Larger Left Ventricular End-diastolic Diameter Research Articles

Lipin1 prevents ischemic heart disease by regulating lipid homeostasis

Abstract Background Lipid metabolism plays a crucial role in the pathophysiology of cardiovascular diseases. Lipin1 plays a pivotal role in lipid metabolism regulation. In the nucleus, Lipin1 acts as a transcriptional co-stimulatory molecule, interacting with peroxisome proliferator–activated receptor–gamma coactivator 1 alpha (PGC1α) and peroxisome proliferator–activated receptor alpha (PPARα). In the cytoplasm, Lipin1 functions as a phosphatidate phosphatase, converting phosphatidic acid to diacylglycerol to regulate lipid metabolism. Low expression of Lipin1 has been implicated in the severity of cardiac dysfunction in mice. Purpose This study aimed to investigate the role of Lipin1 in the cardiac remodeling after myocardial infarction (MI), revealing its impact on lipid metabolism and molecular pathway associated with cardiac dysfunction. Methods Two types of transgenic mice, cardiomyocyte-specific Lipin1 knockout (cKO) and overexpression (cOE) mice were used in this study. Eight to ten-week-old male mice were subjected to MI by coronary artery ligation. Cardiac lipid droplets were quantified, and triacylglycerol and free fatty acid levels were measured one week after MI surgery. Four weeks after MI, cardiac morphology and function were evaluated using echocardiography, alongside measurements of body weight (BW) and heart weight (HW). Additionally, gene expression analysis and histological evaluation were conducted to assess fatty acid metabolism, cardiac fibrosis, inflammation, and oxidative damage. Results Before MI surgery, there were no differences in HW/BW ratio, left ventricular end-diastolic diameter (LVDd) or LV fractional area change (LVFAC) among cKO/ cOE mice and their littermate controls. After MI, cKO mice exhibited significant cardiac dysfunction with larger LVDd, lower LVFAC and increased HW/BW ratio compared to littermate controls. This was accompanied by exacerbated cardiac fibrosis, increased inflammation, and augmented reactive oxygen species accumulation compared with their controls. Conversely, cOE mice displayed improved LVFAC, reduced cardiac fibrosis, inflammation, and reactive oxygen species accumulation compared to their littermate controls. Notably, the transgene of Lipin1 induced changes in the number of cardiac lipid droplets (LDs). cKO mice hearts showed a reduction in cardiac LDs with decreased levels of triacylglycerol and free fatty acids compared to the littermate controls. In contrast, cOE mice displayed increased cardiac LDs and upregulated expression of fatty acid metabolism–related genes after MI. Conclusion These results suggested that Lipin1 has a protective role against ischemic injury through controlling lipid metabolism in ischemic cardiomyocytes. Thus, Lipin1 emerges as a potential therapeutic target for myocardial infarction.

The Utility of Baseline Characteristics and [123I]MIBG Cardiac Adrenergic System Scintigraphy in Qualifying Patients with Post-Infarction Heart Failure for Implantable Cardioverter-Defibrillator (ICD) Placement.

Background: Post-infarction heart failure with reduced ejection fraction (HFrEF) patients often face persistent risks of sudden cardiac arrest leading to sudden cardiac death. While implanting a cardioverter-defibrillator (ICD) can enhance prognosis, complications and costs limit its widespread use. Current patient qualification criteria, relying on imperfect parameters, require refinement. The impairment of the cardiac adrenergic system in heart failure is associated with ventricular arrhythmias. The goal of the study was to assess the utility of cardiac adrenergic system scintigraphy in qualifying patients for ICD placement. Methods: In this prospective study of 85 post-infarction HFrEF patients at a single center, clinical assessments, laboratory tests, echocardiography, [123I]MIBG scintigraphy, and ICD implantation were performed. Scintigraphy involved planar chest images and evaluating the heart-to-mediastinum ratio (H/M) and washout rate (WO). SPECT imaging assessed [123I]MIBG uptake in 17 left ventricular segments to calculate the summed difference score (SDS). Results: During a median of 4-year follow-up, 22% of patients experienced appropriate ICD interventions, and 25% of patients died or underwent heart transplantation. The mean values of analyzed parameters did not significantly differ between groups. In the univariate analysis, younger age and moderately impaired left ventricular ejection fraction (LVEF) were correlated with more frequent ICD interventions. In comparison, older age and elevated NT-proBNP levels were associated with death or heart transplantation. Additionally, the univariate analysis identified SDS-15' as a prognostic factor for death/heart transplant. The multivariate analysis identified predictors for ICD interventions, including younger age, an EF of 30% or greater, and a larger left ventricular end-diastolic diameter. In contrast, older age and an LVEF of less than 25% were significant predictors of death or heart transplantation. Conclusions: Scintigraphic parameters did not effectively predict ICD interventions or death/heart transplantation, though the summed difference score demonstrated potential as a prognostic factor. Younger age with moderately impaired EF correlated with frequent ICD interventions, while in older age, EF < 25% predicted death or transplantation. Further investigation is needed for patients with borderline EF values.

