 4.7 to 5.7) and 8.4 (95% CI: 7.8 to 9.1) per 100 person-years among HFimpEF and persistent HFrEF, respectively (HR: 0.59, 95% CI: 0.52 to 0.67). Among patients with HFimpEF, those with an absolute EF improvement of ≥20% were less likely to experience WHF (HR: 0.82, 95% CI: 0.67 to 0.99) and death (HR: 0.85, 95% CI: 0.69 to 1.04) compared with those with <20% improvement. Conclusions One in three patients experienced improvement in EF within 12 months of initial HFrEF diagnosis. HFimpEF is associated with a reduced risk of WHF events and death, although these patients remain at significant clinical risk. Further research is necessary to assess the potential impact of sustained adherence to GDMT and therapeutic optimization on HFimpEF patient outcomes.

Ablation of right ventricular endocavitary arrhythmias

Abstract Background The right ventricular moderator band-papillary muscle (RV MB-PM) complex has a rich subendocardial network of purkinje fibers which can lead to ventricular arrhythmias (VA)1. Catheter ablation of such arrhythmias is procedurally challenging and there remains limited studies on long-term procedural success. Purpose We aimed to systematically study RV MB-PM complex VA. Methods A single center retrospective study from January 2013 to December 2023 identified 3249 patients who underwent VA ablation. The RV MB-PM complex was targeted in 47 patients. Acute success was defined as suppression of the targeted VA >=30 minutes post ablation. Long-term success was defined as the absence of symptoms, total PVC burden <5% or improvement in EF in patients presenting with isolated PVCs and as freedom from appropriate ICD therapy in patients presenting with malignant PVCs inducing VF, sustained VT or VT storm. Results Mean age was 51.9 ± 16.7 years and 64% were male. 40 (85%) patients had VA targeted from the MB and 7 (15%) from the PM complex (2 anterior, 2 inferior and 3 septal PM). 34 (72%) had no underlying structural heart disease, 3 (6%) ischemic cardiomyopathy and 10 (21%) non-ischemic cardiomyopathy. No patient had delayed gadolinium enhancement in the RV MB-PM complex. VA were inducible in 42 (89%) of patients and activation mapping was used in 9 (19%), pace mapping in 5 (11%) and a combination of activation and pace mapping used in 33 (70%) patients. Intracardiac echocardiography was used in all cases. Pre-QRS duration was 34.0 ± 10.4 ms. Radiofrequency ablation was used in 37 (78.7%) cases, cryotherapy in 4 (8.51%) cases and a combination of the 2 energy sources in 6 (12.8%) cases. In all cases, acute peri-procedural success was achieved. 24 (51.1%) patients presented with isolated PVCs and were followed up for 4.72 ± 3.55 years after their index procedure. 3 patients underwent repeat catheter ablation targeting the same PVC focus but all patients had long term success with a PVC burden of 16.1 ± 12.5% prior to ablation and 2.40 ± 2.44% at last follow-up. 16 patients underwent ablation for recurrent ICD shocks after initially presenting with PVC induced VF. Patients were followed up for 3.22 ± 2.09 years and 14 (88%) patients remained free from ICD therapy. 7 patients had MB ablation for sustained VT and were followed up for 4.06 ± 3.77 years. 5 (71%) patients remained free from ICD therapy. A purkinje potential was seen in 8% (2/24) cases of isolated PVCs and in 39% (9/23) cases of PVC induced VF or VT (p=0.13). Conclusions RV MB-PM VA commonly present with malignant VF and a purkinje potential is more likely to be seen in these cases suggesting different VA mechanisms to isolated PVCs and catheter ablation is an effective long-term strategy.

Epicardial adipose tissue volume and density are associated with heart failure with improved ejection fraction

Abstract Background Heart failure (HF) with improved ejection fraction (EF, HFimpEF) gains increasing attention as a distinct HF subtype, characterized by left ventricular reverse remodeling and myocardial recovery. Multiple cardiometabolic factors are implicated in this process. Epicardial adipose tissue (EAT), emerging as an endocrine and paracrine organ, contributes to the onset and progression of HF. However, the relation between EAT and the incidence of HFimpEF is still unclear. Methods A total of 203 hospitalized HF patients with reduced EF (HFrEF, EF≤ 40%) who underwent coronary CT angiography (CCTA) during index hospitalization were consecutively enrolled between November 2011 and December 2022. Routine follow-up and repeat echocardiograms were performed. The incidence of HFimpEF was defined as (1) an absolute EF improvement ≥10% and (2) a second EF > 40% (at least 3 months apart). EAT volume and density were semiautomatically quantified on non-enhanced series of CCTA scans. Results During a median follow-up of 8.6 (4.9~13.3) months, 104 (51.2%) patients developed HFimpEF. Compared with HFrEF patients, HFimpEF patients had lower EAT volume (126.03 ± 57.71 cm3 vs 182.74 ± 82.99 cm3 , P< 0.001) and higher EAT density (-74.92 ± 6.84 HU vs -78.76 ± 6.28 HU, P< 0.001) both in ischemic and non-ischemic HF patients. EAT density was inversely correlated with EAT volume (r= -0.33, P< 0.001). Multivariate analysis showed lower EAT volume (OR: 0.881 [95% CI 0.821~0.939]) and higher density (OR: 2.354 [95% CI 1.314~4.415]) were both independently associated with the incidence of HFimpEF, after adjusting for conventional risk factors, pharmacological therapies and baseline anthropometric parameters including body mass index. Subgroup analysis revealed that the association between EAT properties and HFimpEF was not modified by HF etiology. Conclusions This study reveals that lower EAT volume and higher EAT density are associated with development of HFimpEF. Therapies targeted at reducing EAT quantity and improving its quality might provide favorable effects on myocardial recovery in HF patients.

