Improvement In Functional Class Research Articles

Angiotensin-Converting Enzyme Inhibitor Therapy Effects in Patients With Heart Failure With Preserved and Mid-Range Ejection Fraction

Background: There is hypothesis that endothelial function enhancement is strongly associated with better outcome and functional class improvement in heart failure with preserved ejection fraction (HFpEF) and heart failure with mid-range ejection fraction (HFmrEF) patients. Perindopril is the only angiotensin-converting enzyme inhibitor (ACEI) drug with proven positive effect on the endothelium in coronary artery disease (CAD) patients. In patients with HFpEF and HFmrEF, its impact is still unknown. The aim of this study was to assess perindopril’s influence on endothelial dysfunction markers in these groups of patients. Methods: We included 60 patients with HFpEF and HFmrEF. At the baseline, endothelial dysfunction biomarkers were measured by IFA and echocardiographic parameters (left atrial volume index (LAVI), ejection fraction (EF), left ventricular mass index (LVMI), left ventricular end-diastolic diameter (LVEDD), and left ventricular end-diastolic volume (LVEDV)) were studied. In patients with no history of previous ACEI or angiotensin II receptor blockers (ARBs) therapy, perindopril was prescribed for 12 months. If patient was treated with ARB or ACEI drug other than perindopril before the study, after 48-h withdrawal period, previous drug was replaced by perindopril. Results: After 12-month therapy with perindopril, E-selectin decreased from 57.25 to 46.05 ng/mL and from 56.55 to 47.6 ng/mL in HFpEF and HFmrEF patients, respectively (P < 0.05). Significant reductions from 0.99 to 0.76 pg/mL (P < 0.05) and from 1.08 to 0.97 pg/mL (P < 0.05) in endothelin-1 level were shown in patients with HFpEF and HFmrEF. Conclusion: The 12-month therapy with perindopril leads to LAVI reduction in HFmrEF patients and potential endothelial dysfunction markers decrease in HFpEF and HFmrEF patients. Cardiol Res. 2021;000(000):000-000 doi: https://doi.org/10.14740/cr1322

Temporal trends in right heart strain in patients undergoing pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension.

Pulmonary thromboendarterectomy (PTE) is a curative procedure for chronic thromboembolic pulmonary hypertension (CTEPH). Right ventricular free wall strain (RV FWS) and right atrial strain (RAS) are not well studied in a CTEPH population. We sought to determine temporal trends in RAS and RV FWS in patients post-PTE. 28 patients undergoing PTE for CTEPH were prospectively enrolled in a surgical database. Comprehensive echocardiographic assessment of the right heart was performed including RV FWS, right atrial volume, and the three components of RAS: reservoir, conduit, and booster strain. Patients undergoing PTE demonstrated improvement in NYHA functional class (P<0.001). Hemodynamic assessment showed improvement in mean pulmonary artery pressure from 49.7±8.5mm Hg to 23.9±6.5mm Hg (P<0.001) and pulmonary vascular resistance decreased from 7.8±3.2 wu to 2.4±1.3 wu (P<0.001). Tricuspid annular plane systolic excursion (TAPSE) and lateral S` declined immediately post-op. RV FWS improved from -14.4±4% to -19±3.4% post-op and -21.2±4.7% at long-term follow-up (P<0.001). Improvement in RV FWS post-op was driven primarily by increases in the apical and mid segments. RA volume declined significantly during the study period. RA reservoir and conduit strain improved after PTE. Patients undergoing PTE for CTEPH had significant improvement in right heart hemodynamics immediately post-op. Traditional echo metrics of RV performance including TAPSE and lateral S` did not improve. RV FWS improved, which was driven by changes in the apical and mid segments. This highlights that RV FWS is a viable and useful metric to follow in CTEPH patients post-PTE.

The results of the balloon pulmonary angioplasty program in chronic thromboembolic pulmonary hypertension patients in a national and European reference center resemble those of Japanese series