Maternal-related factors associated with development and improvement of peripartum cardiomyopathy and therapeutic outcomes of bromocriptine

HIGHLIGHTS Younger age, black race, normotension, and multiparity indicate a poorer prognosis for peripartum cardiomyopathy recovery, while bromocriptine therapy reduces adverse events. ABSTRACT Objectives: This study aimed to fill the significant knowledge gap regarding peripartum cardiomyopathy (PPCM), a heart failure phenotype linked to pregnancy. The main objectives were to explore the factors influencing the development and progression of PPCM and to assess the outcomes of bromocriptine.Materials and Methods: Systematic search across PubMed, ScienceDirect, and Cochrane Library identified studies until December 2022. This study includes non-randomized prospective and retrospective studies, as well as relevant randomized controlled trials. Risk factors were compared between the recovered and non-recovered PPCM groups, and bromocriptine therapy outcomes were evaluated against standard heart failure treatment as the primary endpoint.Results: The analysis included 24 observational studies and 1 randomized controlled trial involving 1,651 PPCM patients; 9 studies evaluating the outcomes of bromocriptine therapy. The most prevalent factors were caesarean delivery (proportion=53%, 95%CI=41%-66%) and anemia (proportion=51%, 95%CI=38%-65%). Non-recovered patients were younger (MD=-1.04 years old, 95%CI=-1.82-(-0.27), p=0.008) and predominantly black (RR=1.82, 95%CI=1.43-2.31, p &lt;0.001). Hypertensive disorders and primiparity were found less among non-recovered patients (RR=0.73, 95%CI=0.60-0.88, p=0.001; RR=0.81, 95%CI=0.66-0.99, p=0.04, respectively). Non-recovered patients also exhibited higher baseline serum creatinine levels, lower LVEF, larger left ventricular end-systolic diameter (LVESD), larger left ventricular end-diastolic diameter (LVEDD), and lower fractional shortening (all P-values&lt;0.05). Furthermore, bromocriptine significantly reduced major adverse cardiac events (MACE), mortality, and increased LVEF (all P-values&lt;0.05).Conclusion: Younger maternal age, black race, absence of hypertension, and multiparity are associated with poorer prognosis for PPCM recovery. Bromocriptine therapy demonstrates superior benefits in reducing adverse events in PPCM.

Sex-Related Differences in Characteristics and Therapy of Heart Failure Patients

Aim: To determine the differences in comorbidities, therapy and echocardiographic measures among patients hospitalized for heart failure relative to gender.Methods: The study included patients hospitalized for heart failure at the Department of Cardiovascular Diseases of the Clinical Hospital Center Osijek in the period from 1 January 2020 to 30 March 2021.Results: There were 200 patients included in the study, of which 100 (50%) were male and 100 (50%) were female. Female patients were older, while male patients more frequently had a history of coronary artery disease. Men had a higher dose of loop diuretic on admission to the hospital. No significant difference was found in the representation of beta blockers and ACE inhibitors in therapy with regard to gender. On the other hand, men more frequently used MRA, sacubitril/valsartan and antiplatelet medication at hospital admission. Male patients had a larger left ventricular end-diastolic diameter, left ventricular end-systolic diameter and a lower left ventricular ejection fraction (EF). Regarding the type of heart failure according to EF, 72% of men had HFrEF, 20% HFmrEF and 8% HFpEF. In women, 47% had HFrEF, 33% HFmrEF and 20% HFpEF. During hospitalization due to heart failure, 22 patients died, an equal number of men and women.Conclusion: This research confirmed the differences in risk factors and pathophysiology of heart failure between males and females. Medicine is progressing towards an individual approach to each patient, so further research will be needed to find the best therapy for both male and female patients.

The impact of gender and frailty on the outcome of older patients with functional mitral regurgitation.

Functional mitral regurgitation (MR) is the second most common valvular heart disease worldwide and is increasing with age. The present study investigates the gender distribution and 1year prognosis of older patients (≥65years) with pharmacologically treated MR in a real-world population with moderate to severe functional MR. This a single-centre retrospective observational cohort study and included 243 medically treated patients with moderate to severe MR from 2014 to 2020. Echocardiography was performed at baseline. The combined endpoint was hospitalization due to heart failure and all-cause death. There were more female than male patients (42% vs. 58%) without differences regarding age (81±7years in males vs. 82±8years in females, P=0.24). Heart failure symptoms were distributed equally in both groups. Almost half of the patients evidenced a high EuroSCORE II (41%/42%). Atrial fibrillation was frequent, affecting 65% male and 64% female patients (P=0.89). There were no differences regarding medical treatment. In both genders, two-thirds of the patients displayed MR grade II° (71% (72), and 69% (97)), and one-third showed MR grade III° (29% (30) vs. 31% (44), respectively, P=0.76). Although males had larger left ventricular end-diastolic diameter, lower ejection fraction (39% (16) vs. 48% (14), P<0.001), and more dilated left atria. After 1year, genders did not differ regarding the combined primary endpoint of hospitalization due to heart failure and all-cause mortality (32% (33) for males vs. 29% (41) for females, P=0.61). One-year mortality was low and equal in both cohorts (11% in males and 9% in females, P=0.69). In univariate Cox regression proportion hazard model, being female was not associated with the primary endpoint (hazard ratio 0.87 (95% confidence interval 0.55 to 1.37), P=0.54). Multivariable adjustment for EuroSCORE II and frailty did not result in a significant change regarding the impact of the female gender. Despite better left ventricular systolic function, mortality in medically treated older female patients suffering from functional mitral regurgitation is not lower than in males. In this real-world cohort, frailty was a stronger predictor of clinical outcome than gender.