Predictors of ejection fraction recovery and baseline differences in patients with peripartum cardiomyopathy and dilated cardiomyopathy

Aims: Dilated cardiomyopathy (DCM) and peripartum cardiomyopathy (PPCM) are heart failure conditions with similar clinical, morphological and pathophysiological features but different underlying pathways. In PPCM and DCM patients, improvement in left ventricular ejection fraction (LVEF) varies depending on a number of factors. In this study, we aimed to determine the main differences between DCM and PPCM patients and the predictors of LVEF recovery in these patients. Methods: This cross-sectional, observational study included 33 consecutive female patients, 10 with PPCM and 23 with DCM, attending a tertiary cardiac center between March 2020 and April 2023. We performed a retrospective analysis of some clinical data and LVEF measurements. The main outcome was accepted as EF improvement at a follow-up of at least 12 months. Binary logistic analysis was conducted to assess predictive factors linked to LVEF recovery. This involved using binary logistic regression analysis to figure out odds ratio (OR) and 95% confidence interval (CI). Results: The PPCM group had a higher mean follow-up LVEF and LVEF value increase (p

Heart failure with improved ejection fraction: patient characteristics, clinical outcomes and predictors for improvement.

Heart failure with improved ejection fraction (HFimpEF) is a recently recognized entity presenting a diagnostic and therapeutic challenge. Our aim was to characterize the profile of HFimpEF patients and evaluate predictors for EF lack of improvement among heart failure with reduced ejection fraction (HFrEF) patients. We included ambulatory HFrEF patients (EF≤40%) between January 1, 2015, and September 1, 2022, with two consecutive echocardiography exams at least 6 months apart. HFimpEF was defined as improved EF from ≤40%->40% and by ≥10%. A total of 567 HFrEF patients (72% male, 54.3 ± 14.4 years old) were analyzed. Patients without EF improvement were more likely to be male, had more comorbidities, ischemic cardiomyopathy (ICMP), markers of adverse cardiac remodeling (lower EF and higher left and right ventricular diameters) and presence of late gadolinium enhancement (LGE) in MRI (P < 0.05 for all). In a multivariate analysis, male sex, ICMP, lower EF, larger ventricular size and LGE remained independent predictors for lack of EF improvement. A prediction model for lack of EF improvement including LVEF, LV diameter, diastolic blood pressure and ischemic etiology exhibited an area under the ROC curve of 0.77 (95% CI 0.73-0.81; P < 0.001). HFimpEF patients had better prognosis with lower hospitalizations and mortality rates. Guideline directed medical therapy (GDMT) were associated with improved outcomes in both groups regardless of EF improvement. Lack of improvement in EF among HFrEF patients may be predicted by HF etiology and imaging parameters of adverse cardiac remodeling, and is associated with worse prognosis. GDMT were associated with improved outcomes in both HFimpEF and HFrEF patients.

Cardiac resynchronization therapy guided by interventricular delay: how to choose between biventricular pacing or conduction system pacing

Abstract Background Biventricular pacing (BIV) is gold standard for cardiac resynchronization therapy (CRT). Thirty % of patients result non responder to CRT. Conduction system pacing (CSP) represents a feasible alternative. Interventricular conduction delay (IVCD), as electrical desynchrony marker, is a CRT response predictor. The aim of the study was to assess CRT responder’s incidence when it has been achieved choosing best approach between BIV and CSP according to intraoperative IVCD measurement in patients with HFrEF and LBBB. Methods Ninety-eight patients have been 1:1 randomized in a standard BIV group (control group, CG) and a group in which CRT approach has been chosen based on IVCD evaluation (study group, SG), as reported in Figure 1. If the right ventricular sensed electrogram (RVs)-left ventricular sensed electrogram (LVs) interval was ≥100 ms, the left ventricular lead was left in its original position; otherwise, the lead was removed and CSP was performed instead, as reported in Figure 2. Clinical, EKG and echocardiographic features have been assessed pre- and 6 months post-implant. Echocardiographic and clinical response have been evaluated. Results Twenty-four % of patients in the SG underwent CSP, according to the operative algorithm adopted. CRT responders’ incidence was significantly higher in the SG (echocardiographic criterion: SG 93,9% vs CG 69,8%; clinical criterion SG 87,9% vs CG 62,8%). Patients in SG presented a significant improvement in EF between pre- and post-implant and a significantly reduced End Diastolic Volumes and End Systolic Volumes vs CG. Univariate and multivariate regression analysis showed that enrolment in SG was the only factor consistently associated to CRT response. Conclusion Intraoperative evaluation of IVCD may guide the choice of the best resynchronization approach between BIV and CSP, allowing to achieve a significant improvement of CRT responders’ rate.Figure 1Figure 2

