Impaired Left Ventricular Ejection Fraction Research Articles

Cardiovascular outcomes after cardiac resynchronization therapy in cardiac amyloidosis.

AimsCardiac resynchronization therapy (CRT) is highly effective in dilated cardiomyopathy (DCM) patients with impaired left ventricular ejection fraction (LVEF) and left bundle block branch. In cardiac amyloidosis (CA) patients, left ventricular dysfunction and conduction defects are common, but the potential of CRT to improve cardiac remodelling and survival in this particular setting remains undefined. We investigated cardiovascular outcomes in CA patients after CRT implantation in terms of CRT echocardiographic response and major cardiovascular events (MACEs).Methods and resultsOur retrospective study included 47 CA patients implanted with CRT devices from January 2012 to February 2020, in nine French university hospitals (77 ± 6 years old, baseline LVEF 30 ± 8%) compared with propensity‐matched (1:1 for age, LVEF at implantation, and CRT indication) DCM patients with a CRT device. CA patients had lower rates of CRT response (absolute delta LVEF ≥ 10%) compared with DCM patients (36% vs. 70%, P = 0.002). After multivariate Cox analysis, CA was independently associated with MACE (hospitalization for heart failure/cardiovascular death) [hazard ratio (HR) 3.73, 95% confidence interval (CI) 1.85–7.54, P < 0.001], along with the absence of CRT response (HR 3.01, 95% CI 1.56–5.79, P = 0.001). The presence of echocardiographic CRT response (absolute delta LVEF ≥ 10%) was the only predictive factor of MACE‐free survival in CA patients (HR 0.36, 95% CI 0.15–0.86, P = 0.002).ConclusionCompared with a matched cohort of DCM patients, CA patients had a lower rate of CRT response and consequently a worse cardiovascular prognosis after CRT implantation. However, CRT could be beneficial even in CA patients given that CRT response was associated with better cardiac outcomes in this population.

Akut Anterior Miyokard İnfarktüsü Geçiren ve Primer Perkütan Koroner Girişim Uygulanan Hastalarda Sol Ventrikül Apikal Trombüs Oluşumunun Öngördürücüleri: SYNTAX Skorunun Önemi

Aim: Left ventricular (LV) apical thrombus development is one of the important advers event patients with anterior ST elevation myocardial infarction (STEMI) and accompanies with LV apical aneurysm and systolic dysfunction. SYNTAX score is an important determinant of cardiovascular morbidity and mortality in patients with coronary artery disease. We aimed that the relationship between LV apical thrombus and SYNTAX score and other clinical risk factors patients with anterior STEMI Methods: A total of 205 consecutive anterior STEMI patients undergoing primary PCI (35 female/ 170 male mean age: 55.8 ± 9.6 years) were included in our study. We assessed the severity and complexity of coronary artery disease by using SYNTAX score. The patients were divided into two groups; patients with apical thrombus (n=19) and patients without apical thrombus(n=186). Results: We found that systolic and diastolic blood pressure were lower patients with apical thrombus groups. (p&amp;lt;0.001 for both). Syntax score was higher and LV ejection fraction (LVEF) is lower in patients with apical thrombus (p&amp;lt;0.001 for both). We also showed that LV apical thrombus formation was independently associated with lower systolic blood pressure (p=0.006), SYNYAX score (p=0.003), and depressed LVEF (p=0.001). Conclusion: In this study, impaired LVEF, lower systolic blood pressure and SYNTAX score have been found to be predictors of LV thrombus generation. Patients presenting with anterior myocardial infarction who have high SYNTAX scores (&amp;gt; 18.25) at PPCI should be followed up closely.