Prognostic Implications of Left Ventricular Ejection Fraction and Left Ventricular End-Diastolic Diameter on Clinical Outcomes in Patients with ICD.

Background: Left ventricular ejection fraction (LVEF) is a suboptimal indicator of risk stratification for patients with an implantable cardioverter defibrillator (ICD). Studies have shown that left ventricular end-diastolic diameter (LVEDD) was associated with all-cause mortality and ventricular arrhythmias. We examined the quantified prognostic value of LVEF and LVEDD for clinical outcomes, respectively. Method: This study retrospectively enrolled patients with ICD implantation in a single center. The associations between LVEF or LVEDD and all-cause mortality and appropriate shocks were analyzed using Cox regression and Fine-gray competing risk regression, respectively. Result: During a median follow up of 59.6 months, 168/630 (26.7%) patients died. LVEF and LVEDD were strongly associated with all-cause mortality (LVEF per 10%: HR 0.77, 95%CI 0.64−0.93, p = 0.006; LVEDD per 10 mm: HR 1.54, 95%CI 1.27−1.85, p < 0.001). After a median interrogation time of 37.1 months, 156 (24.8%) patients received at least one shock. LVEF was not associated with appropriate shock, whereas larger LVEDD (per 10 mm) was significantly associated with a higher risk of shock (HR: 1.27, 95%CI 1.06−1.52, p = 0.008). The addition of LVEF or LVEDD to clinical factors provided incremental prognostic value and discrimination improvement for all-cause mortality, while only the addition of LVEDD to clinical factors improved prognostic value for shock intervention. Conclusions: Baseline LVEF and LVEDD show a linear relationship with all-cause mortality in patients with ICD. However, whereas LVEF is not associated with shock, a linear relationship exists between LVEDD and appropriate shock. LVEDD adds more predictive value in relation to all-cause mortality and appropriate shocks than LVEF.

Association Between Early Left Ventricular Ejection Fraction Improvement After Transcatheter Aortic Valve Replacement and 5-Year Clinical Outcomes

In patients with severe aortic stenosis and left ventricular ejection fraction (LVEF) less than 50%, early LVEF improvement after transcatheter aortic valve replacement (TAVR) is associated with improved 1-year mortality; however, its association with long-term clinical outcomes is not known. To examine the association between early LVEF improvement after TAVR and 5-year outcomes. This cohort study analyzed patients enrolled in the Placement of Aortic Transcatheter Valves (PARTNER) 1, 2, and S3 trials and registries between July 2007 and April 2015. High- and intermediate-risk patients with baseline LVEF less than 50% who underwent transfemoral TAVR were included in the current study. Data were analyzed from August 2020 to May 2021. Early LVEF improvement, defined as increase of 10 percentage points or more at 30 days and also as a continuous variable (ΔLVEF between baseline and 30 days). All-cause death at 5 years. Among 659 included patients with LVEF less than 50%, 468 (71.0%) were male, and the mean (SD) age was 82.4 (7.7) years. LVEF improvement within 30 days following transfemoral TAVR occurred in 216 patients (32.8%) (mean [SD] ΔLVEF, 16.4 [5.7%]). Prior myocardial infarction, diabetes, cancer, higher baseline LVEF, larger left ventricular end-diastolic diameter, and larger aortic valve area were independently associated with lower likelihood of LVEF improvement. Patients with vs without early LVEF improvement after TAVR had lower 5-year all-cause death (102 [50.0%; 95% CI, 43.3-57.1] vs 246 [58.4%; 95% CI, 53.6-63.2]; P = .04) and cardiac death (52 [29.5%; 95% CI, 23.2-37.1] vs 135 [38.1%; 95% CI, 33.1-43.6]; P = .05). In multivariable analyses, early improvement in LVEF (modeled as a continuous variable) was associated with lower 5-year all-cause death (adjusted hazard ratio per 5% increase in LVEF, 0.94 [95% CI, 0.88-1.00]; P = .04) and cardiac death (adjusted hazard ratio per 5% increase in LVEF, 0.90 [95% CI, 0.82-0.98]; P = .02) after TAVR. Restricted cubic spline analysis demonstrated a visual inflection point at ΔLVEF of 10% beyond which there was a steep decline in all-cause mortality with increasing degree of LVEF improvement. There were no statistically significant differences in rehospitalization, New York Heart Association functional class, or Kansas City Cardiomyopathy Questionnaire Overall Summary score at 5 years in patients with vs without early LVEF improvement. In subgroup analysis, the association between early LVEF improvement and 5-year all-cause death was consistent regardless of the presence or absence of coronary artery disease or prior myocardial infarction. In patients with severe aortic stenosis and LVEF less than 50%, 1 in 3 experience LVEF improvement within 1 month after TAVR. Early LVEF improvement is associated with lower 5-year all-cause and cardiac death.

