Improvement In Left Ventricular Ejection Fraction Research Articles

Early improvement of strain imaging parameters predicts long-term response to sacubitril/valsartan in patients with heart failure with reduced ejection fraction: An observational prospective study

BackgroundManagement of patients affected by heart failure with reduced ejection fraction (HFrEF) has deeply changed thanks to novel pharmacological therapies, such as Sacubitril/Valsartan, which assured morbidity and mortality advantages in this population. These effects may be mediated by both left atrial (LA) and ventricular reverse remodeling, although left ventricular ejection fraction (LVEF) recovery still represents the main parameter of treatment response. MethodsIn this prospective, observational study, 66 patients with HFrEF and naïve from Sacubitril/Valsartan were enrolled. All patients were evaluated at baseline, at 3 months and 12 months from therapy initiation. Echocardiographic parameters, including speckle tracking analysis, LA functional and structural metrics, were collected at three timepoints. The endpoints of our study were: (1) to evaluate the effects of Sacubitril/Valsartan on echo measurements; (2) to assess the predictive role of early modifications of these parameters (expressed as ∆ 3–0 months) on long-term LVEF significant recovery, defined as >15% improvement from baseline. ResultsThe majority of echocardiographic parameters evaluated progressively improved during the observation period, including LVEF, ventricular volumes and LA metrics. ∆(3–0 months) of LV Global Longitudinal Strain (LVGLS) and LA Reservoir Strain (LARS) were associated with significant LVEF improvement at 12 months (p < 0.001 and p = 0.019 respectively). A cut-off of ∆(3–0 months) LVGLS of 3% and of ∆(3–0 months) LARS of 2% could predict LVEF recovery with satisfactory sensitivity and specificity. ConclusionsLV and LA strain analysis may identify patients who adequately respond to HFrEF medical treatment and should be routinely used in the evaluation of these patients.

SAFETY AND FEASIBILITY OF HYPOXIA EXPOSURE IN PATIENTS WITH PRIOR MYOCARDIAL INFARCTION

Objective: In mice, normobaric hypoxia exposure corresponding to 8,000 m altitude after myocardial infarction reactivated cardiomyocyte proliferation and improved left ventricular ejection fraction (LVEF). Translating these findings to patients might be limited by hypoxia-induced pulmonary hypertension and myocardial ischemia. Design and method: We conducted a feasibility and safety study at the: envihab facility in 4 patients who had experienced myocardial infarction with fully revascularized LAD-stenosis as culprit lesion 37-104 months prior study entry. Their peak VO2 ranged from 32 - 43 ml/kg/min. The study comprised a two-days baseline, 19 days normobaric hypoxia, and two-days recovery. We gradually lowered atmospheric oxygen to 0.118 FIO2, which is equivalent to 4500 m, and maintained that level for 4.5 days. We obtained transthoracic echocardiography, magnetic resonance imaging, and determined Troponin I, NTproBNP at baseline, during 0.118 FIO2, and recovery. Results: Except for symptoms of acute mountain sickness, hypoxia was well tolerated as severe adverse reactions did not occur and pulmonary hypertension rapidly abated during recovery. During the last 10 days of hypoxia, peripheral oxygen saturation was continuously &lt;90%. LVEF was 50.7±11.0 % (mean±SD) baseline, 57.6±11.2% at 0.118 FIO2, and 57.3±11.2% during recovery. Furthermore, echocardiographic LV global longitudinal strain was -15.28±5.4% at baseline and -17.28±7.56 % in recovery. Magnetic resonance imaging confirmed these findings. NTproBNP diminished (baseline: 203±209 pg/ml, 0.118 FIO2: 122±101/pg/ml, recovery: 85±66 pg/ml) and Troponin I concentrations remained in the reference range throughout the study. In the patient with the largest LVEF increase following hypoxia, an additional 12 weeks follow-up measurement showed stable improvements in LVEF (baseline: 36%, recovery: 48%, 12 weeks follow-up: 47%), left ventricular strain, NTproBNP, and exertional dyspnea. Conclusions: Our study provides evidence regarding safety and potential of hypoxia exposure after myocardial infarction and lays the foundation for future studies assessing hypoxia-influences on cardiac regeneration. However, our findings have to be interpreted with caution given the small sample size and the selected patient population.

SACUBITRIL/VALSARTAN ON CLINICAL, LABORATORY, AND ECHOCARDIOGRAPHIC VARIABLES IN HONDURANS WITH HEART FAILURE WITH REDUCED LEFT VENTRICULAR EJECTION FRACTION. FIVE YEARS EXPERIENCE

Objective: This study aimed to describe the response to sacubitril/valsartan in a group of Hondurans with heart failure and reduced Left Ventricular Ejection Fraction (LVEF) between January 2018 and December 2022. Design and method: This observational, descriptive, retrospective cohort study was conducted on 216 adult patients with heart failure and reduced Left Ventricular Ejection Fraction (LVEF) who received treatment with angiotensin-receptor antagonist/neprilysin inhibitors (sacubitril/valsartan) in two medical center in Honduras. The study participants included the patients with LVEF &lt; 40% treated with sacubitril/valsartan for at least one year. The patients also received optimal medical therapy for HFrEF according to the American Heart Association -guidelines. Results: This study was conducted on 216 patients with HFrEF treated with SAC/VAL. The median age of the patients was 71 years. The sociodemographic and clinical variables have been presented in Table 1. Treatment with SAC/VAL was done at three dosages (24/26 mg, 49/51 mg, and 97/103 mg) twice a day. For most of the patients, the treatment was started with 24/26 mg and the dose was progressively titrated to the maximum tolerated dose. 60% completed the follow-up at the optimal dose of 97/103 mg. All the patients had at least one underlying comorbidity. The main comorbidity was hypertension (92.4%) followed by dyslipidemia (61.9%) At the beginning of the study, 64.8%, 29.5% and 5.7% of the patients were in NYHA functional classes IV, III, and II, respectively. Following six months of treatment with SAC/VAL, 58.1% of the patients were in the functional class II, 28.6% were in class III, 9.5% were in class IV and 3.8% were in class I. Based on the results, 82.9% of the patients (n = 180) presented improvement, 16.2% (n = 34) had unchanged functional classes, and 1% showed worse baseline conditions (Figure 1). The results revealed the improvement of LVEF in 94.3% of the cases after treatment with SAC/VAL, while 3.8% presented no changes in this regard. Conclusions: The study population had sociodemographic and clinical similarities with the Latin American Cohort in the PARADIGM-HF trial with the significant improvement of the LVEF and functional class.