The impact of magnetic resonance imaging in the assessment of iron overload in heart and liver in transfusion-dependent thalassemic children: Minia experience

BackgroundThalassemia is the most prevalent single-gene disorder. Myocardial and hepatic iron depositions lead to complications and eventually death. We aimed to assess the diagnostic efficacy of magnetic resonance imaging T2* (MRI T2*) in quantifying iron overload in liver and heart in transfusion-dependent B-thalassemia major (TDT) children.MethodsProspective clinical study was carried on sixty children diagnosed with TDT. All of them underwent laboratory investigations, including CBC, serum iron, and ferritin levels. MRI T2* of the heart and liver was carried out to measure the iron overload and estimate the left ventricular ejection fraction (LVEF).ResultsThirty-eight males and 22 females with TDT with a mean age of 13.23 years were included. Twenty cases (33.3%) had severe liver iron overload, while 36 (60%) had normal cardiac iron. There was a moderate significant negative association between hepatic and cardiac iron deposition (P = 0.03). All cases with severe cardiac iron overload had impaired LVEF below 56%. A non-significant positive association was noticed between cardiac iron deposition and LVEF in T2* (P = 0.08). A moderate negative significant association was detected between hepatic iron deposition and serum ferritin, while a fair negative significant association was found between serum ferritin and cardiac iron deposition with P values of 0.04 and 0.02, respectively.ConclusionMRI T2* is the gold standard for monitoring and follow-up of iron overload in the heart and liver. It should be routinely performed in all TDT children as liver iron, and serum ferritin do not reflect cardiac iron overload.

Value of Global Longitudinal Strain for Identification and Monitoring of Left Ventricular Dysfunction in Becker Muscular Dystrophy

Cardiac involvement is the main cause of death in Becker muscular dystrophy (BMD). Identification of left ventricular (LV) function is crucial, but standard echocardiographic measurements such as LV ejection fraction (LVEF) might not be sensitive enough to detect early myocardial dysfunction. We explored the value of LV global longitudinal strain (GLS) as a more accurate echocardiographic parameter to detect and monitor LV dysfunction in BMD. Furthermore, we studied possible factors associated with LV dysfunction and progression. A total of 40 patients with BMD (age 39.0 ± 13.2 years) and 21 matched controls were included. Clinical variables, pulmonary tests, serum biomarkers, and echocardiograms were collected at baseline and after 2 years. LV systolic function was assessed by LVEF and LV GLS; a significant progression in LV dysfunction was defined as an absolute LV GLS deterioration ≥15%. Responsiveness to cardiac disease progression was determined using standardized response means. Patients showed impaired LVEF and LV GLS compared with controls (p <0.001). Of interest, 31 patients (77.5%) showed impaired LV GLS (defined as greater than -18%), whereas only 24 patients (60%) had reduced LVEF. LV GLS and LVEF correlated with troponin I (ρ=0.553 and -0.523) and N-terminal pro-b-type natriuretic peptide (ρ=0.506 and -0.585), but not with skeletal muscle or pulmonary function. At follow-up (2.0 ± 0.5 years, n=29), LV GLS worsened significantly (-1.3 ± 0.8%, p=0.002, standardized response mean=0.70, annually=0.60%), whereas LVEF remained stable. No risk factors for LV dysfunction progression were identified. In BMD, LV GLS is frequently impaired and shows deterioration over time compared with LVEF. LV GLS could be used as a more sensitive parameter to identify and monitor LV dysfunction.

Outcomes of novel pacing technologies with right ventricular pacing as a primary strategy for patient undergoing transvenous permanent pacing regardless of pacing indication