Thyroid Storm Patients With Elevated Brain Natriuretic Peptide Levels and Associated Left Ventricular Dilatation May Require Percutaneous Mechanical Support.

OBJECTIVES:To determine the characteristics of thyroid storm patients with acute decompensated heart failure who should be candidates for temporary percutaneous mechanical circulatory support in addition to beta-blocker treatment to prevent cardiogenic shock.DESIGN:A single-center, retrospective review of treatment details and data collected from electronic medical records.SETTING:Thyrotoxicosis complicated with acute decompensated heart failure.PATIENTS:Eight consecutive patients who were admitted to our hospital for acute decompensated heart failure with thyroid storm between December 2011 and August 2020 were retrospectively reviewed. Of the eight patients, four were treated with percutaneous mechanical circulatory support.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Compared with thyroid storm patients who did not require percutaneous mechanical circulatory support, those who did had a significantly higher initial plasma brain natriuretic peptide level (1,231 [911–3,387] vs 447 pg/mL [243–653 pg/mL], respectively; p = 0.015), as well as a significantly larger left ventricular end-diastolic diameter (56 [54–63] vs 48 mm [38–48 mm], respectively; p = 0.029) and end-systolic diameter (50 [49–58] vs 28 mm [28–30 mm], respectively; p = 0.029) on echocardiogram. In terms of thyroid storm severity, the Burch-Wartofsky score was higher in patients with percutaneous mechanical circulatory support than in those without, although the difference was not significant. All patients survived this index admission.CONCLUSIONS:In thyroid storm patients, the presence of a high brain natriuretic peptide level, “left ventricular dilatation,” or both may necessitate hemodynamic assessment to determine the indication of percutaneous mechanical circulatory support before beta-blocker administration.

Abstract 13937: The Association Between Left Ventricular End-Diastolic Diameter and Long-Term Mortality in Patients With Coronary Artery Disease

Background: Left ventricular end-diastolic diameter (LVEDD) is a common indicator in echocardiogram, and increased LVEDD is correlated with left ventricular (LV) insufficiency. However, the relationship between LVEDD and mortality in patients with coronary artery disease (CAD) is uncertain. Methods: This study enrolled 33,147 patients with CAD who had undergone transthoracic echocardiography between January 2007 and December 2018 in Cardiorenal Improvement (CIN) study (ClinicalTrials.gov NCT04407936). These patients were divided into four groups according to the quartile of LVEDD (Quartile 1: LVEDD≤43 mm, Quartile 2: 43&lt;LVEDD≤46 mm, Quartile 3: 46&lt;LVEDD≤51 mm, Quartile 4: LVEDD&gt;51 mm) and were categorized into two groups (Quartile 1-3 versus Quartile 4). Survival curves were generated with the Kaplan-Meier method. The restricted cubic splines and cox proportional hazards models were used to investigate the association with LVEDD and all-cause mortality. Results: In our study, there were a total of 33,147 patients, whose average age was 63.0±10.6 years and 24.01% of them were female. In the average follow-up period of 5.2 years, a totally of 4,288 patients died. After adjusting for confounding factors, patients with the larger LVEDD (Quartile 4) remain had a 1.19-fold risk for all-cause mortality (95% confidence interval: 1.09 to 1.30) compared with the lower quartile (Quartile 1-3). Conclusions: Enlarged LVEDD was an independent predictor of all-cause mortality in patients with CAD. LVEDD measurements may be helpful for risk stratification and providing therapeutic direction for the management of CAD patients.

Vitamin D Correlation with Echocardiographic Function in Patients of Congestive Heart Failure

Background: The association between vitamin D and heart failure, especially left ventricular (LV) function, is still not clear. Objectives: We aimed to study the correlation between 25-hydroxy vitamin D levels and parameters of cardiac systolic and diastolic functions in patients with LV systolic heart failure. Materials and Methods: Ninety patients of heart failure coming to our hospital with systolic heart failure (LV ejection fraction &lt;40%) were included. Venous sample were taken for measurement of 25-hyrdoxy vitamin D levels. Transthoracic echocardiography was done for all patients, and parameters of LV systolic and diastolic functions were taken. Results: Compared to patients having vitamin D &lt;20 ng/ml, patients having vitamin D levels ≥20 ng/ml had higher early diastolic mitral annular velocity (e'), significantly lower ratio of early diastolic mitral inflow velocity (E) to e' (E/e'), significantly shorter isovolumetric relaxation time (IVRT) suggestive of better diastolic function. Furthermore, patients having vitamin D &lt;20 ng/ml had higher LV end-systolic volume, LV end-systolic diameter, larger LV end-diastolic diameter, higher interventricular septum thickness, higher LV wall thickness, and higher LV mass. Conclusion: Reduced vitamin D (&lt;20 ng/ml) was associated with worse systolic function in terms of systolic volume and diameter, diastolic function in terms of lower e′, higher E/e′, and longer IVRT.