Utility of Routine Transthoracic Echocardiographic Parameters to Predict Functional Recovery after Catheter Ablation Therapy in Patients with Atrial Fibrillation and Left Ventricular Systolic Dysfunction.

Arrhythmia-induced cardiomyopathy (AIC) occurring in patients with atrial fibrillation (AF) is a reversible form of cardiomyopathy characterized by LV systolic dysfunction. However, it is difficult to predict the reversibility before rhythm control therapy. We performed this study to develop a parameter for the identification of AIC in routine transthoracic echocardiography (TTE) in patients with presumptive AIC due to AF.We retrospectively studied 72 patients treated with catheter ablation therapy for persistent AF, and LV ejection fraction (LVEF) ≤ 45%. The patients were divided into 2 groups by follow-up TTE performed within 12 ± 6 months postoperatively. Patients with ≥ 15% improvement in LVEF or ≥ 10% improvement and ≥ 50% in LVEF were classified as the AIC group, and the others were classified as the non-AIC group.A total of 57 (79%) patients were classified as the AIC group. In the stepwise multivariate logistic regression model, LV end-diastolic dimension (LVDd) and e' (septal) were independent predictors of AIC. The sensitivities of LVDd ≤ 53 mm and e' (septal) ≥ 6.3 cm/second were 60% and 75%, respectively. Their specificities were 80% and 67%, respectively. The presence of either LVDd ≤ 53 mm or e' (septal) ≥ 6.3 cm/second had a higher sensitivity (90%); their co-occurrence had a higher specificity (93%) in predicting AIC.The functional recovery in patients with AIC can occur in LV systolic dysfunction without remodeling and impairment of relaxation. The combination of LVDd and e' (septal) is useful in predicting AIC due to AF with routine TTE.

Mindfulness-based stress reduction combined with early cardiac rehabilitation improves negative mood states and cardiac function in patients with acute myocardial infarction assisted with an intra-aortic balloon pump: a randomized controlled trial.

To investigate the clinical effects of mindfulness-based stress reduction (MBSR) intervention combined with early cardiac rehabilitation (CR) on patients with acute myocardial infarction (AMI) assisted with an intra-aortic balloon pump (IABP). A total of 100 AMI patients with IABP assistance due to hemodynamic instability at Wuhan Asia Heart Hospital were enrolled in the study. The participants were divided into two groups using the random number table method (n = 50 each group). Patients receiving routine CR were assigned to the CR control group, while patients receiving MBSR plus CR were assigned to the MBSR intervention group. The intervention was performed twice a day until the removal of the IABP (5-7 days). Each patient's level of anxiety/depression and negative mood state were evaluated before and after intervention using the self-rating anxiety scale (SAS), self-rating depression scale (SDS), and profiles of mood state scale (POMS). The results of the control and intervention groups were compared. IABP-related complications and left ventricular ejection fraction (LVEF), measured with echocardiography, were also assessed and compared between the two groups. The SAS, SDS, and POMS scores were lower in the MBSR intervention group than in the CR control group (P < 0.05). There were also less IABP-related complications in the MBSR intervention group. LVEF was significantly improved in both groups, but the degree of LVEF improvement was more significant in the MBSR intervention group than in the CR control group (P < 0.05). MBSR combined with early CR intervention can assist in alleviating anxiety, depression, and other negative mood states, reduce IABP-related complications, and further improve cardiac function in AMI patients with IABP assistance.

The specific value of upgrading to left bundle branch area pacing in patients with pacing-induced cardiomyopathy or non-pacing-induced cardiomyopathy related upgrade status: A retrospective study.

Left bundle branch area pacing (LBBaP) upgrade can improve cardiac function and clinical outcomes in patients with pacing-induced cardiomyopathy (PICM), but the specific value of LBBaP upgrade, especially compared with the cardiac function level before right ventricular pacing (RVP) in patients with PICM and non-pacing-induced cardiomyopathy-related upgrade status (Non-PICMUS) is still unknown. This study retrospectively enrolled 70 patients with LBBaP upgrade (38 patients with PICM and 32 patients with Non-PICMUS). All upgrade patients experienced three stages: before RVP (Pre-RVP), before LBBaP upgrade (Pre-LBBaP), and after LBBaP upgrade (Post-LBBaP). QRS duration (QRSd), lead parameters, echocardiographic indicators, and clinical outcomes evaluation were recorded at multiple time points. At the follow-up of 12 months, for PICM patients, left ventricular ejection fraction (LVEF) significantly increased from 36.6%±7.2% to 51.3%±8.7% Post-LBBaP (p<.001), and left ventricular end-diastolic diameter (LVEDD) significantly decreased from 61.5±6.4mm to 55.2±6.5mm Post-LBBaP (p<.001), but they both failed to restore the level Pre-RVP (both p<.001). For PICM patients, New York Heart Association (NYHA) classification, the number of moderate-to-severe heart failure (NYHA III-IV), and diuretics using rate after the LBBaP upgrade also could not restore to the level Pre-RVP (all p<.001). At the follow-up of 12 months, Non-PICMUS patients after the LBBaP upgrade had no significant improvement in LVEF, LVEDD, and NYHA classification (all p>.05). LBBaP upgrade effectively improved the cardiac function and clinical outcomes in PICM patients, but its effectiveness seemed to be limited as the deteriorated cardiac function cannot be completely reversed. For Non-PICMUS patients, the cardiac function and clinical outcomes Post-LBBaP had no significant improvement.