Abstract Introduction Balloon pulmonary angioplasty (BPA) is an established technique in patients with non-operable chronic thromboembolic pulmonary hypertension (CTEPH). It improves hemodynamics, functional class, biomarkers and survival, with current periprocedural mortality rates below 1–2% in experienced centers. However, there is a discrepancy between the magnitude of European or American series' results and those of Japanese centers, with a pulmonary vascular resistance reduction of 26–43% in the former and 45–65% in the latter. Purpose To present the results of the BPA program of a CTEPH national and European reference center and to compare them with the results of Japanese series. Methods We analyze the improvement in hemodynamics, functional parameters, biomarkers and pulmonary vasodilators requirements of patients with a finished BPA program. Besides, we show safety and survival of the whole cohort of patients undergoing BPA between May 2013 and December 2020 in a CTEPH national and European reference center. Results We performed 503 BPA sessions in 120 patients, 64% women, mean age 61±15 years (19–84). The reasons for BPA were: distal involvement in 105 patients, comorbidities in 3 patients, personal preferences in 3 patients and residual pulmonary hypertension after pulmonary thromboendarterectomy in 9 patients. Mean follow-up from therapy beginning was 50±16 months (22–92). One patient died 7 days after her first BPA due to severe lung injury (peri-procedural mortality 0.83%). BPA therapy was interrupted in 5 patients (4 octogenarians with poor tolerance to procedures or little clinical improvement and 1 patient with relapsing severe hemoptysis during BPA sessions). Seventy three of the 114 remaining patients had finished their BPA program. The table shows the hemodynamic, biomarker and functional class improvement and the decrease in pulmonary vasodilators requirements of patients with complete BPA therapy. During follow-up 2 patients died: one due to hemoptysis related to pneumonia, 23 months after his first BPA, with BPA program already completed; the other due to leukemia, while in active BPA program. Thus, survival of our BPA series at 7 years follow-up is 98.2%. Conclusions The efficacy, safety and survival results of BPA therapy in patients with inoperable CTEPH at a national and European reference CTEPH center are comparable to those of Japanese series. Furthermore, hemodynamic and functional improvement and the reduction of specific medication requirements, along with therapy safety, position BPA as the first choice therapeutic option in patients not subsidiary of surgery. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): University Hospital 12 de Octubre, Madrid, Spain Changes after complete BPA therapySurvival from the initial BPA procedure

Clinical outcome after MitraClip procedure: role of right ventricle

Abstract Background MitraClip system is a device for percutaneous edge-to-edge repair of the mitral valve in symptomatic patients with severe mitral regurgitation (MR) not eligible for surgery, but frequently heart failure symptoms remain substantial on mid-term follow-up. Recently, right ventricular (RV) to pulmonary arterial (PA) coupling has emerged as a relevant prognostic predictor in heart failure but little is known about its prognostic role in patients after MitraClip implantation. Purpose To identify echocardiographic predictors of clinical outcome after MitraClip procedure, with a particular focus on RV-PA coupling. Methods We retrospectively analyzed the data of patients with severe MR who underwent MitraClip implantation between April 2015 and October 2019 at our Institution. Echocardiographic data were assessed at baseline, 3 and 12 months after the procedure; RV to PA coupling was assessed using the ratio between tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP). Functional class was assessed at 12 months of follow-up. Significance level was set to 0.05 and SPSS was used for statistical analysis. Results 41 patients were included (age 77.1±7.3, 71% male, BMI 25.8±5.5). MR was primary, functional and mixed in 22, 76 and 2% of patients, respectively. 1/2/3 mitraclips were implanted in 39/56/5% of patients, respectively. Echocardiographic data at baseline, at 3 and 12 months follow-up are shown in Table. NYHA class at 12 months significantly correlated with TAPSE and PASP at 3 months follow-up echocardiogram (beta coefficient −0.83 and 0.78 respectively). On the contrary, NYHA class did not show a correlation with left ventricular ejection fraction (LVEF) or residual MR grade. At 12 months 44% of patients showed an improvement in NYHA class; these patients had a better TAPSE (22.7±1.3 vs 19.4±4.6 mm), a lower PASP (37.9±10.2 vs 48.5±12.9 mmHg) and a better TAPSE/PASP (0.61±0.2 vs 0.42±0.2) compared to patients who did not improve their functional class, while LVEF and residual MR did not differ. Conclusion In this sample of significant MR undergoing repair with MitraClip System, patients with functional class improvement at 12 months follow-up showed a better RV-coupling without difference in LV function and residual MR. Funding Acknowledgement Type of funding sources: None. Table 1

Impact of left heart disease risk factors on risk stratification and treatment response in pulmonary arterial hypertension