Myocardial disease and ventricular arrhythmia in Marfan syndrome: a prospective study

BackgroundAortic root dilatation and—dissection and mitral valve prolapse are established cardiovascular manifestations in Marfan syndrome (MFS). Heart failure and arrhythmic sudden cardiac death have emerged as additional causes of morbidity and mortality.MethodsTo characterize myocardial dysfunction and arrhythmia in MFS we conducted a prospective longitudinal case–control study including 86 patients with MFS (55.8% women, mean age 36.3 yr—range 13–70 yr–) and 40 age—and sex-matched healthy controls. Cardiac ultrasound, resting and ambulatory ECG (AECG) and NT-proBNP measurements were performed in all subjects at baseline. Additionally, patients with MFS underwent 2 extra evaluations during 30 ± 7 months follow-up. To study primary versus secondary myocardial involvement, patients with MFS were divided in 2 groups: without previous surgery and normal/mild valvular function (MFS-1; N = 55) and with previous surgery or valvular dysfunction (MFS-2; N = 31).ResultsCompared to controls, patients in MFS-1 showed mild myocardial disease reflected in a larger left ventricular end-diastolic diameter (LVEDD), lower TAPSE and higher amount of (supra) ventricular extrasystoles [(S)VES]. Patients in MFS-2 were more severely affected. Seven patients (five in MFS-2) presented decreased LV ejection fraction. Twenty patients (twelve in MFS-2) had non-sustained ventricular tachycardia (NSVT) in at least one AECG. Larger LVEDD and higher amount of VES were independently associated with NSVT.ConclusionOur study shows mild but significant myocardial involvement in patients with MFS. Patients with previous surgery or valvular dysfunction are more severely affected. Evaluation of myocardial function with echocardiography and AECG should be considered in all patients with MFS, especially in those with valvular disease and a history of cardiac surgery.

Response to ECG, August 2020

A prophylactic implantable cardioverter defibrillator (ICD) in patients with heart failure and reduced left ventricular ejection fraction (HFrEF) is only indicated when left ventricular ejection fraction (LVEF) reassessment remains ≤35% after 3–6 months on optimal pharmacological therapy. However, LVEF may not improve during this period and the patient may be exposed to an unnecessary risk of sudden cardiac death. This study aimed to determine the incidence and predictors of the absence of left ventricular reverse remodeling (LVRR) after pharmacological treatment optimization in patients with HFrEF to design a risk score of absence of LVRR.Consecutive outpatients with LVEF ≤35% were included in this observational prospective study. Up-titration of angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradine was performed in our Heart Failure (HF) Unit. The absence of LVRR was defined as the persistence of an LVEF ≤35% at the 6-month follow-up.One hundred and twenty patients were included. At the 6-month follow-up, 64%, 76%, 72%, and 7% of patients were at 100% of the target dose of ACE inhibitors/ARBs, beta-blockers, MRAs, and ivabradine, respectively. LVRR was observed in 48% of the patients. Ischemic cardiomyopathy, prolonged HF duration, and larger left ventricular end-diastolic diameter index (LVEDDI) were independent predictors of the absence of LVRR. The risk score based on these predictors showed a c-statistic value of 0.81.Pharmacological treatment optimization is associated with LVRR in approximately half of cases, reducing potential ICD indications in parallel. However, ischemic cardiomyopathy, prolonged HF duration, and larger LVEDDI predict the absence of LVRR and favor ICD implantation without delay. The risk score based on the former predictors may help the clinician with the timing of ICD implantation.

Outcomes in Patients with Smaller Left Ventricular End Diastolic Diameter Following HeartMate 3 (HM3) Left Ventricular Assist Device (LVAD) Implantation

