Initial Left Ventricular Ejection Fraction Research Articles

Takotsubo syndrome outcomes predicted by thyroid hormone signature: insights from cluster analysis of a multicentre registry

Recently, abnormal thyroid function was shown to be common in patients with Takotsubo syndrome (TTS), being classified into "endocrine-type" and "stress-type" responses. The aim of this study was to investigate the association between thyroid homeostasis and TTS in a larger international registry. In total 288 patients with TTS were enrolled through the GEIST multicentre registry from Germany, Italy and Spain. Thyrotropin (TSH), free T4 (FT4) and free T3 (FT3) concentrations were analysed at admission. Data were collected both retrospectively and prospectively from 2017 onwards. Primary endpoints included in-hospital and all-cause fatality, determined by cluster analysis using an unsupervised machine learning algorithm (k-medoids). Three clusters were identified, classifying TTS with low (TSLT), high (TSHT) and normal (TSNT) thyroid output, based on TSH and FT4 levels in relation to the median thyroid's secretory capacity (SPINA-GT). Although TSH and FT4 concentrations were similar among survivors and non-survivors, these clusters were significantly associated with patient outcomes. In the longitudinal Kaplan-Meier analysis including in- and out-of-hospital survival, the prognosis related to concentrations of TSH, FT4, and FT3 as well as SPINA-GT, deiodinase activity (SPINA-GD) and clusters. Patients in the TSHT cluster and with cardiogenic shock had a lower initial left ventricular ejection fraction (LVEF). This study suggests that thyroid hormones may impact the evolution and prognosis of TTS. The findings indicate that thyroid-derived biomarkers may help identify high-risk patients and pave the way for novel personalized and preventive therapeutic options. This research was not funded by any public, commercial, or not-for-profit agencies.

Case report: the effect of endovascular closure of an open oval window on the course of atrial fibrillation and the processes of reverse remodeling of the heart chambers

The volume of the left atrium is one of the key factors associated with both the development of primary atrial fibrillation and its progression. Open atrial communication is considered as a factor predisposing to dilation and remodeling of the heart cavities. We present a clinical case of endovascular closure of an open oval window in a patient with a persistent form of AF, a moderately reduced left ventricular ejection fraction, who had previously undergone radiofrequency ablation, and persistent manifestations of heart failure. A 58-year-old patient was hospitalized in November 2019 with clinical manifestations of increasing heart failure. History: persistent form of atrial fibrillation with pronounced ventricular tachysystole. In April 2019, the patient underwent radiofrequency ablation, during which signs of open oval window were revealed. The initial left ventricular ejection fraction is 41%, the anterior–posterior left atrium size is 47 mm, the NT-proBNP level is 912 pg/m. In the subsequent period, steady sine waves were recorded.

Mechanical Circulatory Support Strategies in Takotsubo Syndrome with Cardiogenic Shock: A Systematic Review.

Takotsubo syndrome is, by definition, a reversible form of acute heart failure. If cardiac output is severely reduced, Takotsubo syndrome can cause cardiogenic shock, and mechanical circulatory support can serve as a bridge to recovery. To date, there are no recommendations on when to use mechanical circulatory support and on which device is particularly effective in this context. Our aim was to determine the best treatment strategy. A systematic literature research and analysis of individual patient data was performed in MEDLINE/PubMed according to PRISMA guidelines. Our research considered original works published until 31 July 2023. A total of 93 publications that met the inclusion criteria were identified, providing individual data from 124 patients. Of these, 62 (50%) were treated with veno-arterial extracorporeal life support (va-ECLS), and 44 (35.5%) received a microaxial left ventricular assist device (Impella). Eighteen patients received an Impella CP and twenty-one an Impella 2.5. An intra-aortic balloon pump (IABP) without other devices was used in only 13 patients (10.5%), while other devices (BiVAD or Tandem Heart) were used in 5 patients (4%). The median initial left ventricular ejection fraction was 20%, with no difference between the four device groups except for the IABP group, which was less affected by cardiac output failure (p = 0.015). The overall survival was 86.3%. Compared to the other groups, the time to cardiac recovery was shorter with Impella (p < 0.001). Though the Impella treatment is new, our analysis may show a significant benefit of Impella compared to other MCS strategies for cardiogenic shock in Takotsubo syndrome.

Clinical Features of Tachycardia-induced Cardiomyopathy in Patients with Atrial Fibrillation.

Objective Atrial fibrillation (AF) is the most common cause of tachycardia-induced cardiomyopathy (TIC). However, which patients with AF are prone to developing TIC remains unclear. In this study, we investigated the clinical features of AF patients with TIC. Methods This single-center study included 722 patients with AF (average age, 63.1±10.2 years old; 191 women) who underwent radiofrequency catheter ablation. We defined TIC as an initial left ventricular ejection fraction (LVEF) of <40% and a >20% recovery of the LVEF after successful AF ablation and compared the clinical characteristics between the TIC and control groups. Results The proportions of type 2 diabetes (30.5% vs. 14.7%), renal dysfunction (34.2% vs. 23.8%), hypertension (67.1% vs. 54.8%), and persistent AF (62.2% vs. 32.2%) were significantly higher in the TIC group (n=82) than in the control group (n=640). The atrioventricular nodal effective refractory period (AVNERP) (303±72 ms vs. 332±86 ms; p=0.017) was significantly shorter in the TIC group than in the control group. A multivariable analysis found that persistent AF [odds ratio (OR), 3.19; 95% confidence interval (CI), 1.94-5.24], renal dysfunction (OR, 1.87; 95% CI, 1.06-3.32), and type 2 diabetes (OR, 2.30; 95% CI, 1.31-4.05) were significantly associated with TIC. Conclusion Comorbid renal dysfunction and type 2 diabetes were clinical features of AF patients with TIC. Persistent AF, and short AVNERP may be involved in the development of TIC.