Real-world single center experience with the wearable cardioverter defibrillator: sex differences in risk stratification for sudden cardiac death

Abstract Background Wearable cardioverter defibrillator (WCD) demonstrated an important role for prevention of sudden cardiac death in patients with advanced heart failure and reduced left ventricular ejection fraction. Although in randomized trial there are no gender difference in WCD use and defibrillator (ICD) implantation rate, real world data in female patients is lacking. Purposes: We aimed to describe the sex differences in WCD use, the rate of cardiac events detected with WCD and the rate of ICD implantation after WCD use in women in a real-world single center experience. nd reduced left ventricular ejection fraction or prior ventricular tachyarrhythmia. Methods and results According with the current guidelines indications, between August 2017 and June 2023 ninety-six consecutive patients (mean age 66.0±11.1 years) received a WCD at Piacenza Hospitals and were retrospectively included in this analysis. There were no differences in clinical characteristics between female (18 patients, 18,8%) and male: in particular baseline left ventricular ejection fraction (LV EF) were similar between the two groups (29.5±5.2 vs 27.9±7.9, p=0.23) and no differences were found in the rate of ischaemic cardiopathy (66,6% vs 69,2% p=0.51). After 3-months follow up with WCD use, a similar rate of ventricular arrhythmias were found in the two groups (5.5% vs 3.8%, p=0.48) and no ventricular fibrillation was detected. The WCD usage period and median daily wear time were not different between female and male (55.2±50.6 vs 56.2±34.8 days p=0.53, 21.0±6.4 vs 23.1±1.5 hours p=0.48, respectively). However women presented a better LV EF improvement (12.2±9.7 vs 7.2±6.8, p=0.01), with a significant lower ICD implantation rate at the end of WCD use (55.5% vs 43.8%; p&amp;lt; 0.01) Conclusions In this real word analysis women presented a nice compliance using WCD. In spite of a similar burden of ventricular arrhythmic events, women presented a better LV EF improvement with a significant lower ICD implantation rate.

REAL–WORLD SINGLE CENTER EXPERIENCE WITH THE WEARABLE CARDIOVERTER DEFIBRILLATOR: SEX DIFFERENCES IN RISK STRATIFICATION FOR SUDDEN CARDIAC DEATH

Abstract Background Wearable cardioverter defibrillator (WCD) demonstrated an important role for prevention of sudden cardiac death in patients with advanced heart failure and reduced left ventricular ejection fraction. Although in randomized trial there are no gender difference in WCD use and defibrillator (ICD) implantation rate, real world data in female patients is lacking. Purposes: We aimed to describe the sex differences in WCD use, the rate of cardiac events detected with WCD and the rate of ICD implantation after WCD use in women in a real–world single center experience with reduced left ventricular ejection fraction or prior ventricular tachyarrhythmia. Methods and Results According with the current guidelines indications, between August 2017 and June 2023 ninety–six consecutive patients (mean age 66.0±11.1 years) received a WCD at Piacenza Hospitals and were retrospectively included in this analysis. There were no differences in clinical characteristics between female (18 patients, 18,8%) and male: in particular baseline left ventricular ejection fraction (LV EF) were similar between the two groups (29.5±5.2 vs 27.9±7.9, p=0.23) and no differences were found in the rate of ischaemic cardiopathy (66,6% vs 69,2% p=0.51). After 3–months follow up with WCD use, a similar rate of ventricular arrhythmias were found in the two groups (5.5% vs 3.8%, p=0.48) and no ventricular fibrillation was detected. The WCD usage period and median daily wear time were not different between female and male (55.2±50.6 vs 56.2±34.8 days p=0.53, 21.0±6.4 vs 23.1±1.5 hours p=0.48, respectively). However women presented a better LV EF improvement (12.2±9.7 vs 7.2±6.8, p=0.01), with a significant lower ICD implantation rate at the end of WCD use (55.5% vs 43.8%; p&amp;lt; 0.01). Conclusions In this real word analysis women presented a nice compliance using WCD. In spite of a similar burden of ventricular arrhythmic events, women presented a better LV EF improvement with a significant lower ICD implantation rate.