The risk of obesity and the association of body mass index on all-cause mortality after cardiac resynchronization therapy

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union. Background Overweight and obese people have a higher risk of acquiring heart failure, however these patients tend to have more favorable outcome, a phenomenon known as the obesity paradox. Purpose We aimed to investigate the risk of obesity and the association of body mass index (BMI) on all-cause mortality in heart failure CRT patients at long-term. Methods We examined retrospectively 1585 patients undergoing CRT implantation at our clinic between 2000-2020 with their BMI available at baseline. Patients were sorted into three groups: normal weight (BMI ‹25), overweight (BMI 25-29.9) and obese (BMI≥30). The composite primary endpoint was all-cause mortality, heart transplantation or implantation of a left ventricular assist device. Time-to-event data was studied by log-rank and multivariate Cox regression analysis. We studied peri-procedural complication rates, and reverse remodeling, defined as a ≥15% relative increase in left ventricular ejection fraction (LVEF) within 6 months after CRT implantation. Results During our mean follow-up time of 5.1 years, 973 (61%) reached our primary endpoint, 302 (66%) in the BMI ‹25 group, 389 (61%) in the BMI 25-29.9 group and 282 (58%) in the BMI≥30 group. Obese patients showed mortality benefit over normal-weighed patients (HR 0.78; 95%CI 0.66-0.92; p=0.003), with only a trend in overweight patients over normal-weighed patients (HR 0.86; 95%CI 0.74-1.00; p=0.05). At multivariate analysis, BMI ‹25 patients showed a 19% higher risk of all-cause mortality compared to overweight and obese patients (HR 1.19; 95%CI 1.03-1.38; p=0.02) after adjusting for age, sex, NYHA class, diabetes, hypertension, myocardial infarction and atrial fibrillation. Obese and overweight patients were younger than normal-weighed patients (68yrs. vs. 69yrs. vs. 70 yrs.; p‹0.0001), similar sex distribution can be seen. Diabetes (BMI ‹25 48% vs. BMI 25-29.9 37% vs. BMI≥30 26%; p‹0.0001) and hypertension (BMI ‹25 82% vs. BMI 25-29.9 74% vs. BMI≥30 71%; p‹0.001) occurred more frequently in obese and overweight patients. Obese and overweight patients had a higher LVEF than in the normal weight group (30% vs. 28% vs. 27%; p‹0.001), respectively. Peri-procedural complication rates did not differ in the three groups. In all patient groups, a significant improvement in LVEF at 6 months was seen (BMI ‹25 ∆-EF 7%, BMI 25-29.9 ∆-EF 7.5%, and BMI ≥30 ∆-EF 6; p&amp;lt;0.001). No difference was seen in the proportion of developing reverse remodeling (BMI ‹25 58% vs. BMI 25-29.9 61% vs. BMI≥30 57%; p=0.75). Conclusions Despite having more co-morbidities like diabetes or hypertension, obese patients showed mortality benefit over normal-weighed patients proving, that the obesity paradox was present in our CRT patient cohort at long-term. Peri-procedural complications did not occur more frequently in obese or overweight patients. Echocardiographic response did not vary, similar reverse remodeling was observed across the patient groups.

The impact of intravenous ferric carboxymaltose on reverse electrical remodeling following cardiac resynchronization therapy

Abstract Funding Acknowledgements Type of funding sources: None. Background The effect of intravenous ferric carboxymaltose (FCM) on reverse electrical remodeling (RER) in patients with heart failure with reduced ejection fraction (HFrEF) following cardiac resynchronization therapy (CRT) implantation is unknown. Purpose The current study aims to examine the effect of iron replacement with intravenous FCM on RER in CRT-implanted patients with HFrEF and iron deficiency. Methods The present study retrospectively analyzed 65 patients with successful CRT-D device implantation between March 2017 and January 2020 with iron deficiency (defined as ferritin &amp;lt;100 μg/L) at implantation. Follow-up data were obtained from the 6-month routine follow-up visits of patients following CRT implantation. Demographic characteristics, laboratory results, medical history, medication details, functional status, information on whether intravenous FCM therapy was administered during CRT device implantation, echocardiographic left ventricular (LV) measurements, baseline electrocardiogram (ECG) recorded before CRT device implantation, and follow-up ECG were collected for analysis for each study patient. From baseline to 6-month follow-up, the change in intrinsic QRS duration (without biventricular pacing) was calculated as a primary endpoint, and the change in LV ejection fraction (LVEF) was assessed as a secondary endpoint of the study. Results Thirty-five of 65 patients were in the FCM group, while the remaining 30 study participants were in the non-FCM. The two study groups were similar regarding baseline characteristics, except for ferritin levels, which were minimally significantly lower in the FCM group (10.7±5.0μg/L vs 13.5 ±3.9μg/L, p= 0.012). At the 6-month follow-up, both mean ferritin levels increased significantly in the FCM group compared to baseline (from 10.7±5.0 to 86.5±7.6μg/L, p &amp;lt; 0.0001), while these levels were not significantly increased in the non-FCM group (from 13.5±3.9 to 14.1±4.2μg/L, p = 0.962). There was a significant reduction in intrinsic QRS durations compared to baseline at 6-month follow-up after CRT implantation in both FCM and non-FCM group (from 148.4±5.3 to 138.0±5.1ms, p &amp;lt; 0.0001; from 149.8±5.0 to 146.8±4.6ms, p &amp;lt; 0.0001, respectively). The change in intrinsic QRS duration from baseline to 6-month follow-up was significantly greater in the FCM group than in the non-FCM group (-10.4±2.2ms vs -3±2.9ms, p &amp;lt; 0.0001). At the 6-month follow-up, the change in LVEF from baseline was significantly higher in the FCM group than in the non-FCM group (+3.6±1.6% vs -0.1±1.7%, p &amp;lt; 0.0001). The change in ferritin level was negatively correlated with the change in intrinsic QRS duration (r = -0.725, p &amp;lt; 0.0001), whereas there was a positive correlation between the change in ferritin level and the change in LVEF (r = 0.712, p &amp;lt; 0.0001). Conclusions Treatment with FCM was induced RER and improvement in LVEF in HFrEF patients with iron deficiency following CRT implantation.

The feasibility and safety of his-purkinje conduction system pacing in patients with heart failure with severely reduced ejection fraction.