Left bundle branch block cardiomyopathy: an intriguing and defiant entity from diagnosis to treatment

Abstract Introduction and objectives Left bundle branch block cardiomyopathy (LBBB-CM) is an increasingly recognized entity, where electromechanical dyssynchrony seems to play a central role in left ventricular dysfunction (LVD) development. This is a challenging and scarcely studied topic, as causality dilemma between LBBB and LVD is still unsolved. Our aim is to increase current evidence on the subject by analyzing a population of idiopathic LBBB patients (pts) who developed, at some point, LVD not explained by other causes. Methods Retrospective study of LBBB adult pts screened from a large tertiary care hospital electrocardiographic database from 2011 to 2017. After careful evaluation, only possible LBBB-CM pts with serial follow-up (FU) echocardiographic and clinical data were included in the analysis. Results 53 pts were identified as possible LBBB-CMP. At baseline, 44% presented left ventricular ejection fraction (LVEF)&amp;gt;50%, while 56% had LVD. 51% were female and mean age at first-ever LBBB report was 59 years-old. All cohort presented echocardiographic mechanical desynchrony, and additional testing to exclude other causes of LVD (non-invasive ischemia testing in 78%; coronariography in 68%; cardiac magnetic resonance in 38%). Median FU time was 10 years. Worst-LVD was reported as severe in 49% of pts, moderate in 23% and mild in 28%. Median time-to-dysfunction in those with initial LVEF&amp;gt;50% was 8 years. 77% of pts presented heart-failure (HF) symptoms. 40% and 42% presented at least 1 CV event and CV hospitalization, respectively. Most events and/or hospitalizations were due to acute decompensated HF. 2 CV deaths were observed. Cardiac resynchronization therapy (CRT) devices were implanted in 47% of pts. All presented clinical improvement after implantation, and LVEF significantly increased (pre-CRT median LVEF of 24% vs 48% post-CRT; p&amp;lt;0.001). When comparing pts with vs without CRT (Figure 1), better LVEF improvements were achieved in CRT group (median LVEF improvement of 27% in CRT vs 11%; p&amp;lt;0.001). Repeating the latter analysis in pts who only presented at least moderate dysfunction, higher LVEF increase was also reported in CRT group (median LVEF improvement of 27% in CRT pts vs 14%; p=0.002), and significantly more CRT pts recovered LV function (50% CRT vs 14% non-CRT; p=0.028). Notably, no differences were found in rates of medical HF therapy between groups (p=1). Conclusion Our data shows LBBB-CM as a diagnosis of exclusion, where careful evaluation of other LVD etiologies should be performed and discarded. We highlight important morbidity rates in this population, namely HF hospitalizations, as well as the apparently critical role of CRT implantation in these pts. All our CRT pts responded excellently to the therapy. Thus, our study raises awareness to the emerging question of whether this entity can be reversed after LBBB correction with CRT and if early intervention would be desirable.Figure 1

The use of wearable cardioverter defibrillator among patients suffering from myocarditis: data from a multicenter registry

Abstract Background Data on the use of the wearable cardioverter defibrillator (WCD) among patients suffering from myocarditis in a large cohort remains sparse. Subsequently several guidelines give a different recommendation regarding WCD indication in this cohort. Methods 1596 patients were included in a multicenter registry from ten European centers. Among this cohort 132 (8%) patients received a WCD due to myocarditis. The mean follow-up time of the whole cohort was 620.2±607.8 days. The presence of ventricular tachyarrhythmias and/or WCD shocks during WCD use were evaluated. Results The mean age of patients was 52.5±16.3 years (75% males). 20% of patients suffered from atrial fibrillation, 17% diabetes mellitus, 40% were smoker and 38.9% suffered from arterial hypertension. The body-mass-index (BMI) of the cohort was 27.8±5.7 kg/m². The initial left ventricular ejection fraction (LVEF) was 33.4±14.6% and increased to 45.9±13.2% (p&amp;lt;0.05) over long-term follow-up. Patient were discharged on ACE-inhibitors (62.5%), ARNI (21.2%), aldosterone-antagonist (50%), beta-blockers (89.5%) and amiodarone (13.6%). An improvement of LVEF (LVEF&amp;gt;35%) was documented in 81.2% of patients. The BNP level was at baseline 7401±30584 pg/ml and decreased to 530±803 pg/ml (p&amp;lt;0.05) over long-term follow-up. The wear duration was 78.5±51.5 days and 34% of patients wore the WCD for longer than 90 days. The wear-hours per day were 21.1±4.8 hours. In 3.1% sustained ventricular tachycardia, 0.8% ventricular fibrillation and 9.1% non-sustained ventricular tachycardia were documented. Subsequently 3% of patients suffered from an appropriate WCD shock. The rate of inappropriate WCD shock was 0.8%. Patients suffering from WCD shock were at age 31, 31, 61, 24 and 51 years and suffered a former non-sustained ventricular tachycardia before receiving a WCD. Among these patients suffering from appropriate WCD shock only two patients showed an LVEF&amp;lt;35%. Among the myocarditis patients 48% suffered from a former ventricular tachycardia and/or ventricular fibrillation and therefore received a WCD. Conclusions Myocarditis patients can be effectively protected by WCD and may benefit from its’ use. WCD shock occurred also in patients with an LVEF &amp;gt;35%.