MINOCA, experience of a single tertiary center with a high volume of ACS

Abstract Funding Acknowledgements None. Introduction Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a clinical entity for which there is limited evidence regarding the clinical data and prognosis. Purpose To evaluate epidemiological and clinical characteristics as well as short-term outcomes of patients with MINOCA presented at a university hospital center with high volume percutaneous coronary intervention (PCI). Methods We evaluated 1035 consecutive patients admitted to our hospital with acute myocardial infarction from June 2022 to January 2023 who underwent invasive evaluation. In-hospital and follow-up data after 30 and 90 days were collected. Primary endpoint was occurrence of a major adverse cardiovascular and cerebrovascular event (composite of cardiovascular death, cerebrovascular accident, re-hospitalization for non-fatal myocardial infarction, re-hospitalization for heart failure, malignant ventricular arrhythmia). Secondary endpoints were improvement in left ventricular ejection fraction and angina status at 30 and 90 days follow-up. Results Among patients presented with acute myocardial infarction, 8.5% (88 patients) were diagnosed with MINOCA. Mean age was 60.9 years and 61.4% were females. Arterial hypertension was present in 86.4%, hypercholesterolemia in 38.6%, diabetes in 12.5% of the patients. Smokers were 29.5% of them. During hospitalization 14.7% had a major adverse cardiovascular event, cardiovascular death occurred in 1.1%, cerebrovascular accident in 1.1%, acute heart failure in 12.5% and malignant ventricular arrhythmia in 1.1%. Primary endpoint at 30 and 90 days follow-up occurred in 10.3% and 13.7% respectively. At 30 days follow-up there was no cardiovascular death, cerebrovascular accident or malignant ventricular arrhythmia; re-hospitalization for MI was 5.7% and re-hospitalization for heart failure was 4.6%. At 90 days follow-up there was no cardiovascular death, cerebrovascular accident or malignant ventricular arrhythmia; re-hospitalization for MI occurred in 8%, re-hospitalization for heart failure in 5.7%. In regard to secondary endpoints, 24.1% experienced angina, while at 30 days and 90 days follow, 66.7% and 72.2% respectively had improvement of left ventricle EF. Conclusions In our study we found a high incidence of MINOCA affecting more frequently female patients. Angina at short term follow up was frequently recorded among out study population.

Takotsubo cardiomyopathy in India and its electrocardiography (ECG) comparison to myocardial infarction

BackgroundOwing to the limited research on Takotsubo Cardiomyopathy (TCM) in Asia, we aim to evaluate in detail the clinical profiles, lab parameters, investigations, and major adverse cardiovascular events (MACE) seen in patients with TCM in the Indian subcontinent. Additionally, we have compared the electrocardiographic findings of patients with TCM to those of patients with myocardial infarction (MI).ResultsThe average age of the patients affected was found to be 60 ± 11 years. Women (87.5%) and patients with hypertension (40%) were found to be at an increased risk of developing the syndrome. The most common presenting symptom was dyspnea (48%) following a trigger most commonly emotional (45%). ST elevation and significant T wave inversions were observed in 40% of patients with TCM. Echocardiography revealed a low left ventricular ejection fraction of 43 ± 9%. Coronary angiography was normal in 60%, the rest had mild/subcritical stenoses. The 6-month MACE was 20% and the mortality rate was 7.5%. Follow-up echocardiography of patients with TCM showed improvement in EF in 75% patients.ConclusionsTCM was majorly seen in postmenopausal women following an emotional trigger, but a variety of other triggers were noted. T-wave inversions in TCM follow a diffuse pattern in contrast to specific leads seen in MI. Normal or subcritical stenosis in coronaries at presentation, along with a low EF which improves on follow up provide greater evidence for the diagnosis of TCM.

Heart failure with improved ejection fraction: patients' characters and predictors for improvement

Abstract Introduction Heart failure with improved ejection fraction (HFimpEF) is a relatively new definition, which presents a diagnostic and therapeutic challenge. Little is known about these patients' characteristics and predictors for EF improvement. Purpose Characterizing the profile of HFimpEF patients and evaluate predictors for EF improvement within heart failure with reduced ejection fraction (HFrEF) patients. Methods The cohort included ambulatory HFrEF patients (EF≤40%) who had two consecutive echo exams at least 6 months apart in a single tertiary medical center. Patients who improved their EF from ≤40% to &amp;gt;40% and by ≥10% (improved group) were compared to those who did not (not-improved group). Clinical, electrocardiographic and echocardiographic data were collected and compared between the groups. Results A total of 567 HFrEF patients (72% male, 54.3±14.4 years old) were analyzed. Patients without EF improvement (n = 393) were more likely to be male, had more comorbidities and had higher rates of ischemic cardiomyopathy (ICMP), compared with the improved group (n = 174) (Table). Lack of improvement in EF was also associated with lower EF and higher left and right ventricular diameters in the first echo. In a multivariate analysis model adjusted to all statistically significant variables in the univariate analysis, predictors for lack of EF improvement were male sex (adjusted odds ratio [OR] 1.63, 95% CI 1.02-2.61; P = 0.041), ICMP (OR 3.98, 95% CI 2.03-7.81; P&amp;lt;.001), larger left ventricular end diastolic and end systolic diameters (OR 2.07, 95% CI 1.44-2.98 and OR 1.84, 95% CI 1.36-2.5, respectively; P&amp;lt;.001 for both) and enlarged right ventricle (OR 1.93, 95% CI 1.11-3.36; P = 0.02), while higher EF at baseline was a positive predictor for improvement (OR 0.95, 95% CI 0.92-0.98; P = 0.001) (Figure). Interestingly, NYHA functional class was not associated with EF improvement (OR 1.16, 95% CI 0.87-1.55; P = 0.306). Hospitalization and mortality rates were both higher in the not-improved group (median of 1 (IQR 1-2) vs. 0 (IQR 0-1); P&amp;lt;.001 and 24% vs. 13%; P = 0.001, respectively). Patients in both groups were generally treated with high rates of guideline directed medical therapy (GDMT) for HFrEF. Although no correlation was found between GDMT and EF improvement, these drugs were associated with reduced hospitalization and mortality rates in both groups. Conclusions Improvement in EF among HFrEF patients may be predicted by the HF etiology and echocardiographic parameters. HFimpEF patients have better prognosis compared to HFrEF patients. While GDMT was not associated with EF improvement, it improved outcomes in both HFimpEF and HFrEF regardless of EF.