The purpose of this study was to evaluate the feasibility and outcomes of conduction system pacing (CSP) in patients with heart failure (HF) who had a severely reduced left ventricular ejection fraction (LVEF) of less than 30% (HFsrEF). Between January 2018 and December 2020, all consecutive HF patients with LVEF < 30% who underwent CSP at our center were evaluated. Clinical outcomes and echocardiographic data [LVEF and left ventricular end-systolic volume (LVESV)], and complications were all recorded. In addition, clinical and echocardiographic (≥5% improvement in LVEF or ≥15% decrease in LVESV) responses were assessed. The patients were classified into a complete left bundle branch block (CLBBB) morphology group and a non-CLBBB morphology group according to the baseline QRS configuration. Seventy patients (66 ± 8.84 years; 55.7% male) with a mean LVEF of 23.2 ± 3.23%, LVEDd of 67.33 ± 7.47 mm and LVESV of 212.08 ± 39.74 ml were included. QRS configuration at baseline was CLBBB in 67.1% (47/70) of patients and non-CLBBB in 32.9%. At implantation, the CSP threshold was 0.6 ± 0.3 V @ 0.4 ms and remained stable during a mean follow-up of 23.43 ± 11.44 months. CSP resulted in significant LVEF improvement from 23.2 ± 3.23% to 34.93 ± 10.34% (P < 0.001) and significant QRS narrowing from 154.99 ± 34.42 to 130.81 ± 25.18 ms (P < 0.001). Clinical and echocardiographic responses were observed in 91.4% (64/70) and 77.1% (54/70) of patients. Super-response to CSP (≥15% improvement in LVEF or ≥30% decrease in LVESV) was observed in 52.9% (37/70) of patients. One patient died due to acute HF and following severe metabolic disorders. Baseline BNP (odds ratio: 0.969; 95% confidence interval: 0.939-0.989; P = 0.045) was associated with echocardiographic response. The proportions of clinical and echocardiographic responses in the CLBBB group were higher than those in the non-CLBBB group but without significant statistical differences. CSP is feasible and safe in patients with HFsrEF. CSP is associated with a significant improvement in clinical and echocardiographic outcomes, even for patients with non-CLBBB widened QRS.

Effects of Atrioventricular Optimization on Left Ventricular Reverse Remodeling With Cardiac Resynchronization Therapy: Results of the SMART-CRT Trial.

The role of atrioventricular optimization (AVO) to improve cardiac resynchronization therapy outcomes remains controversial. Previous post hoc analyses of a multicenter trial showed that measures of electrical dyssynchrony (right ventricular-left ventricular [LV] or QLV durations) are associated with patients who benefit from AVO. This was a global, multicenter, prospective, randomized trial of de novo cardiac resynchronization therapy implant patients with an right ventricular-LV duration ≥70 ms to determine whether AVO results in greater reverse remodeling. Patients were randomized 1:1 for either an AVO algorithm (SmartDelay) that determines atrioventricular delay and pacing chamber, biventricular or LV only, or a fixed atrioventricular delay of 120 ms with biventricular pacing. Paired echocardiograms performed at baseline and 6 months were evaluated. The primary end point was echocardiographic cardiac resynchronization therapy response, defined dichotomously as a >15% reduction in LV end-systolic volume. A total of 310 patients (n=120 women) were randomized and had completed 6 months of follow-up. The echocardiographic cardiac resynchronization therapy response rate did not statistically differ between the groups (SmartDelay, 74.8%; fixed, 67.7%; P=0.17). Analyses of prespecified secondary end points demonstrated significant improvements in the absolute (median: SmartDelay, -41.0 mL; fixed, -33.0 mL; P=0.01) and relative change in LV end-systolic volume (SmartDelay, -38.3%; fixed, -27.8%; P=0.03) for patients with SmartDelay optimization. Similar results were observed for the relative improvement in LV ejection fraction (SmartDelay, 46.7%; fixed, 32.1%; P=0.050); absolute improvement in LV ejection fraction trended to be higher with SmartDelay (P=0.06). Analysis of reverse remodeling parameters demonstrated that AVO via SmartDelay, relative to the nonoptimized fixed atrioventricular delay comparator group, improved absolute and relative changes in LV function in patients with longer right ventricular-LV duration. URL: https://www. gov; Unique identifier: NCT03089281.

Comparative analysis of ischemic and non-ischemic etiology of acute heart failure - analysis from the "OP-AHF" registry

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): This work was supported by a grant from the Institute of Medical Sciences, University of Opole, Poland. ROCHE Diagnostics Poland. Introduction Current guidelines of the European Society of Cardiology define acute heart failure as the rapid onset of symptoms and/or signs of heart failure, severe enough for the patient to seek urgent medical attention, leading to an unplanned hospital admission or an emergency department visit. Purpose The aim of this study was to compare clinical characteristics, treatment, and 12-month outcomes of patients with ischemic(I-AHF) and non-ischemic acute heart failure(NI-AHF). Materials and Methods As a part of the open prospective Acute Heart Failure Registry (OP-AHF),data 122 patients hospitalized in the Intensive Cardiac Care Unit were collected in the period from June 2019. The inclusion criteria were hospitalization for acute heart failure and the need to use at least one of: intravenous diuretics, catecholamines or mechanical circulatory support. The project was approved by the Bioethical Committee. Results Patients with ischemic etiology of acute heart failure (I-AHF) constituted 43% of the study group (53 of 122 patients). Compared to patients with non-ischemic etiology of acute heart failure (NI-AHF), patients with I-AHF were older (69 vs. 64 years, p = 0.04) and slightly more frequently male (79% vs. 67%, p=0.12). BMI was similar in both groups (29 vs. 30, p=0.21). On admission, they reported more frequently chest pain (49% vs. 33%, p = 0.08), and less frequently than NI-AHF patients, edema (40% vs. 54%, p = 0.12) and dyspnoea (91% vs. 97%, p =0.25). History of diabetes (60% vs. 20%, p&amp;lt;0.01) and chronic kidney disease (38% vs. 20%, p =0.03) were predominant in I-AHF patients,but atrial fibrillation (36% vs 57%, p=0.02) was less common than in NI-AHF patients. Laboratory results on admission showed significantly higher NT-proBNP levels in the I-AHF patients (11078 vs 7785 pg/ml, p &amp;lt; 0.004). Left ventricle ejection fraction (LVEF) was lower on admission (29% vs 35%, p= 0.02) and at discharge (34% vs 39%, p = 0.19) in I-AHF patients. At 12-month follow-up, there was no improvement of LVEF in I-AHF patients in contrast to NI-AHF patients (34% vs 47%, p &amp;lt;0.001). Death during hospitalization occurred more frequently in the I-AHF patients group (15% vs 3%, p=0.01). The rates of cardiovascular rehospitalisations within 12 months was 23% in patients with I-AHF patients compared to 32% in NI-AHF patients, p=0.3;HR=0.70 (95% CI = 0.35-1.38). The risk of death from any cause within 12 months was lower in patients with I-AHF (17% vs. 32%, p=0.056; HR = 0.49 (95% CI = 0.23-1.02)), nevertheless, after adjustment for age, sex, LVEF and NT-proBNP, mortality was essentially identical in both groups, 24% inI-AHF and 23% in NI-AHF, p=0.99; HR=1.00 (0.45-2.24). Conclusions Despite a worse in-hospital outcomes, ischemic etiology of acute heart failure was not associated with a higher risk of cardiovascular rehospitalization and death at 12-month follow-up than non-ischemic etiology.