Outcomes in patients with small left ventricular end diastolic diameter (LVEDD) following HM3 LVAD implantation have not been well characterized. We sought to compare the clinical outcomes of patients with small LVEDD to those with dilated left ventricles. Patients who received a HeartMate 3 LVAD at our institution between October 1, 2015 and June 30, 2019 were analyzed. Patients who received a HM3 LVAD as a pump exchange were excluded. The cohort was divided in 2 groups: smaller LVEDD (≤60 mm in males and ≤58 mm in females) and larger LVEDD (>60 mm in males and >58 mm in females). One hundred and nineteen patients underwent HeartMate 3 LVAD implantation at our institution. Patients in the smaller LVEDD group (n: 22) had a mean LVEDD of 55.7±5 mm and patients in the larger LVEDD group had a mean LVEDD of 70.6±8 mm (p=<0.0001). Patients in the smaller LVEDD group tended to be older (60±11 vs 56±11 years, p=0.07), and included more males (82% vs. 68%, p=0.3) and fewer African-Americans (59% vs. 79%, p=0.08). Patients in the smaller LVEDD group were more likely to have a history of ischemic cardiomyopathy (50% vs. 23%, p=0.01), CAD (82% vs. 30%, p<0.001)) and diabetes (73% vs. 47%, p=0.03). INTERMACS class 1 + 2 was similar between groups (72% vs. 68%, p=0.9). Mean days on the ventilator (2.4±3 vs. 3.2±5 days, p=0.5), on inotropes (16±12 vs. 15±8 days, p=0.69) and vasopressors (9±9 vs. 7±11 days, p=0.6) was similar between groups. Mean length of stay (25±14 vs. 29±17 days, p=0.2) and readmissions days (25±52 vs. 27±46 days, p=0.8) were also similar. One-year survival was 90% for the smaller LVEDD group and 95% for the larger LVEDD group (Figure, log rank 0.696). Adult patients with smaller LVEDD who received a HeartMate 3 LVAD have comparable clinical outcomes to patients with larger LVEDD. A small left ventricle should not be a contraindication to implantation of this particular durable device in adult patients.

The MitraClip Procedure in Patients With Moderate Resting but Severe Exercise-Induced Mitral Regurgitation.

Optimal timing for percutaneous mitral regurgitation (MR) treatment using MitraClip (Abbott Vascular) remains unclear. We evaluated the outcome after MitraClip in patients with moderate resting MR, progressing to severe exercise- induced MR (MR2+) compared to patients with severe resting MR (MR3). We retrospectively investigated 221 patients undergoing MitraClip. All-cause deaths and heart failure (HF) hospitalizations were assessed as the combined primary endpoint. We identified 55 MR2+ and 166 MR3 patients. At baseline, MR3 patients showed higher STS scores (6.7 ± 7.3 vs 4.4 ± 5.5; P<.01), more HF hospitalizations in the 2 years prior to the procedure (51% vs 29%; P<.01), worse left ventricular ejection fraction (44.9 ± 16.5% vs 52.5 ± 14.3%; P<.01), larger left ventricular end-diastolic diameter (LVEDd; 57.0 ± 9.3 mm vs 51.7 ± 8.2 mm; P<.001), and larger left atrial volumes (118.3 ± 55.8 mL vs 98.6 ± 35.2 mL; P=.02). Long-term outcome according to the combined endpoint was significantly worse in MR3 patients (P=.01). HF hospitalizations significantly declined in both groups 2 years after MitraClip (P<.001 in MR3 patients, P=.03 in MR2+ patients). Multivariate Cox regression analysis revealed LVEDd (hazard ratio, 1.035; 95% confidence interval, 1.005-1.066; P=.02) and previous HF hospitalizations (hazard ratio, 1.813; 95% confidence interval, 1.016-3.234; P=.04) as strong outcome predictors. Symptomatic patients with moderate resting and severe exercise-induced MR during handgrip echocardiography may represent an MR cohort at an earlier disease stage with improved treatment response following MitraClip implantation compared to individuals with severe resting MR. Larger left ventricular diameters and preprocedural HF hospitalizations were identified as independent adverse outcome predictors.

P2601Trans-catheter or surgical mitral valve procedure versus conservative treatment in heart failure patients with preserved ejection fraction

Abstract Background Secondary mitral regurgitation (SMR) impacts outcomes in heart failure with reduced ejection fraction (HFrEF) but whether it is a specific therapeutic target in heart failure patients with preserved ejection fraction (HFpEF) is less clear. Purpose The aims of this study were to investigate whether surgical or trans-catheter intervention reduces SMR and improves outcomes compared to optimal medical therapy in HFpEF patients. Methods We retrospectively identified 120 HFpEF patients with moderate-to-severe or greater SMR from January 1, 2007, until December 31, 2017. Moderate-to-severe SMR was defined as an effective regurgitant orifice area of &gt;0.3cm2, and/or a regurgitation volume of &gt;45ml per beat. Those with primary mitral regurgitation, endocarditis, HFrEF, hypertrophic cardiomyopathy, congenital heart disease, and history of valve intervention were excluded. All-cause mortality was analyzed and correlated to clinical and echocardiographic characteristics. Amongst the 120 patients, 36 received surgical or trans-catheter procedure in addition to medical therapy (procedure group) and 84 patients received optimal medical therapy only (conservative treatment group). The median follow-up period was 864 (15–3553) days. Results Patients in the procedure group were younger (75±8 vs 81±10, P=0.0002) and with fewer comorbidities (Charlson Comorbidity Index 7.0±2.4 vs 8.0±2.0, P=0.022) compared to the conservative treatment group. In addition, the procedure group had larger left ventricular end-diastolic diameters and higher SMR volume at baseline. During follow-up, SMR decreased by ≥2 grades in 75% of patients (27/36) in the procedure group compared to 20% of patients (12/60) in the conservative treatment group. After adjusting for age and comorbidities, the procedure group showed better overall survival compared to the conservative treatment group (HR 0.37; 95% CI 0.17–0.80; P=0.011). On multivariate analysis for the different groups (procedure group vs. conservative treatment group) (HR 0.40; 95% CI 0.17–0.91; P=0.019), increasing Charlson Comorbidity Index (HR 1.16; 95% CI 1.02–1.32; P=0.028) and average mitral E/e' ratio (HR 1.06; 95% CI 1.01–1.11; P=0.031) were independent predictors of increased all-cause mortality. Kaplan-Meier Survival Curve Conclusion Among heart failure patients with preserved ejection fraction and moderate-to-severe or severe SMR, surgical or trans-catheter mitral-valve repair or replacement resulted in lower all-cause mortality compared to conservative treatment after 9 years of follow-up.