Abstract 15746: Longitudinal Remodeling in Persistent Heart Failure With Reduced Ejection Fraction and Improved Ejection Fraction

Background: Among patients with heart failure (HF) with reduced ejection fraction (HFrEF), a subpopulation improves ventricular function, HF with improved ejection fraction (HFimpEF). This study aimed to investigate the longitudinal remodeling trajectories associated with HFimpEF and with HFrEF. Methods: This was a retrospective cohort study, UC Davis Medical Center (2014 to 2022). The inclusion criteria included HF related ICD codes, a left ventricular ejection fraction (LVEF) ≤40%, and a B-type natriuretic peptide (BNP) ≥100 pg/mL. Longitudinal BNP and echocardiographic data were retrieved from electronic medical records. The HFimpEF group was defined as follows: an initial LVEF ≤40% with a subsequent &gt;40% with a minimum 10% improvement after ≥3 months. Those not meeting these criteria were classified as persistent HFrEF. Longitudinal assessments were performed using linear mixed models, adjusted for baseline values. Results: The study included 1307 patients. The cohort median age was 65, 68% male, 57% white, with 39% developing HFimpEF. Compared to persistent HFrEF, the HFimpEF group exhibited evidence of reverse remodeling with increasing trends in LVEF, interventricular septal end diastole (IVSd), and decreasing trends in left ventricular internal dimension in systole (LVIDs) values with a p= &lt;.01 between groups (Figure). However, BNP did not present significant changes over time, presenting sustained initial measurements ( p =0.08). Conclusion: Patients with HFimpEF in this cohort had different longitudinal remodeling patterns compared with persistent HFrEF. The HFimpEF group had increasing trends of LVEF, IVSd and decreasing trends of LVIDs. Suggesting reverse remodeling and lower longitudinal levels of BNP.

Abstract 15015: Clinical Outcomes of Patients With Heart Failure With Improved Ejection Fraction After Acute MI: A Multicenter Prospective Study From the COREA-AMI Registry

Background: The 2021 Universal Definition of Heart Failure introduce a new classification, heart failure with improved ejection fraction (HFimpEF). As yet, little is known about the long-term clinical outcomes of patients with HFimpEF after acute myocardial infarction (AMI). Methods: From a multicenter, prospective cohort of AMI patients undergoing PCI, patients with an initial TTE at the time of PCI and at least one follow-up TTE 1 month to 2 years after the initial event were considered for analysis. HFimpEF was defined as initial left ventricular ejection fraction (LVEF)≤40% and at least one follow-up LVEF&gt;40% with an increase of ≥10% from baseline. Persistent HFrEF was defined as LVEF ≤40% without interval improvement. Patients with LVEF&gt;40% were defined as having preserved LVEF. The primary endpoint was all-cause mortality. Results: In total, 3038 patients with repeated TTE measurements were selected for initial analysis. 187 patients were identified as having HFimpEF, 190 patients had persistent HFrEF, 631 patients had HFmrEF, and 2030 patients had preserved EF. Kaplan-Meier analysis revealed that HFimpEF was associated with improved survival compared to chronic HFrEF, but inferior to preserved LVEF (log-rank p&lt;0.001). Even after multivariate Cox regression analysis was done to account for confounding variables, HFimpEF was associated with reduced mortality compared to persistent HFrEF (HR 0.49, 95% CI 0.31-0.78). Compared to patients with preserved LVEF, HFimpEF patients had a tendency toward higher mortality, but did not reach statistical significance (HR 1.18, 95% CI 0.80-1.76). Conclusion: HFimpEF is associated with decreased all-cause mortality compared to persistent HFrEF in patients with AMI. Figure 1. Kaplan-Meier Survival Analysis According to Changes in LVEF

COMPARATIVE ANALYSIS OF LONG-TERM OUTCOMES FOLLOWING THE STIMULATION OF CARDIAC CONDUCTION SYSTEM AND RIGHT VENTRICULAR PACING IN PATIENTS WITH BRADYARRHYTHMIAS