Abstract Background Contemporary registries have documented a change in the epidemiology of PAH patients displaying increasing co-morbidities associated with left heart disease (LHD). These patients are often excluded from randomized clinical trials. It is unclear whether the presence of LHD comorbidities may adversely impact the accuracy of risk stratification and response to PAH therapy. Method Data was extracted from the Pulmonary Hypertension Society of Australia and New Zealand registry for incident patients with a diagnosis with idiopathic/heritable/toxin-induced (I/H/D)-PAH and connective tissue disease (CTD) associated PAH from 2011 - 2020. Patients without available medication and follow up data were excluded. We used the AMBITION trial exclusion criteria to define the subpopulation with LHD risk factors and haemodynamic phenotype (PAH-rLHD). Results 489 patients (I/H/D-PAH=251, CTD-PAH=238) were included in our analysis, with 103 (21.0%) fulfilling the definition of PAH-rLHD (34 had ≥3 risk factors for left heart disease (rLHD-hypertension, diabetes, obesity or ischaemic heart disease) and 76 had borderline haemodynamics (mean capillary wedge pressure 13–15 with pulmonary vascular resistance &amp;lt;500 dynes sec/cm5) including 7 who met both criteria). Compared to classical PAH, patients with PAH-rLHD were older at diagnosis (66±13 vs 58±19, p&amp;lt;0.001), had lower pulmonary vascular resistance (PVR: 393±266 vs 708±391, p=0.031) but worse exercise capacity (6MWD: 286±130m vs 327±136m, p=0.005). PAH-rLHD were more likely to be started on initial monotherapy, compared with “classical” PAH (73% vs 56%, p=0.002). In the monotherapy groups, endothelin receptor antagonists (ERA) were used in 73% PAH-rLHD, compared with 66% in classical PAH group. Both groups exhibited similar response to both mono- and combination therapy with commensurate improvements in WHO functional class (mean change 0.3±0.6 vs 0.3±0.8, p=0.443) and 6-minute walk distance (mean change 44±82 vs 48±101, p=0.723). There was no difference in survival between classical PAH and PAH-rLHD (log rank, p=0.29). The REVEAL 2.0 risk score effectively discriminated risk in both populations at baseline and first follow up (classical PAH: baseline C statistic 0.750, follow up 0.774 and PAH-rLHD: baseline C statistic 0.756, follow up 0.791). Conclusion Despite lower PVR at diagnosis, PAH-rLHD patients and “classical” PAH demonstrate similar response to first-line therapy with similar long term survival. The REVEAL 2.0 risk score can be effectively applied to the subpopulation of PAH-rLHD in real life clinical practice. Funding Acknowledgement Type of funding sources: None.

MitraClip NTR vs XTR system for transcatheter tricuspid valve repair of tricuspid regurgitation

Abstract Background Transcatheter tricuspid valve repair (TTVr) is a novel modality for treatment of severe tricuspid regurgitation (TR) in patients at high surgical risk. So far, the most frequently used system is the MitraClip® providing two different clip types (NTR vs XTR). Purpose To compare XTR vs NTR clip systems for TTVr regarding safety, feasibility, and effectiveness. Methods 35 consecutive high-risk patients (78.4±7.9 years, EUROScore II 10.7±10.8%, STS Score 7.9±4.1) with symptomatic TR were treated using the MitraClip® system between 2017–2020. with an NTR (N=18, 51.4%) or XTR (N=17, 48.6%) system. The primary outcome was successful TTVr with TR reduction of ≥1 grade with no mortality, single leaflet device attachment (SLDA), or conversion to surgery until hospital discharge. At 30-day follow-up, TR severity grade and NYHA functional class were assessed. Results We found more severe initial TR grades in the XTR group compared to the NTR group expressed with wider TR V. contracta (14.8±4.3 vs 11.1±3.8 mm, p=0.011), larger EROA (0.99±0.4 vs 0.72±0.3 cm2, p=0.032), wider coaptation depth (9.6±2.8 vs 7.3±0.4 mm, p=0.036) and V. cava inferior (30.7±3.6 vs. 25.8±6.4 mm in NTR, p=0.013). 5 patients (29.4%) in the XTR and 3 patients (16.7%) in the NTR group presented initially with torrential TR. No significant differences were observed for clinical characteristics, comorbidities, co-medication, laboratory parameters or initial NYHA functional class (3.0±0.5 in NTR vs 3.2±0.4 in XTR, p=0.45). TTVr was safe with no intraprocedural deaths, emergency surgery or major vascular complications. Duration of the procedure and fluoroscopy did not differ. Both, NTR and XTR system led to procedural success in 72.2% (N=13) and 76.5% (N=13), respectively. At discharge, a significant reduction of initial TR grade was observed in both groups (2.4±0.9 in NTR and 2.3±0.9 in XTR, p&amp;lt;0.001) with a tendency of greater mean reduction in the XTR group (1.9±1.0 vs. 1.3±0.9, p=0.09). All 5 patients with torrential TR in the XTR group (100%) and just 1 patient (33.3%) in the NTR group achieved the primary outcome. At 30-day follow-up, overall SLDA rate was 22% vs 17.6% for NTR and XTR, respectively. However, these cases were attributed to very high risk patients with poor anatomy. Mortality rate was 11.1% in NTR vs 5.9% in XTR group (p=0.59). Achieved reduction of TR was maintained in both groups (2.6±0.9 in NTR and 2.8±0.9 in XTR, p&amp;lt;0.001). Also, improvement of NYHA functional class was seen (2.5±0.5, p=0.001 in NTR and 2.9±0.6, p=0.055 in XTR). Conclusion MitraClip® NTR and XTR systems for TTVr of severe TR in high-risk patients are safe and effective leading to a significant reduction of TR and clinical improvement. The XTR system seems to allow successful treatment of more severe TR stages compared to NTR. Funding Acknowledgement Type of funding sources: None.