Anemia in patients with Takayasu arteritis: prevalence, clinical features, and treatment.

BackgroundAnemia is a common comorbidity of patients with Takayasu arteritis (TA). This study evaluated the prevalence, clinical characteristics, and treatment in Chinese TA patients with anemia.MethodsThis retrospective study included 533 consecutive patients hospitalized for TA from January 2009 to April 2018. Anemia was diagnosed on the basis of hemoglobin level, according to World Health Organization criteria.ResultsA total of 194 patients (36.4%) were diagnosed with anemia. Most had mild anemia (177, 91.2%). Female patients were predominant (92.8% of anemic patients). Normocytic anemia (62.9%) was the most common pattern. Anemic patients were more likely than non-anemic patients to have dizziness (29.4% vs. 21.2%), low body mass index (22.0 ± 3.6 vs. 22.9 ± 3.4 kg/m2), and active disease stage (64.9% vs. 50.1%); pulmonary involvement (12.4% vs. 26.8%), pulmonary hypertension (12.9% vs. 20.1%) and pulmonary hypertensive-target drugs (2.8% vs. 11.6%) were less common among anemic than non-anemic patients (all P < 0.05). Larger left ventricular end-diastolic diameter and lower left ventricular ejection fraction were observed in anemic patients. Over a median follow-up of four months, the increase of hemoglobin in anemic patients was associated with the use of iron supplementation.ConclusionsAnemia is a very common concurrent condition in TA, especially in young, female patients. Patients with anemia are more likely to be in the active disease stage. Iron supplementation helps increase hemoglobin.

Impact of Arteriovenous Fistula on Cardiac Size and Function in Kidney Transplant Recipients: A Retrospective Evaluation of 5-Year Echocardiographic Outcome.

The effect of a functioning arteriovenous fistula on cardiac function in kidney transplant recipients has not been thoroughly investigated. We retrospectively evaluated cardiac function in 99 renal transplant recipients using transthoracic echocardiography, with available follow-up at baseline and 2 and 5 years posttransplant. Patients were divided into 2 groups: a control group (n = 47) with no functioning arteriovenous fistula immediately after transplant and an arteriovenous fistula group (n = 52) with a functioning arteriovenous fistula for at least 5 years after transplant. Left ventricular ejection fraction, diastolic thickness of the interventricular septum, and left ventricular end-diastolic diameter were assessed. In our study, patients (62.6% men, 7.1% with diabetes, mean age of 55.6 ± 11.5 years), we observed no significant differences with respect to baseline left ventricular ejection fraction and interventricular septum; however, in the arteriovenous fistula group, baseline left ventricular end-diastolic diameter was marginally higher than that shown in the control group (50.6 ± 5.4 vs 48.6 ± 4.4 mm; P = .054). In multivariate analysis, functioning fistula and peripheral arterial disease were negatively associated with left ventricular ejection fraction at 5 years posttransplant, whereas baseline left ventricular ejection fraction had a minimal positive effect: B (95% confidence interval) of -2.186 (-4.312 to -0.061) (P = .044), -5.304 (-9.686 to -0.922) (P = .018), and 0.247 (0.047 to 0.446) (P = .016), respectively. Functioning fistula also emerged as associated with larger left ventricular end-diastolic diameter at 2 and 5 years posttransplant: B (95% confidence interval) of 3.047 (1.470-4.625) (P < .001) and 2.122 (0.406-3.838) (P = .016), respectively. Maintenance of a functioning fistula in kidney transplant recipients may be associated with adverse long-term effects on left ventricular ejection fraction and left ventricular end-diastolic diameter.