Introduction. Right ventricular myocardial pacing induces asynchronous ventricular contraction, potentially resulting in pacing-induced cardiomyopathy and adverse long-term clinical outcomes. Conduction system pacing is a physiological alternative to right ventricular myocardial pacing. The objective of this study is to analyze the long-term outcomes of the conduction system pacing in comparison with right ventricular myocardial pacing in patients requiring permanent ventricular pacing and who have preserved initial left ventricular ejection fraction (≥ 50%). Materials and methods. 48 patients with indications for permanent ventricular pacing were selected for comparative analysis. Of these, 18 patients had cardiac conduction system pacing and 30 patients had right ventricular myocardial pacing. Permanent pacemaker implantation in both groups of this study was performed from 2012 to 2022. Patients in both groups had to meet the following selection criteria for this study: 1) preserved systolic function of the left ventricle at the time of pacemaker implantation (≥ 50%); 2) total percentage of ventricular pacing from the time of implantation had to be not less than 90%.&#x0D; Results. The observation period was 35.3 ± 37 months in the conduction system pacing group and 46 ± 28.73 months in the right ventricular pacing group. Since the time of pacemaker implantation, pacing-induced cardiomyopathy occurred in 7 (23%) patients in the right ventricular pacing group and in none in the conduction system pacing group. The mean left ventricular ejection fraction at the control visit was significantly lower in the right ventricular pacing group (51.59 ± 8.55 vs. 58.64 ± 4.58%, p =.004). A significant reduction in global longitudinal strain was observed in the right ventricular pacing group compared to the conduction system pacing group (14.22 ± 3.66 vs. 18.49 ± 2.5%, p = &lt;.001). Paced QRS width was significantly greater in the right ventricular pacing group (152.32 ± 18.13 vs. 119.12 ± 8.8 ms, p &lt;.001). Conclusions. Applying new physiological methods of cardiac pacing enables to avoid the negative consequences of an asynchronous pattern of ventricular activation during conventional right ventricular pacing.

Usefulness of heart failure categories based on left ventricular ejection fraction

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): This study was sponsored by AstraZeneca. Introduction Heart failure, a common disease with a mortality on par with many cancers, is one of the costliest diseases to society in the western world. Current heart failure guidelines are based on categories of left ventricular ejection fraction (LVEF) and have recently introduced a narrow category with mid-range/mildly reduced ejection fraction (HFmrEF; LVEF 41-49%) between the previous categories with reduced (HFrEF; LVEF ≤40%) and preserved (HFpEF; LVEF ≥50%) ejection fraction. The grouping of continuous variables into narrow categories can be questioned if the variability is high. Purpose To determine the shape of the LVEF distribution and quantify the stability of LVEF categories over time in a large real-world heart failure population, in order to establish the usefulness of LVEF categories for treatment decisions. Methods Population-based observational cohort study of all new cases of chronic heart failure in Region Stockholm, Sweden, from 2016-01-01 until 2020-12-31. All available values of LVEF were collected over time and patients were followed until death or end of study. Mixed models were used to quantify within-person variance in LVEF, and Multistate Markov models, with death as an absorbing state, to quantify the stability of LVEF categories. Results During the study period, 8,455 patients were diagnosed with heart failure. LVEF values followed a perfect normal distribution. The standard deviation of the within-person variance in LVEF was 7.4%. Regardless of initial LVEF category, age or sex, the mean time spent in any LVEF category before transition to another category (mean sojourn time) was on average less than 0.6 years (Figure 1). The one-year probabilities of transitioning between states were substantial (Figure 2). Patients with HFmrEF had a probability of 1/4 of remaining in that category one year later; the probability of patients with HFrEF of remaining in that category one year later was 1/4 for women and 1/3 for men; and patients with HFpEF had a probability of remaining in that category of 2/3 for women and 1/2 for men. Conclusion In patients with heart failure, LVEF has considerable variability over time. Hence, LVEF has limited use for categorisation of the heart failure population into narrow categories.

Incidence, characteristics and one-year outcomes of peripartum cardiomyopathy in Reunion Island

Peripartum cardiomyopathy (PPCM) is a form a dilated cardiomyopathy affecting young women, inducing a high morbidity and mortality rate. Little is known about the incidence and outcomes in France. We sought to describe the incidence, clinical characteristics, and one-year outcomes in women with PPCM. We included all women from 18- to 44-year-old hospitalized in Reunion Island University Hospital Center from 2014 to 2019 with a new diagnosis of PPCM. The incidence was 1/2300 births. In our cohort of forty patients, median age was 34 ± 6 years and mean left ventricular ejection fraction (LVEF) was 27 ± 9%. Most patients (42%) were diagnosed during the first month after delivery. 74% presented with severe dyspnea (class III or IV NYHA). Known risk factors for PPCM were: age > 30-year-old (75%), multiparity (65%), gestational hypertension or preexisting chronic hypertension (60%), obesity (40%) and diabetes (28%). Complete recovery (defined by LVEF ≥ 50%) was obtained in 71% of women after one-year follow-up and 6% of patients still had a severe left ventricular impairment (LVEF < 35%). One-year mortality rate was 3%. Prognostic factors were: initial LVEF, left ventricular end-diastolic diameter, and diabetes. Peripartum cardiomyopathy has a particularly high incidence in Reunion Island. Complete recovery is frequent. Targeted screening should be proposed to high-risk patients.