Transcatheter mitral valve repair (TMVR) using MitraClip in patients younger than 65 years: a multicenter analysis of 2-years outcomes

Abstract Background TMVR using MitraClip became a well-established interventional therapy for severe MR. However, TMVR has been almost only applied to old aged patients rejected from surgical therapy. Objective To present 2-years outcomes of 36 patients younger than 65 years with no surgical options treated by TMVR. Methods A retrospective clinical and TEE study was conducted to evaluate 36 patients younger than 65 years treated by TMVR in 3 heart centers. Results Mean age of the 36 study patients was 56.3±6.6 years, male gender was 72.2%. High operative risk was estimated by STS score (mean = 8.73±2.97) and EuroSCORE (mean = 24.71±12.79). All patients were refused for surgery by heart team decision, therefore admitted to TMVR. Baseline severity of MR was assessed by 3D-TEE based biplane vena contracta width (mean = 8.35±1.87 mm). Baseline transmitral mean pressure gradient was 1.81±0.78 mmHg. 21 patients showed mitral annular dilatation as the main cause of MR, 8 patients had leaflet prolapse, 4 patients exhibited papillary muscle displacement leading to leaflet tethering and 3 patients showed mitral leaflet thickening and/or retraction due to fibrosis. Procedural success was achieved in all patients with 1/2/3 clips implanted in 52.8%/44.4%/2.8% of cases with a mean of 1.5 clip per case. Two grades or more reduction in severity of MR (MR grade ≤ II/IV) was accomplished in 88.9% of patients. Mean postprocedural MPG was 3.78±1.96 mmHg. Average follow-up (FU) period was 25,8 months and the median was 20 months (25th–75th percentile: 12–36 months). During 2-years FU, statistically significant difference (p value &amp;lt;0.002) was detected for NT-proBNP levels compared to baseline (mean = 9870±10819, median = 7748, 25th–75th percentile: 2702–14237 pg/ml) and at follow up visits (mean = 7645±11292, median = 3263, 25th-75th percentile: 883–8078 pg/ml). Furthermore, persistent symptomatic improvement during FU, defined as NYHA functional class improvement by 2 or more Grades, was achieved in 69% of patient in parallel with efficient reduction of MR in 34 patients so that a second intervention by reclipping was required in 2 patients to correct recurrent significant MR. Only two patients experienced procedure-related complications by large puncture site hematoma. No procedure-related mortality during the first 30 days was detected. However, mortality was recorded in 2 patients during the first month and was attributed to severe advanced heart failure in one case and septicemia after exclusion of infective endocarditis in another case. Over 2 years FU, other 5 patients passed away, 3 cases owing to advanced heart failure, one case due to multi-organ failure and one because of tumor disease. Conclusion TMVR in patients younger than 65 years refused from surgical repair provides satisfactory clinical and echocardiography outcomes at 2 years. Future studies should evaluate the outcomes of MitraClip in this population in a larger cohort. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Hassan M.H. Mohammed received a scholarship grant from the Egyptian ministry of higher education and Minia University, Egypt.

Safety and efficacy of balloon pulmonary angioplasty in a Portuguese pulmonary hypertension expert center