Abstract 14082: Evans Syndrome Post Transcatheter Aortic Valve Replacement: A Rare Presentation

Description of Case: Evans Syndrome is a rare hematologic condition. Here we present a patient who developed Evans Syndrome post TAVR. A 63-year-old male with history of HFrEF and aortic stenosis presented with 2-week history of worsening shortness of breath and bilateral lower extremity swelling. He was found to be in cardiogenic shock. TTE showed (LFLG) aortic stenosis (AS). Due to concomitant cardiogenic shock and tachyarrhythmias, we were unable to perform dobutamine stress echo. A cardiac CT was performed which revealed an aortic valve calcium score of 2761 (Figure 1). The diagnosis of severe AS was confirmed, and patient underwent TAVR. Postprocedural TTE showed significant improvement in EF. Patient’s complete blood count on admission was remarkable for Hgb of 12.5 g/dL and PLT of 148 k/mm 3 . Both Hgb and PLT began to drop significantly following TAVR. We ruled out vascular access site bleeding, mechanical complication from paravalvular leak, nutritional deficiencies, disseminated intravascular coagulation, heparin-induced thrombocytopenia, thrombotic thrombocytopenic purpura, myelodysplastic syndrome, HIV, hepatitis C. Autoimmune hemolytic anemia was identified given elevated lactate dehydrogenase, low haptoglobin, and positive IgG direct antiglobulin test. We started steroids and treat the case as Evans syndrome. PLT count improved from 67 to 117 k/mm 3 within 2 days of steroids initiation. The bone marrow biopsy was deferred to outpatient follow up given the response to steroids. Patient was discharged on oral prednisone. Three-month follow up showed Hgb and PLT with normal limits. Discussion: Anemia and thrombocytopenia are common complications post TAVR. Both anemia and thrombocytopenia are suggested to be excellent markers for clinical outcomes, morbidity and mortality after TAVR. It is crucial to keep a broad differential for post TAVR anemia and thrombocytopenia. Less common causes should be evaluated and addressed to improve prognosis.

Abstract 17574: A Unique Incident Presentation of Cardiac Involvement in Mitochondrial Myopathy

Case: A 68 year old female with mitochondrial myopathy (MT-TK subset) and no significant cardiac history presented with shortness of breath and palpitations for 1 day. Initial vitals were HR 152, BP 174/102, RR 31, SpO2 83% on RA. Imaging showed pulmonary congestion, EKG showed new onset atrial flutter with RVR, and 2D echo showed a new drop in EF to 15% with global hypokinesis. BNP was elevated (861 pg/ml). Other labs including serial troponins were unremarkable. Patient was started on diuresis, nitroglycerin infusion, and anticoagulation. RVR persisted despite iv metoprolol, digoxin, and esmolol infusion. Cardioversion was planned but TEE revealed a LAA thrombus. Finally on day 3 of hospitalization, patient spontaneously converted to sinus rhythm. Amiodarone was added for rhythm control. Notably, a repeat 2DE showed improvement in EF to 35%, concerning for tachycardia induced cardiomyopathy. GDMT was started and patient was discharged in a stable condition. A month later patient successfully underwent cavotricuspid isthmus ablation and pulmonary vein isolation. Discussion: The heart is critically dependent on mitochondrial oxidative phosphorylation and is one of the most frequently affected organs in mitochondrial disorders (MIDs). Cardiac involvement (CI) can be structural (myocardium, coronary arteries, pericardium, aortic root), functional (impulse generation/ conduction, arrhythmias) or both. Since almost half of the cardiac ATP is used to maintain ion channel homeostasis, mitochondria is a key player in arrhythmogenesis. It is crucial to avoid conditions that may create a high metabolic demand (fever, stress) and drugs that may interfere with enzymes involved in mitochondrial metabolism (such as metformin, propofol, valproic acid, erythromycin). Antioxidants and respiratory chain cofactors are commonly used for supportive management, however benefits are inconsistent. Interventions targeted towards definite control, like ablation should be considered early. Additionally, a comprehensive cardiac evaluation is important at diagnosis considering the progressive nature of MIDs. At present, there is no targeted treatment and further studies are needed to explore mitochondria as a potential therapeutic target in arrhythmias.