RELATIONSHIP BETWEEN SEDATION, PATIENTS' LEFT VENTRICULAR EJECTION FRACTION AND FREQUENCY OF NEED FOR SYMPATHOMIMETIC AND INOTROPIC SUPPORT IN PATIENTS AFTER CARDIAC SURGERY IN THE EARLY POSTOPERATIVE PERIOD

Introduction: Most patients who are indicated for cardiac surgery are patients with reduced left ventricular ejection fraction (LVEF). Also, most patients after cardiac surgery receive sedation, which, in combination with reduced LVEF, can lead to severe hemodynamic disturbances. Whether there is a relationship between the drug for sedation in the early postoperative period in patients after cardiac surgery and the initial left ventricular ejection fraction until the end, there is still no consensus.&#x0D; Purpose: To monitor the relationship between the drug for sedation, the patients' initial left ventricular ejection fraction and the frequency of the need for sympathomimetic support and inotropic support in the early postoperative period.&#x0D; Materials and methods: A randomized controlled parallel study was conducted. The study included 194 patients over 18 years of age who underwent cardiac surgical treatment using artificial blood circulation. The control point for evaluating the effect of sedation on hemodynamics was the use of inotropic and sympathomimetic therapy and the analysis of the frequency of use in groups with different ejection fractions of the left ventricle. An assessment of the frequency of vasopressor/inotropic therapy without taking into account the sedation strategy was also carried out. Statistical data processing was carried out on the basis of GraphPad Prism 9.0 software.&#x0D; Results: In the group receiving propofol sedation (n=95), 83.16 % (n=79) of patients received inotropic/vasopressor therapy, which is 40.72 % of the total number of patients in all 3 groups (n=194). In the group receiving received sedation with dexmedetomidine (n=16), 81.25 % (n=13) received supportive inotropic/vasopressor therapy, which is 6.7 % of the total number of patients in all 3 groups (n=194). Patients who were sedated with a combination of these drugs (n =83) received supportive inotropic/vasopressor therapy in 91.57 % (n=76) of cases, which is 39.18 % of the total number of patients in all 3 groups (n=194). (p = 0.2093). When analyzing the frequency of use of inotropic therapy in each LVEF group, regardless of the type of sedation, it was found that the frequency of use depended on the fraction of LVEF emission below 55 % (p=0.0484). When comparing the groups of patients with LVEF ≥ 55 % and LVEF 40 – 30 %, more patients with PV 40 – 30 % received inotropic support (p=0.0299 RR 0.7878 95 % CI 0.6542-0.9528). No difference was found in the frequency of use of inotropic support when comparing LVEF ≥ 55 % and LVEF≤ 30% (p=0.7474 RR 0.9103 95% CI 0.7255-1.275), PV 55 – 40% and PV 40 – 30 % (p=0.4527 RR – 1.592)&#x0D; Conclusions: According to the conducted study, in patients in the early postoperative period after cardiac surgery, no influence was found between the strategy of sedation, the output fraction of the left ventricle and the frequency of use of norepinephrine, dobutamine, dopamine or their combination (p=0.2093). But it was found that inotropic/vasopressor therapy was more often needed in patients with LVEF less than 55 % regardless of the sedation strategy. The doses of dobutamine and dopamine were the same in all 3 sedation groups, which can speak in favor of the absence of a difference in the frequency of the syndrome of decreased cardiac output. During the analysis, it was also found that the doses and frequency of norepinephrine use were higher in the group where sedation was carried out with propofol (p=0.0011), which may indicate that sedation with propofol leads to a higher frequency of hypotension, the correction of which requires higher doses of norepinephrine.

Abstract 10337: Early Adaptation of the Mitral Valve After St-Elevation Myocardial Infarction

Introduction: Ischemic mitral regurgitation (IMR) is associated with worse outcomes and higher mortality after myocardial infarction (MI). Clinical observations and experimental data have shown that mitral valve leaflets have the potential to enlarge over time to compensate left ventricular remodeling and prevent IMR. Previous animal studies have demonstrated that MI is associated with fibrotic changes in the mitral valve leaflets and prevent this adaptive compensation. However, the timing of mitral valve geometric changes are not well described. While previous data shows an increase in leaflet size at 6 and 12 months after MI, its short-term evolution after an ischemic event is not well documented. Methods: Twenty-two patients with ST-elevation myocardial infarction and initial left ventricular ejection fraction ≤ 45% were enrolled in Quebec Heart and Lung Institute. Participants had 3D transthoracic echocardiography (TTE) at baseline and 3 months, as well as cardiac magnetic resonance (CMR) at 3-month follow-up. Mitral valve leaflet size was measured from the 3D TTE using a custom software (Omni4D). CMR was used to derive left ventricular volumes, function and mitral regurgitant volume. Significant IMR was defined as a mitral regurgitant fraction ≥ 15% derived from the 3-month CMR. Results: Twenty-one of the 22 patients completed the imaging follow-up. Left ventricular ejection fraction at 3 months was 53 ± 10% (range from 37 to 69%). Eight patients (38%) had mild IMR at 3 months. Mitral valve surface area was significantly increased at 3 months compared with baseline for patients without IMR (10.96 ± 1.78 cm 2 vs 9.51 ± 1.62 cm 2 ; p = 0.001). Valve enlargement vs baseline was significantly greater in patients without IMR (+17 ± 13% vs -5 ± 4% for those with IMR at follow-up, p=0.0007). Conclusions: Mitral valvular surface increases within the first few months after MI, but not in all patients. Adequate valve enlargement seems related to the absence of IMR at 3 months.