Balloon pulmonary angioplasty (BPA) is an alternative therapy in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) or residual/recurrent pulmonary hypertension (PH) after surgery. The aim of this study was to assess the short-term efficacy and safety of a BPA program.This prospective single-center study included all BPA sessions performed in CTEPH patients between 2017 and 2019. Clinical assessment including WHO functional class, plasma biomarkers, 6-min walk test (6MWT) and right heart catheterization was performed at baseline and six months after the last BPA session.A total of 57 BPA sessions were performed in 11 CTEPH patients (64% with inoperable disease, 82% under pulmonar vasodilator therapy). Nine patients completed both the BPA program and a minimum six-month follow-up period. There were significant improvements in WHO functional class (p=0.004) and 6MWT (mean increase of 42 m; p=0.050) and a trend for significant hemodynamic improvement: 25% decrease in mean pulmonary artery pressure (mPAP) (p=0.082) and 42% decrease in pulmonary vascular resistance (PVR) (p=0.056). In the group of patients with severely impaired hemodynamics (three patients with mPAP >40 mmHg), the reduction was significant: 51% in mPAP (p=0.013) and 67% in PVR (p=0.050). Prostacyclin analogs and long-term oxygen therapy were withdrawn in all patients. Minor complications were recorded in 25% of patients. There were no major complications or deaths.A BPA strategy on top of pulmonary vasodilator therapy further improves symptoms, exercise capacity and hemodynamics with an acceptable risk-benefit ratio in patients with inoperable CTEPH or residual/recurrent PH after surgery.

A NEWLY ESTABLISHED SURGICAL SEPTAL MYECTOMY PROGRAM FOR OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY IN BRITISH COLUMBIA: EARLY CLINICAL AND ECHOCARDIOGRAPHIC RESULTS

<h3>BACKGROUND</h3> Surgical septal myectomy is an effective treatment for drug-refractory heart failure symptoms in patients with obstructive hypertrophic cardiomyopathy (HCM). Given the low case volume, current practice guidelines recommend HCM surgery to be performed at experienced HCM centres for optimal outcomes. To meet the growing need for septal reduction therapy in British Columbia, a dedicated septal myectomy program was established in September 2019 as part of the provincial HCM referral centre at St. Paul's Hospital in Vancouver. Concerted efforts were made to centralize the case volume and develop standardized perioperative protocols. In this study, we report the early clinical and echocardiographic results of our initial case series. <h3>METHODS AND RESULTS</h3> We retrospectively reviewed our initial experience with septal myectomy performed for symptomatic obstructive HCM at our institution between September 2019 and December 2020. Patients whose primary surgical indication was unrelated to obstructive HCM were excluded. Among 45 patients (62±10 years of age; 49% male) reviewed, 69% had isolated septal myectomy while 31% had planned concomitant procedures (CABG, AVR, and/or MV repair/replacement). Intraoperative provocation with inducible PVCs and isoproterenol infusion, with simultaneous direct needle measurement of LVOT gradient, was performed before and after cardiopulmonary bypass. All operations were performed by one surgeon (JMK) with support of another senior surgeon (JA). All patients underwent comprehensive preoperative assessment by a dedicated HCM cardiologist (KO). Preoperatively, 85% of patients were in NYHA class III or IV while 15% were in NYHA class II. Preoperative echocardiography demonstrated resting LVOT gradient of 65±39 mmHg and Valsalva-provoked gradient of 94±38 mmHg. Five patients had SAM-related 3 or 4+ mitral regurgitation (MR). First postoperative echocardiography at 1-3 months showed significant reduction of resting LVOT gradient to 8±6 mmHg and Valsalva-provoked gradient to 11±8 mmHg. None of the patients had significant SAM or residual 3 or 4+ MR. At time of postoperative follow-up at 3-4 months, 98% of patients had improvement in NYHA functional class, with 76% in class I and 24% in class II. There was no mortality. There was no iatrogenic ventricular septal defect, and none of the patients required unplanned mitral valve repair/replacement. There was no postoperative CVA, AKI requiring dialysis, or complete heart block requiring permanent pacemaker. One patient required mediastinal re-exploration for bleeding in immediate postoperative period. <h3>CONCLUSION</h3> Our experience demonstrates that, with appropriate planning and support, it is feasible for new HCM surgical programs to achieve safe and desired operative results comparable with those of experienced high-volume centres.

Left Bundle Branch Area Pacing: Implant Technique, Definitions, Outcomes, and Complications.

Conduction system pacing (CSP) has emerged during the last few years as the cornerstone of physiological pacing. Two different CSP modalities have been described so far: His bundle pacing (HBP) and left bundle branch area pacing (LBBAP). This review will be focused on the description of LBBAP technique, definitions, outcomes, and complications. Large observational studies have demonstrated the safety and feasibility of LBBAP in different scenarios. LBBAP has been associated with excellent pacing electrical parameters (pacing threshold and R wave sensing) and low complication rates including lead revision < 1%. In patients with cardiac resynchronization therapy (CRT) indication, LBBAP has shown significant improvement of functional class and left ventricular ejection fraction during short-term follow-up. LBBAP is a relatively new CSP modality showing excellent results for patients with conventional bradycardia pacing indications and promising expectations about its potential role for CRT.