Multiple Autoantibodies against Cardiovascular Receptors as Biomarkers in Hypertensive Heart Disease

Objectives: The pathogenesis of hypertensive heart disease (HHD) remains unclear, which might include autoimmunity. The aim of the present study was to determine whether a relationship exists between the presence of autoantibodies against β₁, β₂, α₁ adrenoreceptors, M₂-muscarinic receptors, angiotensin II type₁ receptors and HHD. Methods: In the present study, 44 patients diagnosed with HHD, 36 patients with hypertension, and 40 controls were also enrolled. The measurement of these 5 autoantibodies was performed by enzyme-linked immunosorbent assay. Results: The frequencies of autoantibodies against β₁, β₂, α₁ adrenoreceptors, autoantibodies against M₂-muscarinic receptors and autoantibodies against angiotensin II type₁ receptors were significantly higher in patients with HHD, when compared to patients with hypertension and normal controls (all p < 0.001). In addition, the titers of these 5 autoantibodies significantly increased in patients with HHD. Patients who were positive for all 5 autoantibodies had larger left ventricular end-diastolic diameter (60.5 ± 4.9 vs. 57.8 ± 5.0 vs. 52.5 ± 5.3 mm) and worse left ventricular ejection fraction (45.0 ± 11.0 vs. 56.6 ± 10.4 vs. 57.8 ± 5.3%), when compared to patients not positive for all the 5 autoantibodies and patients negative for all the 5 autoantibodies (χ² = 9.524, p = 0.009 and χ² = 7.689, p = 0.021). Furthermore, a significant positive correlation was observed between each 2 autoantibodies of these 5 autoantibodies (all p < 0.001). Conclusion: Multiple autoantibodies of cardiovascular receptors may be involved in the pathogenesis and may be predictive factors of HHD.

Benefits of left ventricular endocardial pacing comparing failed implants and prior non-responders to conventional cardiac resynchronization therapy: A subanalysis from the ALSYNC study

ObjectiveCardiac resynchronisation therapy (CRT) is limited by a substantial proportion of non-responders. Left ventricular endocardial pacing (LVEP) may offer enhanced possibility to deliver CRT in patients with a failed attempt at implantation and to improve clinical status of CRT non-responders. MethodsThe ALternate Site Cardiac ResYNChronisation (ALSYNC) study was a prospective, multi-centre cohort study that included 118 CRT patients with a successfully implanted endocardial left ventricular (LV) lead, including 90 failed coronary sinus (CS) implants and 28 prior non-responders who had worsened or unchanged heart failure status after at least 6 months of optimal conventional CRT therapy. ResultsPatients were followed for 19 ± 9 months. At baseline, prior non-responders were sicker as evidenced by a larger LV end-diastolic diameter (70 ± 12 vs 65 ± 9 mm, p = .03) and a trend towards larger LV end-systolic volume index (LVESVi, 95 ± 51 vs 74 ± 39 ml/m2, p = .07), and were more frequently anti-coagulated (96% vs 72%, p = .008) despite similar history of atrial fibrillation (54% vs 51%, p = .83). At 6 months, LVEP significantly improved LV ejection fraction (2.3 ± 7.5 and 8.6 ± 10.0%), New York Heart Association Class (0.4 ± 0.9 and 0.7 ± 0.8), LVESVi (9 ± 16 and 18 ± 43 ml/m2), and six-minute walk test (56 ± 73 and 54 ± 92 m) in prior non-responders and failed CS implants, relative to baseline (all p < .05), respectively. LVESVi reduction ≥15% was seen in 47% of the prior non-responder patients and 57% of failed CS patients. ConclusionThese data suggest that a sizable proportion of CRT non-responders can improve by LVEP, though to a lesser extent than failed CS implants.Clinical trial registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01277783

A risk score to predict the absence of left ventricular reverse remodeling: Implications for the timing of ICD implantation in primary prevention

BackgroundA prophylactic implantable cardioverter defibrillator (ICD) in patients with heart failure and reduced left ventricular ejection fraction (HFrEF) is only indicated when left ventricular ejection fraction (LVEF) reassessment remains ≤35% after 3–6 months on optimal pharmacological therapy. However, LVEF may not improve during this period and the patient may be exposed to an unnecessary risk of sudden cardiac death. This study aimed to determine the incidence and predictors of the absence of left ventricular reverse remodeling (LVRR) after pharmacological treatment optimization in patients with HFrEF to design a risk score of absence of LVRR. MethodsConsecutive outpatients with LVEF ≤35% were included in this observational prospective study. Up-titration of angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradine was performed in our Heart Failure (HF) Unit. The absence of LVRR was defined as the persistence of an LVEF ≤35% at the 6-month follow-up. ResultsOne hundred and twenty patients were included. At the 6-month follow-up, 64%, 76%, 72%, and 7% of patients were at 100% of the target dose of ACE inhibitors/ARBs, beta-blockers, MRAs, and ivabradine, respectively. LVRR was observed in 48% of the patients. Ischemic cardiomyopathy, prolonged HF duration, and larger left ventricular end-diastolic diameter index (LVEDDI) were independent predictors of the absence of LVRR. The risk score based on these predictors showed a c-statistic value of 0.81. ConclusionsPharmacological treatment optimization is associated with LVRR in approximately half of cases, reducing potential ICD indications in parallel. However, ischemic cardiomyopathy, prolonged HF duration, and larger LVEDDI predict the absence of LVRR and favor ICD implantation without delay. The risk score based on the former predictors may help the clinician with the timing of ICD implantation.