Quality of life in patients with heart failure and improved ejection fraction: one year changes and prognostic implication

Abstract Background Inconsistent and controversial results have been reported about the association of quality of life (QoL) and left ventricular ejection fraction (LVEF) in patients with heart failure (HF). The 2021 universal definition of HF specifically describes the criteria for the patients with HF and improved LVEF (HFimpEF): HF with a baseline LVEF ≤40%, a ≥10 point increase from baseline LVEF, and a second measurement of LVEF &amp;gt;40%. Purpose 1) To assess whether patients with HF and reduced LVEF (HFrEF) at first visit in an outpatient HF Clinic that fulfil the HFimpEF criteria one year later presented a higher improvement in QoL assessed by the Minnesota Living With Heart Failure Questionnaire (MLWHFQ) than those patients that did not fulfil HFimpEF criteria. 2) To assess the prognostic role of QoL on outcomes in HFimpEF patients. Methods In a prospective registry of real-life HF outpatients LVEF and QoL evaluated by MLWHFQ were assessed at first visit at the HF Clinic and at one year of follow-up. Results From August 2001 to August 2021, baseline and one year LVEF and MLWFQ scores were available in 1040 patients with an initial LVEF ≤40%. Table 1 shows baseline demographic and clinical characteristics of patients. In summary, mean age was 65.2±11.7 years, 75.9% of the patients were men, the main aetiology was ischaemic heart disease (52.9%) and patients were mostly in New York heart Association (NHYA) class II (71.1%) and III (21.6%). Baseline LVEF was 28.5% ± 7.3 and baseline MLWHFQ score was 30.2±19.5. At one year, mean LVEF increased to 38.0±12.2 while MLWHFQ scores improved to 17.4±16.0. There were 361 patients that fulfilled the HFimpEF criteria (34.7%). These patients significantly and markedly improved both LVEF (from 28.7±6.6 to 50.9±7.6, p&amp;lt;0.001) and QoL (from 32.9±20.6 to 16.9±16.0, p&amp;lt;0.001). Although in patients that did not fulfil the criteria of HFimpEF both LVEF (from 28.4±7.6 to 31.1±7.9, p&amp;lt;0.001) and QoL (from 28.7±18.8 to 17.6±15.9, p&amp;lt;0.001) also significantly improved, the improvement in QoL was significantly higher in HFimpEF patients (−16.0±23.8 vs. −11.1±20.3, p=0.001), taking into account that baseline MLWHFQ score was worse in HFimpEF patients (p=0.001). However, at one year QoL was similar when both groups were compared (p=0.50). MLWHFQ score at one year proved to be superior to QoL improvement (using a cut-off of at least 5 points) from the prognostic point of view. Conclusions QoL improved both in patients with and without HFimpEF criteria, and QoL perception at one year was similar in both groups, suggesting the influence of other factors other than LVEF in QoL perception. QoL at one year revealed to be superior to QoL changes from baseline from the prognostic point of view. Funding Acknowledgement Type of funding sources: None.

Direct oral anticoagulants compared to vitamin K-antagonists in patients with left ventricular thrombus

Abstract Background/Introduction In the setting of left ventricular thrombus (LVT), direct oral anticoagulants (DAOC) are poorly studied. Current European guidelines recommend treatment with Vitamin K antagonists (VKA) for 6 months. So far, several observational studies reported similar efficacity and safety of DOACs, compared to VKAs. Controversial findings were found in one big cohort, where higher stroke rates were reported among patients treated with DOAC compared to VKA, what raised concerns about the efficiency and safety to use DOACS in the setting of LVT. Purpose This retrospective multicenter study compared thrombus resolution and clinical outcomes of patients with LVT treated with DOACs or VKAs. Methods From an echocardiography database of three teaching hospitals in Switzerland, patients diagnosed with LVT between 2015 and 2021 were identified. All echocardiograms and outcomes were reviewed by independent physicians. Thrombus resolution rate and clinical outcomes were compared according to the underlying anticoagulation regimen. Results Overall, 101 patients (17.8% females, mean age 63.3±13.2 years) were included. Among those, 50.5% had a recent myocardial infarction, 38.6% chronic ischemic heart disease and 10.9% suffered from non-ischemic cardiomyopathy. At hospital discharge, 48 (47.5%) were treated with DOACs and 53 (52.5%) with VKAs. Initial left ventricular ejection fraction was 38±13%. 93.1% patients presented with apical wall motion abnormalities, mean wall motion score index was 1.91±0.39. Initial thrombus size was comparable in both groups (table 1). Median follow-up was 799 (354; 1236) days and the clinical composite endpoint combining stroke, systemic embolism, bleedings, myocardial infarction and death was comparable in the VKA (22.6%) and DOAC (27.1%) group, respectively. There was no difference in major (4% vs. 6.3%) and minor (13.5% vs. 4.3%) bleeding events, neither for stroke and systemic thromboembolism (14.3% vs 14.9%) or death (11.3% vs 8.5%). Thrombus resolution rate after 1 year was similar in the VKA and DOAC group (75.5% vs. 76.7%), but early thrombus dissolution within the first month was faster in the VKA arm (p=0.049). In each group, 3 subjects had thrombus recurrence after cessation of anticoagulation. Conclusion Among patients with LVT, DOACs appear to be a safe and effective alternative to vitamin K antagonists, but thrombus seems to dissolve slower in the first month. An adequately powered randomized trial is needed to confirm these findings. Funding Acknowledgement Type of funding sources: None.