Outcome of angiotensin receptor-neprilysin inhibitor on anxiety and depression in heart failure with reduced ejection fraction vs. heart failure with preserved ejection fraction

ABSTRACT Objective: In patients with heart failure (HF), anxiety and depression are commonly observed and confer an adverse outcome. The first-in-class member of angiotensin receptor-neprilysin inhibitor (ARNI), sacubitril/valsartan has been demonstrated to improve functional class and decrease mortality in patients with heart failure with reduced ejection fraction (HFrEF) and reduce the readmission of heart failure with preserved ejection fraction (HFpEF). However, its effects on anxiety and depression levels remain unknown.Methods: Sacubitril/valsartan was started on 764 symptomatic patients with HFrEF and HFpEF who were receiving guideline-directed medical therapy (GDMT) with an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB). Patients were evaluated using Hamilton’s depression rating scale (HDRS) and the hospital anxiety and depression scale (HADS) for their levels of depression and anxiety before and after treatment at a six-month follow-up.Results: A significant reduction in HADS and HDRS scores was observed in patients with HFrEF (9.7 ± 1.3 to 6.4 ± 0.7, p = 0.032 and 19.2 ± 2.2 to 8.9 ± 1.6, p < 0.001, respectively) compared with HFpEF (p = 0.161 and 0.273, respectively). The six-minute walk test (6-MWT) significantly increased HFrEF from 195 ± 68 to 321 ± 97 (p < 0.001). There was an overall improvement in the functional class of all patients.Conclusion: Patients with HFrEF have the additional advantage of using sacubitril/valsartan in the form of decreased anxiety and depression symptoms in addition to an improvement in functional class. However, patients with HFpEF did not exhibit significant improvement in their psychological scores.

Acute and Short-term Results of MitraClip XTR vs. PASCAL Transcatheter Valve Repair System for Edge-to-Edge Repair of Severe Tricuspid Regurgitation

Background Novel device developments enable the edge-to-edge treatment of inoperable patients with severe tricuspid regurgitation (TR) and large coaptation gaps. We compared the acute and short-term results of patients treated with the MitraClip XTR vs. PASCAL system. Methods We retrospectively analysed 120 patients (72 pts. MitraClip XTR, 48 pts. PASCAL) treated for isolated severe TR on a compassionate-use basis. Results Mean patient age was 77 ± 8 years and the LaPar risk score was 6.7 ± 1.7 %. Patients in the PASCAL group had a larger coaptation gap and a trend to more severe TR. Procedural success (TR ≤ 2) was achieved in 92 % of patients in each group (XTR group: 66/72, PASCAL group: 44/48). Thirty-day follow-up was available in 94 % of patients. Two patients in the PASCAL group and one patient in the MitraClip XTR group died within 30-days of the procedure. Device complications were observed in 15.3 % of patients in the XTR group and in 10.4% of patients in the PASCAL group. There was a trend for a more pronounced reduction of vena contracta width in the PASCAL group compared to the XTR group. Tricuspid repair was associated with a comparable improvement in NYHA functional class and 6-minute walking distance in both groups. Conclusion The PASCAL and the MitraClip XTR system appeared to be highly efficacious in treating patients with severe TR with a comparable rate of device complications in both groups but a trend for a more pronounced reduction of vena contracta width in the PASCAL group.

EARLY OUTCOME OF CORONARY ARTERY BYPASS GRAFTING WITH OR WITHOUT MITRAL VALVE INTERVENTION IN PATIENTS WITH MODERATE ISCHEMIC MITRAL REGURGITATION

Background: Ischemic mitral regurgitation is a common clinical problem of coronary artery disease, developing acutely after myocardial infarction in up to 19 % of patients. It may be chronic condition being found approximately in 3 % of patients undergoing coronary angiography, or may less commonly occur as a regional episode of ischemia.Aim of the Work: We reviewed outcomes of the most problematic subgroup of patients in terms of surgical approach—patients with moderate IMR. We evaluated the effectiveness of CABG with or without repair MVr with regard to changes in functional class, postoperative MR, LV function and short term survival benefit.Patients and Methods: Between July 2017 and June 2020, a cohort of sixty patients with ischemic heart disease associated with moderate chronic ischemic mitral regurgitation. The study was carried out in the department of cardiac surgery and other multicenters after obtaining the approval of the local ethical committee and a fully-informed written consent from each patient.Results: After our study evaluation, we found that patients who were offered the combined approach of CABG with repair, showed more improvement as to clinical and echocardiographic parameters, compared to those who were offered the CABG alone procedure. We also found that a worse preoperative LV function is the reason that leads to the persistence or progression of the IMR pathology towards severer grades in the CABG only patients.Conclusion: The efficacy of adding MVR to CABG is well demonstrated by the improvement of NYHA functional class and LVEF over the early (3 months) & late (6 months) postoperative follow-up periods.