Alcoholic cardiomyopathy- characterization and outcomes

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Alcoholic cardiomyopathy is a severe consequence of chronic alcohol abuse and causes gradual changes in the structure and function of the heart, being a form of dilated cardiomyopathy. Purpose To characterize the population of patients (pts) with alcoholic cardiomyopathy (AC) in terms of baseline characteristics, echocardiographic parameters, alcohol consumption, medication and outcomes. We also intended to evaluate the impact of alcohol reduction/cessation. Methods We performed a retrospective study of the group of pts with the diagnosis of AC, established after exclusion of other aetiologies, followed in the heart failure consultation between 2018 and 2022. We divided the population into patients who maintained (2), reduced (1) (to an average of 2 drinks in men and 1 in women) or discontinued consumption (0). Results A total of 39 pts with a mean age of 68.13 ± 11 years were included. Of these, 35 were males (89.7%). In terms of cardiovascular risk factors, 64.1% had hypertension, 33.3% had diabetes, 53.5% dyslipidaemia, 10.3% had chronic hepatic disease, 30.8% were smokers and 10.3% ex-smokers. The prevalence of atrial fibrillation (AF) was 46.2%, with a median heart rate of 72.50 ± 20.99 bpm. At the beginning of follow-up, this population had a mean left ventricular ejection fraction (LVEF) of 30.46% ± 9.99, a mean indexed LA volume of 58.5 ml/m2 ± 32.63 and a mean indexed LV volume 87.44% ± 27.73. Concerning the alcohol consumption, during the follow-up, 43.6% of the patients stopped drinking alcohol, 10.3% reduced the habits and 20.5% maintained the consumption. Regarding the medication, at the end of follow-up 24.4% were medicated with sacubitril/valsartan, 51.1% with angiotensin-converting enzyme inhibitors, 71.1% with beta blockers, 51.1% with mineralocorticoid receptor antagonists and 35.6% with SGLT2 inhibitors. In a mean follow-up of 26.62± 11.11 months, there was a significant improvement of the ejection fraction (mean of 9.59% ± 12.97, p&amp;lt; 0.001), with a mean LVEF of 40.59% ± 12.78 at the end of follow-up. In fact, in 17.8% of the patients the final LVEF was more than 50%. Regarding indexed LV volume, there was a significant reduction during follow-up (102.250 ± 43.46 ml/m2, p= 0.018). Concerning alcohol consumption, pts who quit drinking had a mean improvement of LVEF of 13,73% ± 15.83 (p= 0.003), pts who reduced alcohol consumption 8.6% ± 5.81 (p=0.03) and pts that kept the consumption 2.67% ± 3.01 (p= 0.82). The variation of LVEF was statistically significant between the groups (p=0.03). These three groups had no statistically significant differences in medical history of hypertension (p=0.37), diabetes (p=0.22), dyslipidaemia (p=0.17), AF (p=0.70) and medication. Conclusion Pts with alcoholic cardiomyopathy had a high prevalence of atrial fibrillation and cardiovascular risk factors. Improvement and even recovery of cardiac function depends on reduction/extinction of alcohol consumption.

CE-452776-3 IS RATE CONTROL EVER ADEQUATE? CATHER ABLATION IN RATE CONTROLLED ATRIAL FIBRILLATION WITH REDUCED EJECTION FRACTION

The optimal rate control target for atrial fibrillation (AF) in the setting of heart failure with reduced ejection fraction (HFrEF) is not defined. Prior clinical trials have demonstrated benefits of AF ablation for patients with HFrEF, including recovery in left ventricular ejection fraction (LVEF). However, it is unknown if degree of rate control prior to ablation affects outcomes. To evaluate whether degree of pre-ablation rate control impacts LVEF recovery following AF ablation in patients with HFrEF. A single center, retrospective cohort study of 75 consecutive patients with LVEF ≤35% who underwent first-time ablation for persistent AF at NYU Langone Health between January 2014 and January 2021. Patients were classified as having a LVEF recovery if their post-ablation LVEF was >35%. Proportion of patients with LVEF recovery were compared between multiple rate control cutoffs: 110 bpm, 90 bpm, and 70 bpm. A binomial logistic regression analysis was then performed examining the relationship of pre-ablation HR on LVEF recovery. The mean pre-ablation HR was 90±25 bpm, baseline LVEF was 27±6%, and 64% (48/75) of patients had at least 3 months of maximal GDMT prior to ablation (Table 1A). Significant improvement in LVEF was observed in all patient subgroups irrespective of rate control status (Figure 1A) and regardless of prior GDMT (Figure 1B). Overall, LVEF recovery to >35% occurred in 59% (44/75) of patients. Compared to patients with pre-ablation HR faster than evaluated rate control cutoffs (Table 1B), there were no differences in frequency of LVEF recovery when using ≤110 bpm (controlled: 58% vs. not controlled: 63%, p=0.73) or ≤90 bpm (controlled: 52% vs. not controlled: 66%, p=0.21). In contrast, patients achieving rate control ≤70 bpm were significantly less likely to have LVEF recovery (41%) compared to those with HR above the cutoff (66%; p=0.04). Binomial logistic regression analysis did not reveal HR as a significant predictor of LVEF recovery (OR=1.01; CI 95%=0.99-1.03; p=0.16). Catheter ablation of persistent in AF in patients with HFrEF frequently resulted in improvement in LVEF, irrespective of achieved rate control. LVEF recovery >35% following catheter ablation was reduced only with rate control of HR 70bpm. Catheter ablation should be considered in HFrEF patients regardless of degree of rate control achieved. Heart rate 70bpm should be evaluated as a goal for adequate rate control in patients with HFrEF in whom rhythm control is not pursued.