Abstract Background Right ventricular pacing (RVP) may cause electrical and mechanical desynchrony leading to impaired left ventricular ejection fraction (LVEF). We investigated the outcomes of RVP with His bundle pacing (HBP) and left bundle branch pacing (LBBP) for patients requiring a de novo permeant pacemaker (PPM) irrespective of baseline pacing indication. Methods and results Systematic review of randomized clinical trials and observational studies comparing HBP or LBP with RVP for de novo PPM implantation between 01 January 2013 and 17 November 2020 using MEDLINE and Embase. Two independent reviewers extracted the data and assessed the risk of bias of included studies. Random and fixed effects meta-analyses of the effect of pacing technology on study outcomes (all-cause mortality, heart failure hospitalization (HFH), left ventricular ejection fraction, QRS duration, lead revision, atrial fibrillation and procedure and pacing metrics) were performed. Overall, 7 studies were included. HBP compared with RVP was associated with decreased mortality (risk ratio [RR] 0.76, 95% CI 0.59 to 0.98), preservation of LVEF (mean difference [MD] 1.2, 95% CI −1.37 to 3.8 vs. −5.22, 95% CI: −6.94 to −3.51), increased procedure duration (MD 15.17 min, 95% CI: 11.27 to 19.07) and more lead revisions (RR 6.30, 95% CI: 2.31 to 17.19). LBBP compared with RVP was associated with shorter paced QRS durations (MD 5.6 ms, 95% CI −6.4 to 17.6) vs. (51.0 ms, 95% CI 39.2 to 62.9) and increased procedure durations (MD 37.78 min, 95% CI: 20.04 to 55.51). Conclusion Of the limited studies published, this meta-analysis found that HBP and LBBP were superior to RVP in maintaining physiological ventricular activation as an initial pacing strategy. Well conducted comparative studies are required to understand the impact of such novel pacing strategies on clinical outcomes. Funding Acknowledgement Type of funding sources: None.

B-lines by lung ultrasound is associated with pulmonary symptoms and cardiac function in acute malaria: a prospective cohort study

Abstract Background Malaria patients are at risk of cardiopulmonary complications, but diagnosis and management are difficult in resource limited environments. B-lines by lung ultrasonography (LUS) can identify pulmonary alterations, however, little is known about the usefulness in malaria. Purpose We aimed to investigate the occurrence of B-lines in acute malaria patients at baseline and at follow-up, and whether they are associated with shortness of breath and impaired left ventricular ejection fraction (LVEF). Methods Adult patients with non-severe acute malaria were prospectively enrolled from June to December 2020 in community healthcare clinics in a remote area. Patients were age- and sex-matched to controls without a prior history of malaria. We examined patients prior to anti-malaria treatment and at follow-up. Malaria treatment was administered according to national guidelines. Patients were excluded if they were pregnant, had concomitant infections or recent chest trauma. Patients underwent LUS (8-zones), echocardiography and peripheral blood smear. Measurements were blinded to clinical variables and outcomes. Results We included a total of 99 patients (median age 40±15 years, 55% men). Patients suffered from Plasmodium vivax (n=75), P. falciparum (n=22), and a mix of the two (n=2) and median parasite density was 1,595 parasites/mL (interquartile range [IQR] 528–6,585/mL). Follow-up was completed in 71 patients and the median follow-up time was 31 days (IQR 27–40 days). Patients with acute malaria had significantly more B-lines at baseline than matched controls (P-value&amp;lt;0.001) and fewer B-lines at follow-up (P-value&amp;lt;0.001) (Figure 1). In acute malaria patients, number of B-lines at baseline correlated significantly with shortness of breath (OR 1.20, [1.04 to 1.39], P-value=0.01) and with LVEF (adjusted for age and sex: +8% [+1% to +15%], P-value=0.016 per 1% decrease in LVEF). There was no correlation between number of B-lines and parasite density (+2% [−5% to +11%], P-value=0.53 per 1000 increase in parasite density). Conclusion B-lines detected by LUS are more frequent in patients with acute malaria than in age- and sex-matched controls and decrease in response to treatment. B-lines also correlate with shortness of breath and lower LVEF at baseline. Because LUS is a quick and accessible examination, it may potentially facilitate risk stratification and therapeutic decisions regarding cardiopulmonary complications in patients with acute malaria. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Danish Heart Association

Clinical and echocardiographic parameters associated with left ventricular recovery after TAVI