Abstract 13005: Depletion of XCR1+ Conventional Dendritic Cell After Myocardial Infarction Improved Adverse Cardiac Remodeling via CXCR3 Chemokine Signaling

Introduction: We have demonstrated immune reactions of probucol treatment on cardiac remodeling using SR-BI KO/ApoeR61 h/h (SRBI KO) mice in which ischemic myocardial injury is induced by high fat diet. In the previous study, we identified the role of XCR1 + conventional dendritic cells 1 (cDC1)-activated CD4 + T Helper-1 (Th1) cells after ischemic myocardial injury. Hypothesis: Deletion of XCR1 + cDC1 cells after myocardial infarction (MI) might improve adverse cardiac remodeling through the suppression of Th1 cells. Methods: Using Xcr1 +/DTRvenus mice, which allow the XCR1-expressing cell elimination by treatment with diphtheria toxin (DT), permanent coronary ligation was conducted. DT was injected into Xcr1 +/DTRvenus mice 1 day after MI (XCR1 depleted-MI group). We analyze cDCs and CD4 + T cell subsets by flow cytometry. Results: The XCR1 depleted-MI group showed improvement of EF evaluated by cardiac MRI (p&lt;0.05). In CD4 + T cell subsets, Th1 and Tregs were significantly localized in border and infarcted area, while Th1 cells were decreased in XCR1 depleted-MI group (p&lt;0.001). To elucidate the mechanism of the predominant reduction of Th1 cells, we focused on CXCR3 chemokine receptor and its ligands, CXCL9 and CXCL10. CXCR3 is enriched on Th1 in the heart after MI, while it is not enriched on Tregs. Regarding the precise source of CXCL9 and CXCL10 in the ischemic heart, the percentage of XCR1 + cDC1 cells were most predominant in the cDCs subsets expressing CXCL9 and CXCL10 (p&lt;0.001). These results suggested that XCR1 + cDC1 cell-derived CXCL9 and CXCL10 are significant contributor to the chemotaxis of CXCR3 + Th1 cells after MI. Finally, we analyzed autopsy samples of human MI cases to demonstrate clinical significance. CXCR3 + Th1 and XCR1 + cDC1 cells were detected significantly more in the infarcted area than in marginal zone. Conclusions: The modulation of XCR1+cDC1-activated CXCR3 + Th1 cells could be a novel therapeutic target to reduce post-MI remodeling.

Abstract 12525: Acute Pulmonary Edema, Mid-Ventricular Stress Cardiomyopathy and Cardiogenic Shock Following Intranasal Lidocaine/Epinephrine Administration During Septorhinoplasty

Case Presentation: A 19-year-old female presented for elective septorhinoplasty for nasal septal deviation and turbinate hypertrophy. After induction of anesthesia, and orotracheal intubation, pledgets soaked in 4% topical lidocaine with 1:1,000 epinephrine were placed in bilateral nares. Next, 1% lidocaine with 1:100,000 epinephrine was locally injected in the nasal mucosa to obtain hemostasis and analgesia. This resulted in transient hypertensive emergency, followed by undifferentiated shock requiring the initiation of norepinephrine. No signs of ischemia were seen on EKG. Chest X-ray revealed acute pulmonary edema. TTE showed reduced left ventricular systolic function, EF 30%, with mid-segment akinesis, consistent with mid-ventricular stress cardiomyopathy. Coronary angiography identified normal anatomy and patent arteries, supporting the diagnosis. Surveillance TTE after extubation and empiric treatment with metoprolol and losartan, showed improvement of EF to 45-50% and resolution of regional wall motion abnormalities. Discussion: Stress cardiomyopathy, also known as Takotsubo (TCM), is a rare form of cardiomyopathy accounting for 2-3% of ACS. The syndrome mainly affects the LV, causing a regional, transient, systolic dysfunction visualized on TTE or left ventriculography, that occurs in the absence of obstructive epicardial coronary lesions. Pathogenesis is poorly understood. Postulated mechanisms include catecholamine excess, coronary artery spasm and microvascular dysfunction. A systematic review found elevated norepinephrine levels in 74.3% of patients diagnosed with TCM, as was the case for our patient. Rapid systemic absorption of epinephrine can cause diffuse microvascular spasm and myocardial stunning. Catecholamine surge may also afflict direct myocardial toxicity, leading to disorganized cytoskeletal structures, excess extracellular matrix proteins and dysfunctional contractile properties of the myocardium.

Abstract 13067: Conduction System Pacing to Achieve Cardiac Resynchronization Therapy: Is There a Sex Difference in Response Rates?

Background: It is well established that in patients with dyssynchronous heart failure related to left bundle branch block (LBBB) and reduced left ventricular ejection fraction (LVEF), females show higher response rates than males when cardiac resynchronization (CRT) is achieved by conventional biventricular (BiV) pacing. Whether this sex difference is also true when CRT is achieved via conduction system pacing is unknown. Hypothesis: There is no difference between women and men in response rates when CRT is achieved by conduction system pacing (CSP), either by His bundle pacing (HBP) or by left bundle area pacing (LBAP). Methods: Patients who underwent CSP with a baseline LVEF ≤40% and a QRS duration ≥140 milliseconds (ms) were retrospectively selected from a CSP database maintained at our institution. 52 patients were included: 17 females and 35 males. Baseline clinical, electrocardiographic, echocardiographic, and follow up data were gathered and analyzed. Electrocardiograms and echocardiograms closest to the dates of implant and at last known follow up were used. Super-response was defined as absolute EF improvement ≥15%. Results: At baseline, there were no statistically significant differences in clinical, electrocardiographic, and echocardiographic characteristics between females and males except for higher prevalence of coronary disease in men, and higher percentage use of guideline directed medical therapy in men (Table 1). At median follow up of 113 days, there were no differences in electrocardiographic or echocardiographic response, number of super-responders, and mortality between females and males (Table 1). Conclusions: Unlike conventional CRT where females show superior response rates, CRT with CSP seems to provide comparable benefits in females and males. If confirmed in larger data sets, this may represent an important advantage of CSP over conventional CRT.