PO-01-099 EARLY REMODELING OF THE LEFT ATRIUM FOLLOWING CATHETER ABLATION OF PERSISTENT ATRIAL FIBRILLATION: THE IMPACT OF SUBSTRATE MODIFICATION IN DECAAF II

Left Atrial (LA) enlargement is prevalent amongst atrial fibrillation (AF) patients and constitutes an important marker of underlying atrial myopathy. Several studies have described reduction in LA volume following catheter ablation (CA) of AF, however, none have investigated differences in remodeling related to additional ablation outside of the pulmonary veins. We sought to compare early remodeling of the LA between patients who received pulmonary vein isolation (PVI) only, and those who received additional fibrosis-guided extra-PV ablation. This study was a retrospective analysis of the DECAAF II randomized controlled trial. Patients with persistent AF (perAF) were randomized to receive PVI only or PVI + fibrosis-guided ablation. Late Gadolinium Enhancement Magnetic Resonance Imaging (LGE-MRI) was performed before and three months after CA to measure LA volume. Only patients in sinus rhythm at both MRIs are included. Patients were followed up with single-lead ECG devices for 12-18 months. Arrhythmic burden was calculated as the percentage of ECGs exhibiting AF. Univariate and multivariate regression were used to identify predictors of LA volume change. This analysis included 206 patients who met our inclusion criteria. The mean LA volume before ablation was 114.6 ± 36.9 mm3, and the mean volume post-ablation was 101.2 ± 32.3 mm3, with a mean reduction of 13.5 ± 22.3 mm3 (9.92% reduction, p <0.001). Patients randomized to receive MRI-guided fibrosis ablation had more LA volume reduction than patients who were randomized to PVI only (17.03 ± 25.04 mm3 vs 10.17 ± 18.89 mm3, p=0.03). This association persisted with multivariate analysis where pre-ablation left ventricular ejection fraction (LVEF) and randomization to receive substrate modification were the only predictors of LA volume reduction (table). LA volume reduction was associated with greater improvement in LVEF, regardless of treatment randomization (r = 0.242, p = 0.01). LA volume reduction did not predict arrhythmia recurrence when considered as a continuous variable. We noted more pronounced LA volume reductions in patients randomized to receive PVI + fibrosis-guided ablation when compared to those randomized to receive PVI only. We hypothesize worsened left atrial relaxation and diastolic dysfunction as an etiology for this difference, but further study is needed to better characterize the important structural impacts of extra-PV ablation.

PO-455617-16 EFFECTS OF ADDING POSTERIOR WALL ISOLATION TO PULMONARY VEIN ISOLATION IN PERSISTENT ATRIAL FIBRILLATION AND HEART FAILURE WITH REDUCED EJECTION FRACTION (HFREF)

Catheter ablation in AF and heart failure with reduced ejection fraction (HFrEF) is associated with improved left ventricular ejection fraction(LVEF) and survival compared with medical therapy. Previous non-randomized studies have shown high success rates with adjunctive ablation strategies beyond pulmonary vein isolation (PVI), including posterior wall isolation (PWI). To examine differences in arrhythmia outcomes between PVI alone versus PVI with PWI in patients with concomitant persistent AF (PsAF) and HFrEF CAPLA was a multi-centre, prospective, randomized trial involving PsAF patients assigned to PVI alone or PVI with PWI. This substudy included patients with HFrEF(LVEF<50% on echocardiography). The primary endpoint was freedom from any documented atrial arrhythmia of>30 seconds, after a single ablation procedure, off anti-arrhythmic therapy(AAD) at 12 months. 98 patients with PsAF and HFrEF(mean age 62.1+/-9.8 years, 79.5% males, median LVEF 35+/-13%). 46.9% underwent PVI with PWI. After 12 months, 58.7% with PVI and PWI were free from recurrent atrial arrhythmia off AAD vs 61.5% of patients with PVI alone (HR1.02, 95% CI 0.54-1.91, p=0.96). There were no significant differences in freedom from any atrial arrhythmia on/off AAD after multiple procedures (PVI with PWI 60.9% vs PVI 65.4%; HR1.12, 95%CI 0.58-2.16; p=0.73), freedom from symptomatic atrial arrhythmia on/off AAD after multiple procedures (PVI with PWI 69.5% vs PVI 75%; HR 1.23, 95%CI 0.58-2.62; p=0.59), or median AF burden at 12 months (PVI with PWI 0% [IQR 0-2.63] vs PVI 0% [IQR0-2.59]; p=0.78). Median LVEF improved in PVI with PWI(LVEF increased by19.3+/-12.9%,p<0.01), and PVI alone (LVEF increased by 18.2+/-14%, p<0.01), with no difference between groups(p=0.71). Normalisation of LV function(≥50%) occurred in 71.4% in PVI with PWI compared with 59.1% with PVI alone(p=0.26). Catheter ablation is associated with significant LVEF improvements in PsAF and HFrEF. However adding PWI to PVI did not improve freedom from arrhythmia recurrence nor recovery of LVEF.