Initial Experience With the PASCAL Ace Implant System for Treatment of Severe Tricuspid Regurgitation.

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Sacubitril/Valsartan for heart failure in adults with systemic right ventricle: A single center safety and efficacy experience

Heart failure in adult with congenital heart disease is an important cause of morbi-mortality. Sacubitril/Valsartan has been validated for the treatment of heart failure in adults with left ventricular dysfunction. The aim of this study was to assess safety and efficacy of Sacubitril/Valsartan in symptomatic adults with systemic right ventricle dysfunction. This is a retrospective and single center study (Quebec Heart and Lung Institute, Quebec City, Canada). Eight patients (mean age 41 ± 9.2 years, 5 males) with a significant systemic right ventricle dysfunction in New York functional class II–III despite optimal heart failure medication were included. Sacubitril/Valsartan was up titrated at the maximal dosage tolerated. The mean dosage reached was 85 ± 22 mg/90 ± 24 mg. During a median follow-up of 248 (213–430) days, systolic (121 ± 13 vs. 116 ± 13 mmHg, P = 0.238) and diastolic (76 ± 6 mmHg vs. 72 ± 5 mmHg, P = 0.105) blood pressure, potassium (4.1 ± 0.4 mmol/L vs. 3.9 ± 0.2 mmol/L, P = 0.111) and creatinine (71.7 ± 14.5 μmol/L vs. 68.9 ± 14.7 μmol/L, P = 0.516) levels remained stable. No discontinuation, reduction in dose or side effects were noted. A significant improvement in functional status was observed ( P = 0.03): 6 patients had a New York Heart Association class improvement and 2 remained in the same class ( Fig. 1 ). Maximal oxygen uptake, NTproBNP levels and echocardiographic data did not reach significant improvement. Sacubitril/Valsartan titration in a population of patients with congenital heart disease and significant right ventricle dysfunction was well tolerated and associated with significant improvement in functional status class. Whether Sacubitril/Valsartan improved right ventricle remodeling or decrease heart failure hospitalization or mortality in that population remained to determined.

Hipertensão pulmonar tromboembólica crónica: experiência inicial de doentes submetidos a tromboendarterectomia pulmonar

Introduction and objectivesPulmonary endarterectomy (PEA) is a potentially curative procedure in patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study reports the initial experience of a Portuguese PH center with patients undergoing PEA at an international surgical reference center. MethodsProspective observational study of consecutive CTEPH patients followed at a national PH center, who underwent PEA at an international surgical reference center between October 2015 and March 2019. Clinical, functional, laboratory, imaging and hemodynamic parameters were obtained in the 12 months preceding the surgery and repeated between four and six months after PEA. Results27 consecutive patients (59% female) with a median age of 60 (49‐71) years underwent PEA. During a median follow‐up of 34 (21‐48) months, there was an improvement in functional class in all patients, with only one cardiac death. From a hemodynamic perspective, there was a reduction in mean pulmonary artery pressure from 48 (42‐59) mmHg to 26 (22‐38) mmHg, an increase in cardiac output from 3.3 (2.9‐4.0) L/min to 4.9 (4.2‐5.5) L/min and a reduction in pulmonary vascular resistance from 12.1 (7.2‐15.5) uW to 3.5 (2.6‐5, 2) uW. During the follow‐up, 44% (n=12) of patients had no PH criteria, 44% (n=12) had residual PH and 11% (n = 3) had PH recurrence. There was a reduction of N‐terminal pro‐B‐type natriureticpeptide from 868 (212‐1730) pg/mL to 171 (98‐382) pg/mL. Rright ventricular systolic function parameters revealed an improvement in longitudinal systolic excursion and peak velocity of the plane of the tricuspid ring from 14 (13‐14) mm and 9 (8‐10) cm/s to 17 (16‐18) mm and 13 (11‐15) cm/s, respectively. Of the 26 patients with preoperative right ventricular dysfunction, 85% (n=22) recovered. The proportion of patients on specific vasodilator therapy decreased from 93% to 44% (p<0.001) and the proportion of those requiring oxygen therapy decreased from 52% to 26% (p=0.003). The six‐minute walk test distance increased by about 25% compared to the baseline and only eight patients had significant desaturation during the test. ConclusionPulmonary endarterectomy performed at an experienced high‐volume center is a safe procedure with a very favorable medium‐term impact on functional, hemodynamic and right ventricular function parameters in CTEPH patients with operable disease. It is possible for PH centers without PEA differentiation to refer patients safely and effectively to an international surgical center in which air transport is necessary.