Abstract 18997: Management of Immune Checkpoint Inhibitor Mediated Myocarditis

Clinical Presentation: A 52-year-old female with metastatic Stage IVB (T4N3M1c) lung adenocarcinoma presented with worsening dyspnea. She had just completed her 3 rd round of carboplatin/pemetrexed/pembrolizumab/MK-5890 chemotherapy. Upon examination she was noted to be hypertensive and tachycardic with an elevated high-sensitivity troponin T. ECG showed sinus tachycardia, left axis deviation, and flattened T waves in lead V5 and V6. In the ED, she subsequently developed supraventricular tachycardia and was admitted to the ICU. TTE demonstrated moderately reduced EF of 30-35%. TTE also identified hypokinesis in the basal to mid anterior and lateral walls and apical akinesis. Initial CMR showed an EF of 31% with akinesis of the mid and apical anterior, septal and inferior wall. Given the clinical and imaging findings, she was diagnosed with myopericarditis secondary to pembrolizumab and started on 1 mg/kg methylprednisolone taper for 60 days. Repeat CMR after completion of steroid taper showed evidence of weighted T2 edema in myocardium and pericardium. Late gadolinium enhancement (LGE) in inferior and lateral epicardium and adjacent pericardium as well as patchy LGE throughout the myocardium with significant EF improvement (57%) (Figure 1A-B). In our patient, multi-modality imaging was used to confirm the diagnosis and monitor treatment response. Discussion: Immune checkpoint inhibitors (ICI) are a novel class of immunotherapies used in certain malignancies. Initial treatment of myocarditis consists of cessation of further ICI and administration of corticosteroids. Additionally, symptomatic myocarditis treatment should be started. Reinitiating ICI therapy should ultimately be done with shared decision making.

Effects of sacubitril/valsartan in patients with cancer therapy-related heart failure

To evaluate the effect of Sacubitril/Valsartan (S/V) on the functional status, systolic and diastolic function of the left ventricle (LV), tolerability of therapy and to determine predictors of its effectiveness in patients with cancer therapy-related heart failure (СTRHF). Forty patients 58 [46; 65.5] years of age with HF associated with anthracycline-containing cancer therapy were enrolled. Clinical examination, echocardiography, and assessment of potassium and creatinine levels were performed at baseline and after 6 months of S/V therapy. NYHA functional class (FC) improvement was observed in 22 (64.7%) patients. Radiation therapy (RT) decreased (OR 0.091; 95% CI 0.01-0.83; p=0.03) while baseline low LV EF increased (OR 9.0; 95% CI 1.78-45.33; p=0.008) the odds of FC improvement. LV EF increased from 37.3 [30; 42.5] % to 45 [38; 48] % (p<0.0001) and exceeded 50% in 7 (20.6%) patients. The odds of LV EF recovery increased when S/V therapy was initiated ≤1 year after anthracycline therapy (OR 10.67; 95% CI 1.57-72.67; p=0.0016) and decreased in patients with the history of RT (OR 0.14; 95% CI 0.02-0.89; p=0.0037) and in patients over 58 years (OR 0.07; 95% CI 0.01-0.68; p=0.022). LV diastolic function improvement included E/e' descent from 13.6 [10; 18.3] to 8.9 [6.9; 13.7] (p=0.0005), and decrease in diastolic dysfunction grade in 18 (45%) patients (p=0.0001). No significant change in serum potassium (4.45 [4.2; 4.8] versus 4.5 [4.3; 4.8]; p=0.5) and creatinine (75.4 [67.6; 85.1] versus 75.5 [68.2; 98.3]; p=0.08) levels were observed. S/V therapy is associated with improvement of EF, systolic and diastolic LV function, demonstrates a favorable tolerability profile in patients with СTRHF. Lack of RT and low baseline LV EF increased the odds of LV EF improvement; lack of RT, early (≤1 year) start of treatment after discontinuation of anthracycline therapy, and age <58 years increased the odds of LV EF recovery.