Transcranial Doppler Ultrasound for Monitoring the Cerebral Hemodynamic Changes and Prognosticating Outcomes in Venoarterial Extracorporeal Membrane-Oxygenated Patients.

Objective Patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) support may have cerebral hemodynamic changes whose impact on patient outcome are not fully elucidated. This study aims to evaluate the correlation between cerebral hemodynamic changes and prognostic outcome in patients during VA-ECMO. Methods Transcranial Doppler (TCD) ultrasound examination was performed to attain the systolic velocity (Vs), diastolic velocity (Vd), mean velocity (Vm), and pulsatility index (PI) of patients undergoing VA-ECMO. Cardiac ultrasound was also performed to assess the correlation between the left ventricular outflow tract velocity time integral (LVOT VTI), left ventricular ejection fraction (LVEF), and middle cerebral artery (MCA) with the systolic peak. Moreover, we assessed the predictive value of LVOT VTI and LVEF in patients with the systolic peak. Patients were divided into survival and death groups according to the 28-day survival period. Clinical data were compared between the two groups to investigate the effects of cerebral hemodynamic changes on the prognosis of VA-ECMO patients. Results We found that the patient's LVOT VTI and LVEF had high predictive values for the systolic peak of the right middle cerebral artery. The initial LVEF, Vs, Vd and PI, and lactate level as well as the MODS incidence rate difference were significantly different between the survival and death groups. In addition, the results showed that the initial Vs value was an independent risk factor for the prognosis of patients undergoing VA-ECMO. Conclusions Cerebral hemodynamic changes may occur in patients supported by VA-ECMO. In addition, a poor cerebral arterial pulsatile blood flow was closely correlated with an unfavorable outcome in these patients.

Quality of life in patients with heart failure and improved ejection fraction: one-year changes and prognosis.

The criteria for patients with heart failure (HF) and improved ejection fraction (HFimpEF) are a baseline left ventricular ejection fraction (LVEF) ≤40%, a ≥10-point increase from baseline LVEF, and a second LVEF measurement >40%. We aimed to (i) assess patients with HF and reduced LVEF (HFrEF) at baseline and compare quality of life (QoL) changes between those that fulfilled and those that did not fulfil the HFimpEF criteria 1year later and (ii) assess the prognostic role of QoL in patients with HFimpEF. We reviewed data from a prospective registry of real-world outpatients with HF that were assessed for LVEF and QoL at a first visit to the HF clinic and 1year later. QoL was evaluated with the Minnesota Living with Heart Failure Questionnaire (MLWHFQ). The primary prognostic endpoint was the composite of all-cause death or HF hospitalization. Baseline and 1-year LVEF and MLWFQ scores were available for 1040 patients with an initial LVEF ≤40% (mean age, 65.2±11.7years; 75.9% men). The main aetiology was ischaemic heart disease (52.9%), and patients were mostly in New York heart Association Classes II (71.1%) and III (21.6%). At baseline, the mean LVEF was 28.5%±7.3, and the mean MLWHFQ score was 30.2±19.5. After 1year, the mean LVEF increased to 38.0%±12.2, and the MLWHFQ scores improved to 17.4±16.0. In 361 patients that fulfilled the HFimpEF criteria (34.7%), significant improvements were observed in both LVEF (from 28.7%±6.6 to 50.9%±7.6, P<0.001) and QoL (from 32.9±20.6 to 16.9±16.0, P<0.001). Patients that did not fulfil the HFimpEF criteria also showed significant improvements in LVEF (from 28.4%±7.6 to 31.1%±7.9, P<0.001) and QoL (from 28.7±18.8 to 17.6±15.9, P<0.001). However, the QoL improvement was significantly higher in the HFimpEF group (-16.0±23.8 vs. -11.1±20.3, P=0.001), despite the worse mean baseline MLWHFQ score, compared with the non-HFimpEF group (P=0.001). The 1-year QoL was similar between groups (P=0.50). The 1-year MLWHFQ score was independently associated with outcomes; the hazard ratio for the composite endpoint was 1.02 (95% CI: 1.01-1.03, P=0.006). In contrast, the QoL improvement (with a cut-off ≥5 points) was not independently associated with the composite outcome. Patients with HFrEF showed improved QoL after 1year, regardless of whether they met the HFimpEF criteria. The similar 1-year QoL perception between groups suggested that factors other than LVEF influenced QoL perception. The 1-year QoL was superior to the QoL change from baseline for predicting prognosis in patients with HFimpEF.

Longitudinal Assessment of Cardiac Function Following Multisystem Inflammatory Syndrome in Children Associated with COVID-19.