CI-452766-3 LEFT BUNDLE BRANCH AREA PACING IN PATIENTS WITH SEVERELY REDUCED LEFT VENTRICULAR EJECTION FRACTION

Left bundle branch area pacing (LBBAP) has been used as an alternative to biventricular pacing (BiVp) to achieve cardiac resynchronization therapy (CRT). However, its use in patients with severely reduced left ventricular ejection fraction (LVEF) has not been described. To evaluate the outcomes of LBBAP compared to BiVp in patients with an LVEF ≦20%. In this multicenter study, consecutive adult patients with ischemic and non-ischemic cardiomyopathy and an LVEF <35% undergoing CRT were included. LBBAP was offered as a first line treatment strategy after thorough discussion with patients; the last consecutive patients in whom BiVp was performed were used as controls. Patients were analyzed according to their LVEF (≤20% vs. 21-35%) and the pacing strategy used (LBBAP vs BiVp). The primary outcome was a composite of HF-related hospitalization and all-cause mortality. Secondary outcomes included individual components of the primary outcome, procedural and fluoroscopy times, paced QRS duration, change in LVEF, final LVEF, and change in HF-related symptoms. A total of 342 patients (mean age 69.7±11.2, female 30.1%; 117 with LVEF ≤20%) were included. No significant differences in the primary outcome or HF-related hospitalization were found in patients with LVEF ≤20% compared to patients with an LVEF 21-35%, but patients with a baseline LVEF ≤20% had a higher all-cause mortality (OR: 2.35; 95%CI 1.018-5.436, p=0.047). There were no differences in the primary outcome in patients with LVEF ≤20% treated with LBBAP vs. BiVp. However, patients with an LVEF ≤20% treated with LBBAP had significantly lower fluoroscopy times (17.5±10.3 vs. 23.1±15.4 mins., p=0.03), shorter paced QRS durations (124.6±18.7 vs. 151.1±34.3 msec, p<0.001), greater improvements in LVEF (8.1±11.2 vs. 3±5.7%, p=0.011), higher final LVEF (26.7±12.9 vs. 21.1±7.2%, p=0.018) and were less symptomatic (NYHA class 1.83±0.93 vs. 2.27±0.88, p=0.018) than patients treated with BiVp, respectively. A baseline LVEF ≤20% was associated with significantly longer procedural and fluoroscopy times in patients undergoing LBBAP compared to a baseline LVEF 21-35%. Patients with a baseline LVEF ≤20% have a higher all-cause mortality than patients with an LVEF 21-35%. Patients with an LVEF ≤20% treated with LBBAP have lower fluoroscopy time, shorter paced QRS duration, significantly less HF related symtpoms, greater changes and higher final LVEF than patients treated with BiVp.

MP-453089-9 OUTCOMES WITH GUIDELINE-DIRECTED MEDICAL THERAPY AND CARDIAC IMPLANTABLE ELECTRONIC DEVICE THERAPIES FOR PATIENTS WITH HEART FAILURE WITH REDUCED EJECTION FRACTION

Foundational guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) now consists of 4 classes. There is limited real-world evidence for outcomes associated with GDMT or GDMT with cardiac implantable electronic device therapies (here, implantable cardiac defibrillators [ICDs]/cardiac resynchronization therapy defibrillators [CRT-Ds]). The present study assessed outcomes associated with GDMT or GDMT with ICD/CRT-D for patients with HFrEF and left ventricular ejection fraction (LVEF) ≤35%. We analyzed patients (age ≥18 years) with HFrEF (LVEF ≤35%) in a deidentified real-world dataset including 5,218,134 patients from 20 US institutions with appropriate permissions (egnite Database; egnite, Aliso Viejo, CA, US). Treatment rates, LVEF improvement, and all-cause mortality were examined using unadjusted Kaplan–Meier analysis with first documented echocardiogram with LVEF ≤35% as index event. Mortality analysis used prescribed GDMT class count and device placement as time-varying covariates and censored patients at last clinical encounter. Treatment rate and LVEF improvement analysis censored patients at last clinical encounter/death. Of 362,693 patients with documented HF, 22,061 were included with LVEF ≤35%, prescription history through ≥1 year pre-index, and no device therapy pre-index. Median (IQR) time from index to censor/death was 13.5 (4.2–27.1) months. At index, 95.7%, 73.5%, 29.4%, and 3.5% of patients had ≥1, 2, 3, or all 4 GDMT classes prescribed, respectively. At 18 months, an estimated (95% CI) 98.7% (98.5–98.9%), 84.8% (84.5–85.1%), 43.2% (42.7–43.7%), and 8.1% (7.7–8.4%) had ≥1, 2, 3, or all 4 GDMT classes prescribed, respectively; an estimated 15.3% (14.7–15.9%) had device placement. Of those without a device, by 18 months, an estimated 39.1% (38.2–40.0%) had a documented LVEF >35%. Cohorts with a device and 2, 3, or 4 GDMT classes prescribed had estimated 18-month survival of 83.1% (79.2–87.2%), 85.4% (82.0–89.0%), or 88.9% (83.5–94.8%), respectively (Figure). There were insufficient data for analysis of those with a device and 0/1 GDMT classes. Cohorts without a device and 0, 1, 2, 3, or 4 GDMT classes prescribed had estimated 18-month survival of 70.8% (66.3–75.6%), 73.4% (71.7–75.2%), 77.8% (76.8–78.8%), 81.8% (80.7–82.9%), and 87.6% (85.4–89.9%), respectively (Figure). Higher counts of GDMT classes prescribed and device therapy with GDMT were associated with greater survival in this population.

AB-452643-4 EFFECTS OF ADDING POSTERIOR WALL ISOLATION TO PULMONARY VEIN ISOLATION IN PERSISTENT ATRIAL FIBRILLATION AND HEART FAILURE WITH REDUCED EJECTION FRACTION (HFREF)