PREVALENCE OF IRON DEFICIENCY ANEMIA AND ITS OUTCOME WITH THREE MONTHS ORAL IRON THERAPY IN PATIENTS WITH CHRONIC HEART FAILURE

Background: To find out the prevalence of Iron deficiency Anemia in CHF patient. Prognostic outcome of treating the underlying Iron deficiency anemia in CHF patient with 3 month oral iron therapy will be measured by peak oxygen uptake, 6 minute walk test, 2D-Echo finding. Methods: The present study was conducted in Cardiac Care Unit (ICCU) of Medicine Department, Dr. S. N. Medical College, Jodhpur. Detailed data collected from 200 patients of congestive heart failure with reduced ejection fraction (LVEF<45%). Patients of acute decompensated heart failure were managed according to standard management guidelines and stabilized. After stabilizing the patient, they were investigated according to the patient Performa. Results: Before therapy, 4 patients had NYHA class II symptoms (9.8%) and 13 had NYHA class III symptoms (31.7%). After 3 months of oral iron therapy, 6 patients were having NYHA class I symptoms, 13 having NYHA class II symptoms and 19 patients were having NYHA class 13 symptoms out of 41 patients. This shows significant improvement in NYHA functional class (P value<0.001). Functional status although improved without change in LV dimensions. Conclusion: Patient with chronic heart failure has high morbidity and mortality despite multimodal therapy. Iron deficiency anemia is common associated co morbidity in HF patients. Oral Iron therapy is associated with improvement in NYHA functional class, patient’s global assessment and 6MWT distance. Keywords: NYHA, MWT, CHF

A randomized, double-blind, placebo-controlled study to evaluate sildenafil, ambrisentan combination therapy in pulmonary hypertension, particularly of Eisenmenger syndrome

Pulmonary arterial hypertension (PAH) - a complex and progressive disease that carries significant morbidity and mortality despite optimal medical treatment. Combination therapy for PAH can be more effective than monotherapy. The present randomized trial compared the safety and efficacy of sildenafil ambrisentan combination therapy with sildenafil monotherapy. Twenty-two patients of Eisenmenger syndrome and five patients of idiopathic PAH were randomized to two arms. There was a significant improvement in NYHA functional class and mean pulmonary artery pressure, while an insignificant improving trend was observed for 6-min walk distance and oxygen saturation, following the 12 weeks of combination therapy. An upfront combination therapy was found to be safe and effective in the management of PAH patients.

Stem cell therapy for dilated cardiomyopathy.

Stem cell therapy for dilated cardiomyopathy.

ADDition of DAPAgliflozin, Sodium-Glucose Cotransporter-2 Inhibitor to Angiotensin Receptor Blocker-Neprilysin Inhibitors Non-Responders in Patient with Refractory Heart Failure with Reduced Ejection Fraction (ADD DAPA trial)

ObjectivesWe evaluated the efficacy and safety of dapagliflozin, a SGLT2i along with ARNI in refractory HFrEF irrespective of their diabetic status. MethodsWe performed a retrospective analysis of 104 symptomatic patients of HFrEF despite of optimal medical management with ARNI between January–June 2020. Despite the optimal GDMT, dapagliflozin, SGLT2i was added inpatients withrefractory heart failure. At 6-months follow-up, the primary outcome was change in left ventricular ejection fraction, and secondary outcomes included changes in NYHA functional class, vital parameters, renal function, potassium levels, and NT-pro BNP levels. ResultsThe primary outcomeat 6-months follow-up was a mean change in left ventricular ejection fraction (LVEF) +9.00 ± 0.62 (p < 0.001). The secondary outcome was a significant improvement (69%) in median NYHA functional class by 2.3 (95% Confidence interval 2.245–2.355) with 92.6% of patients were in NYHA class I and 7.4% were in NYHA class II.Diabetic subgroup reached the HbA1C goal of <7%. None of them had either symptomatic hypotension, hypoglycaemia, dyselectrolaemia, and decline in renal function. The drug was well received by most of the patients. ConclusionsDapagliflozin, an SGLT2i, should be used in symptomatic, refractory HFrEF patients despite the use of ARNI. The combination of ARNI and SGLT2i is well tolerated, but large, randomized trials are needed to prove this hypothesis.