Multisystem inflammatory syndrome in children (MIS-C) after COVID-19 is commonly associated with cardiac involvement. Studies found myocardial dysfunction, as measured by decreased ejection fraction and abnormal strain, to be common early in illness. However, there is limited data on longitudinal cardiac outcomes. We aim to describe the evolution of cardiac findings in pediatric MIS-C from acute illness through at least 2-month follow-up. A retrospective single-center review of 36 patients admitted with MIS-C from April 2020 through September 2021 was performed. Echocardiographic data including cardiac function and global longitudinal strain (GLS) were analyzed at initial presentation, discharge, 2–4-week follow-up, and at least 2-month follow-up. Patients with mild and severe disease, normal and abnormal left ventricular ejection fraction (LVEF), and normal and abnormal GLS at presentation were compared. On presentation, 42% of patients with MIS-C had decreased LVEF < 55%. In patients in whom GLS was obtained (N = 18), 44% were abnormal (GLS < |− 18|%). Of patients with normal LVEF, 22% had abnormal GLS. There were no significant differences in troponin or brain natriuretic peptide between those with normal and abnormal LVEF. In most MIS-C patients with initial LVEF < 55% (90%), LVEF normalized upon discharge. At 2-month follow-up, all patients had normal LVEF with 21% having persistently abnormal GLS. Myocardial systolic dysfunction and abnormal deformation were common findings in MIS-C at presentation. While EF often normalized by 2 months, persistently abnormal GLS was more common, suggesting ongoing subclinical dysfunction. Our study offers an optimistic outlook for recovery in patients with MIS-C and carditis, however ongoing investigation for longitudinal effects is warranted.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00246-022-02972-3.

Clinical predictors of improvement in left ventricular ejection fraction in U.S. veterans with heart failure

BackgroundOur understanding of the factors associated with improvement of LVEF and a heart failure with improved EF (HFimpEF) phenotype remains incomplete. MethodsWe conducted a retrospective study using a national database of patients followed in the Veterans Affairs (VA) health system with serial assessment of left ventricular ejection fraction (LVEF) by echocardiography. We identified US veterans with a new diagnosis of heart failure with: (i) LVEF of <40 % in the 12 months prior to diagnosis, and (ii) follow-up LVEF assessment at least 6 months after their diagnosis. We defined HFimpEF as a final LVEF of ≥40 %. ResultsAmong the 106,414 US veterans with an initial LVEF of <40 % in this analysis, 39,994 (37.6 %) had a final EF of >40 % after a median follow up of 5 years. Multivariate regression analysis identified several factors that were independently associated with LVEF improvement including female sex, younger age, higher BMI, and a history of specific comorbid conditions such as hypertension, valve disease, atrial fibrillation, connective tissue disease, liver disease, and malignancy (p < 0.001). Conversely, a history of ischemic heart disease and peripheral arterial disease, as well as specific racial backgrounds (Black and Hispanic) were associated with lower rates of LVEF improvement. The model c-statistic for predicting LVEF improvement was 0.70. ConclusionsThis large, detailed dataset facilitated an analysis of a large number of variables that significantly associated with HFimpEF; however, their combined discriminatory value for LVEF improvement remained modest, underscoring the complexity of the gene-environment-treatment interactions that govern LV function.

Prognostic impact of hyperuricemia in chronic heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Today there is numerous evidence of the importance of hyperuricemia in the progression of chronic heart failure (HF). Purpose To study the impact of uricemia in patients (pts) with HF with reduced ejection fraction (HFrEF) followed in a Heart Failure Clinic (HFC). Methods Retrospective study of consecutive patients admitted in heart failure clinic of a cardiology center from February/2018 to December/2020, with an initial left ventricular ejection fraction (LVEF) &amp;lt; 50%; Primary outcomes were a composite of death, HF hospitalizations or emergency department admission. Results A total of 269 patients were selected, (mean age 71.0 ± 11.1 years; 69% males; ~40% ischemic etiology) of which 31,9% had uric acid (UA) ≥ 7 mg/dl in the first measure. These patients had more ischemic heart disease (44% vs 31,4%, p=0,048) and were mostly man (81,8 vs 63,80%, p= 0,004), but had less arterial hypertension (61,4 vs 72,8%; p=0.41). Both groups had the same incidence of diabetes mellitus (35,1 VS 34,1, p=0,868), active or previous tabagism (11,7 VS 7, p=0,456, 24,7 vs 24,9 p=0,456), dyslipidemia ( 53,2 vs 58, p=0,456), functional NYHA class ≥ 2 (93,8 VS 94,1, p=0,207) and use of allopurinol (68,8 vs 75,7%, p=0,252). During a median follow-up of 16 months (IQR 15–51), 65 patients (24,2%) had the primary outcome. After adjusting for ischemic heart disease, sex and use of allopurinol, uric acid levels superior to 7 mg /dl on admission is a predictor of poor outcomes in HFrER (HR 1.83, 95% CI: 1,89-3,08; p&amp;lt;0,023). Conclusion Patients with uric acid levels superior or equal to 7 mg/dl on admission had a higher risk of death, HF hospitalizations or emergency department admission during follow-up in HFC. UA might be considered a HF prognostic marker.