Catheter ablation in AF and heart failure with reduced ejection fraction (HFrEF) is associated with improved left ventricular ejection fraction(LVEF) and survival compared with medical therapy. Previous non-randomized studies have shown high success rates with adjunctive ablation strategies beyond pulmonary vein isolation (PVI), including posterior wall isolation (PWI). To examine differences in arrhythmia outcomes between PVI alone versus PVI with PWI in patients with concomitant persistent AF (PsAF) and HFrEF CAPLA was a multi-centre, prospective, randomized trial involving PsAF patients assigned to PVI alone or PVI with PWI. This substudy included patients with HFrEF(LVEF<50% on echocardiography). The primary endpoint was freedom from any documented atrial arrhythmia of>30 seconds, after a single ablation procedure, off anti-arrhythmic therapy(AAD) at 12 months. 98 patients with PsAF and HFrEF(mean age 62.1+/-9.8 years, 79.5% males, median LVEF 35+/-13%). 46.9% underwent PVI with PWI. After 12 months, 58.7% with PVI and PWI were free from recurrent atrial arrhythmia off AAD vs 61.5% of patients with PVI alone (HR1.02, 95% CI 0.54-1.91, p=0.96). There were no significant differences in freedom from any atrial arrhythmia on/off AAD after multiple procedures (PVI with PWI 60.9% vs PVI 65.4%; HR1.12, 95%CI 0.58-2.16; p=0.73), freedom from symptomatic atrial arrhythmia on/off AAD after multiple procedures (PVI with PWI 69.5% vs PVI 75%; HR 1.23, 95%CI 0.58-2.62; p=0.59), or median AF burden at 12 months (PVI with PWI 0% [IQR 0-2.63] vs PVI 0% [IQR0-2.59]; p=0.78). Median LVEF improved in PVI with PWI(LVEF increased by19.3+/-12.9%,p<0.01), and PVI alone (LVEF increased by 18.2+/-14%, p<0.01), with no difference between groups(p=0.71). Normalisation of LV function(≥50%) occurred in 71.4% in PVI with PWI compared with 59.1% with PVI alone(p=0.26). Catheter ablation is associated with significant LVEF improvements in PsAF and HFrEF. However adding PWI to PVI did not improve freedom from arrhythmia recurrence nor recovery of LVEF.

CI-452766-4 LONG-TERM CLINICAL OUTCOMES OF LEFT BUNDLE BRANCH AREA PACING VERSUS BIVENTRICULAR PACING FOR HEART FAILURE TREATMENT: REAL-WORLD EXPERIENCE

Left bundle branch area pacing (LBBAP) has shown potential to be an alternative to biventricular pacing (BiVP) in patients with indications for cardiac resynchronization therapy (CRT). However, few studies focused on the long-term clinical outcomes of LBBAP versus BiVP. This prospective observational study aimed to compare long-term clinical outcomes and complications between LBBAP and BiVP. Consecutive patients with left ventricular ejection fraction (LVEF) <50% and CRT indications were enrolled and prospectively followed up at device clinic if they received successful LBBAP or BiVP from Jan. 2019 to Dec. 2020 at two centers. The primary endpoint was the composite outcomes of all-cause death or heart failure hospitalization (HFH). Secondary endpoints included the occurrence of death, or HFH, or malignant ventricular arrhythmias (VAs). The safety endpoints were device-related complications. Pacing parameters and cardiac function were routinely tracked. A total of 259 patients (mean age 63 ± 11 years, male 65.6%, LVEF 30.4% ± 6.9%) were enrolled, including 106 cases with LBBAP and 153 with BiVP. The paced QRS duration of LBBAP was significantly shorter than that of BiVP (137.3 ± 27.8 ms vs. 148.8 ± 22.1 ms, p<0.001). During the median follow-up of 27 months, LBBAP achieved a higher LVEF improvement from baseline (12.8 ± 12.3% vs. 9.81 ± 12.7%, p=0.043) and similar echo response or super response as compared with BiVP. The risk of the primary endpoint was significantly decreased by 42% in patients with LBBAP than those with BiVP [21.7% vs. 41.2%, adjusted hazard ratio (aHR) 0.58; 95% confidence interval (CI) 0.35–0.98; p=0.041], which was primarily driven by significantly reduced events of HFH after LBBAP treatment [16.0% vs. 36.6%, aHR (95%CI): 0.49 (0.28, 0.85), p=0.012]. The events of all-cause death or malignant VAs were comparable between two groups. Subgroup analysis revealed that patients with left bundle branch block (LBBB) benefited more from LBBAP [aHR (95%CI): 0.35 (0.17, 0.73), p=0.005] than those with non-LBBB or narrow QRS (p for interaction=0.005). The device-related complications were lower in the LBBAP than BiVP group (3.8% vs. 13.1%, p=0.005), mainly due to lead-related complications (1.9% vs. 11.1%, p<0.001). The long-term clinical outcomes of LBBAP for HF treatment might be superior to BiVP with reduced HFH events and lead-related complications in patients with indications for CRT.

The Impact of Trimethylamine N-Oxide and Coronary Microcirculatory Dysfunction on Outcomes following ST-Elevation Myocardial Infarction

Persistent coronary microcirculatory dysfunction (CMD) and elevated trimethylamine N-oxide (TMAO) levels after ST-elevation myocardial infarction (STEMI) may drive negative structural and electrical cardiac remodeling, resulting in new-onset atrial fibrillation (AF) and a decrease in left ventricular ejection fraction (LVEF). TMAO and CMD are investigated as potential predictors of new-onset AF and left ventricular remodeling following STEMI. This prospective study included STEMI patients who had primary percutaneous coronary intervention (PCI) followed by staged PCI three months later. Cardiac ultrasound images were obtained at baseline and after 12 months to assess LVEF. Coronary flow reserve (CFR), and index of microvascular resistance (IMR) were assessed using the coronary pressure wire during the staged PCI. Microcirculatory dysfunction was defined as having an IMR value ≥25 U and CFR value <2.5 U. A total of 200 patients were included in the study. Patients were categorized according to whether or not they had CMD. Neither group differed from the other with regards to known risk factors. Despite making up only 40.5% of the study population, females represented 67.4% of the CMD group p < 0.001. Similarly, CMD patients had a much higher prevalence of diabetes than those without CMD (45.7% vs. 18.2%; p < 0.001). At the one-year follow-up, the LVEF in the CMD group had decreased to significantly lower levels than those in the non-CMD group (40% vs. 50%; p < 0.001), whereas it had been higher in the CMD group at baseline (45% vs. 40%; p = 0.019). Similarly, during the follow-up, the CMD group had a greater incidence of AF (32.6% vs. 4.5%; p < 0.001). In the adjusted multivariable analysis, the IMR and TMAO were associated with increased odds of AF development (OR: 1.066, 95% CI: 1.018-1.117, p = 0.007), and (OR: 1.290, 95% CI: 1.002-1.660, p = 0.048), respectively. Similarly, elevated levels of IMR and TMAO were linked with decreased odds of LVEF improvement, while higher CFR values are related to a greater likelihood of LVEF improvement. CMD and elevated TMAO levels were highly prevalent three months after STEMI. Patients with CMD had an increased incidence of AF and a lower LVEF 12 months after STEMI.