Does speckle tracking transthorasic echocardiography show subtle changes in left ventricular function in patient with heart failure with reduced ejection fraction treated by Sacubitril-Valsartan

Abstract Introduction Pathophysiology of HF involves a maladaptive response during which the (RAAS) is activated. RAAS activation leads to VC, HT, increased aldosterone levels, increased sympathetic tone, and eventually, cardiac remodeling, all of which are detrimental to the progression of the disease. By blocking these maladaptive elements, ACEIs or ARBs play a major role in reducing morbidity and mortality due to HF, Simultaneously, the NP system is also activated, hence the elevated BNP and NT-pro BNP seen in HF exacerbations. This is a Compensatory mechanism that leads to VD, natriuresis and diuresis, lowers BP, lowers sympathetic tone, and reduces aldosterone levels. The NP system works antagonistically to the RAAS and has favorable effects on the pathogenesis of HF NP are broken down by an enzyme called neprilysin and blocking of its action by neprilysin inhibitor prevent the breakdown of NP leading to prolonged duration of the favorable effects of these peptides. Sacubitril/valsartan is a first-in-class medicine that contains a neprilysin (NEP) inhibitor (sacubitril) and (Ang-II) receptor blocker (valsartan). STE is a sensitive tool for assessing ventricular function, even subclinical myocardial alterations that traditional imaging techniques are not able to detect. Sub endocardial function is powered mostly by longitudinal contraction, it is impaired earlier than circumferential or radial component's. Therefore, Longitudinal function is in most cases the best early marker of LV dysfunction. Objective The aim of our study is to retrospectively detect if the patients treated by sacubitril/valsartan showed no improvement in LVEF assessed by TTE, is the same patient will shows improvement in LVEF assessed by 2D STE? Methods Our study will include 200 patients with HFrEF. All participants were subjected to the following: History taking, Physical examination, Serial 12-lead ECG, 2D echo to assess: -LVEDD, LVESD and LVEF%, LVEDVI (ml/m2), LVESVI (ml/m2), (LAVI) ml/m2, E/e′ ratio. 2D STE was done before and after 6 months of sacubitril/valsartan. Results Age 48 ± 9 years, 63% females, 9 (4.5%) were in NYHA FC I, 120 (60%) NYHA FC II, 64 (32%) of patients were in NYHA FC III &amp; 7 (3.5%) were in FC IV. improved to NYHA FC I, 82 (41%) NYHA FC II 118 (59%), LVEDV, LVESV, LVEF, E/e′ were 139.3 ± 7.3, 89.7 ± 4.7, 34.9 ± 2.8, 11.2 ± 2.7, that all improved to 139.1 ± 10.5, 89.0 ± 4.4, 35.6 ± 2.6, 9.1 ± 2.3. 82 (41%) patient showed improvement in LVEF either by traditional TTE or STE, 118 (59%) patients showed no improvement of EF by traditional TTE, of them 74 (37%) patients was improved detected by STE while 44 (22%) patients showed no improvement in EF neither by TTE nor by STE. Conclusion STE is more accurate diagnostic tool for detecting early improvment in LVEF that not detected by traditional TTE in patient with HFREF treated by scubitril/valsartan. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

The Relationship between Loading of a High Dose Atorvastatin and No Reflow in STEMI Patients Undergoing Primary PCI

Abstract Background Worldwide, ischemic heart disease is the single most common cause of death and its frequency is increasing. STEMI is a significant cause of morbidity and mortality in patients with coronary heart disease. Aim of the Work The aim of our study was to assess the impact of high dose atorvastatin loading before primary PCI in patients presenting with acute STEMI on No-reflow and MACE at 1 month follow up. Patients and Methods This is a randomized control clinical trial based at the coronary care units &amp; coronary catheterization lab unit of the cardiology department in Ain Shams University Hospitals. Patients who presented, between April 2021 to October 2021, with STEMI and undergoing primary percutaneous coronary intervention were allocated to the study and divided into 2 groups: Study group: received high intensity statin (80 mg of Atorvastatin) besides guideline recommended therapy before primary PCI, Control group: received guideline recommended therapy before primary PCI. Results Results for age, gender, hypertension, Diabetes and smoking did not show any statistical significance between the control and study groups. There was a statistically significant improvement in study group compared to control group in No-reflow (28% vs 47%) with a P-value of 0.006; primarily derived by improvement in MBG (0-1: 28% vs 43%, 2-3: 72% vs 57%) with a P-value 0.027, and improvement in EF at 24 h after PCI (Mean±SD 48.35 ± 8.78 vs 45.20 ± 7.89) with a P-value of 0.008 and at 1 month follow up (43% vs 20%) with a P-value of 0.039, but it did not have a significant impact on MACE at 1 month follow up. Conclusion Our study concluded that high dose atorvastatin loading before primary PCI resulted in improved post-procedural MBG, no-reflow and Ejection fraction as measured by bi-plane Simpson's method but did not decrease in MACE at 1 month follow up. Based on the results of this study, we highly recommend the routine use of high dose atorvastatin before primary PCI in patients presenting with STEMI. Abbreviations ACS: Acute coronary syndrome; BP: Blood pressure; ECG:. Electrocardiography; ESC: European society of cardiology; EF: Ejection fraction; MACE: Major adverse cardiac events; MBG: Myocardial blush grade; MRI: Magnetic resonance imaging; PCI: Percutaneous coronary intervention; SPSS: Statistical Package for Social Science; STEMI: ST segment elevation myocardial infarction; STR: ST segment resolution; TIMI: Thrombolysis in myocardial infarction