Abstract Introduction The relationship between severe Aortic Stenosis (AS) and Left Ventricular (LV) dysfunction is well established. However, there is a paucity of data regarding LV functional recovery after TAVI. Purpose To study the clinical and echocardiographic parameters associated with LV functional recovery after TAVI. Methods We evaluated all patients who underwent TAVI between 2009–2020 in a tertiary medical center. We included patients with pre-procedural LV Ejection Fraction (LVEF) of 40% and below. All patients had baseline and in-hospital post-procedural echo, and their clinical characteristics were recorded in a designated TAVI registry. LV functional recovery was defined as an absolute increase in at least 10% in LVEF post-procedurally. No LV recovery was defined as an absolute change of up to ±10% in post-procedure LVEF, and LVEF deterioration was defined as an absolute decrease of more than 10% in post-procedural LVEF compared to baseline. Univariate analysis consisting clinical and echocardiographic factors for LV functional recovery was performed, followed by logistic regression adjusting for confounders. Results Out of 1,349 consecutive TAVI patients, 100 (7.4%) had LVEF of 40% or less. There were 69 (69%) men with a mean age of 82±8 years, and average BMI of 27±4 kg/m2. Prior coronary artery disease and hypertension were present in 34 (34%) and 21 (21%) of patients, respectively. Out of these 100 patients, 32 (32%) had achieved LV functional recovery and no patient had experienced LVEF deterioration (FIGURE). Mean Left Ventricular End Systolic Diameter (LVESD) was 3.79 and 4.43 in the LV functional recovery and no LV recovery groups, respectively. Mean aortic pressure gradient was higher among patients who had LV functional recovery compared to no LV recovery (45.9 vs. 31.5 mmHg, respectively). Multivariable analysis revealed parameters that were independently associated with LV functional recovery: Coronary artery disease – OR 5.29 (95% CI 1.59–20.44), LVESD – OR 0.87 (95% CI 0.8–0.95) for each 1 mm increment and mean aortic pressure gradient – OR 1.91 (95% CI 1.21–3.28) per each 10 mmHg increment. Conclusion In patients with severe AS and LV dysfunction undergoing TAVI, the presence of coronary artery disease, increased aortic pressure gradient and reduced LVESD were associated with early LV functional recovery. Funding Acknowledgement Type of funding sources: None. Figure 1

Impact of left ventricular ejection fraction on clinical outcomes in females undergoing percutaneous coronary intervention with drug-eluting stents

Abstract Background Reduced left ventricular ejection fraction (LVEF) is associated with increased risk of adverse events among patients undergoing percutaneous coronary intervention (PCI). Due to under-enrollment of females in randomized trials, there is limited data on the impact of LVEF on post-PCI outcomes in female patients. Purpose To evaluate the impact of varying degrees of LVEF impairment on 3-year outcomes in female patients undergoing PCI with drug-eluting stents (DES). Methods We pooled patient-level data of female patients from 26 randomized trials of coronary stents. The study population was stratified into three groups according to the 2016 European Society of Cardiology Heart Failure guidelines: LVEF ≥50% (normal), LVEF 40–49% (mid-range), and LVEF &amp;lt;40% (reduced). The primary outcome was major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction (MI), or stent thrombosis (ST) at 3-year follow-up. The Kaplan-Meier method was used for time-to-event analyses, with comparative risks being assessed using Cox regression. Results Out of 5672 female patients with available LVEF values at baseline, 4427 (78.1%) had normal LVEF, 602 (10.6%) had mid-range LVEF, and 643 (11.3%) had reduced LVEF. Patients with reduced LVEF were older and had a higher prevalence of smoking, prior MI, and multi-vessel disease. There was a stepwise increase in 3-year event rates moving from normal, to mid-range and reduced LVEF (Figure 1). After multivariable adjustment, hazard ratio (HR) for MACE was 1.45 (95% CI: 1.10–1.92) in patients with mid-range LVEF and 2.43 (95% CI: 1.84–3.22) in patients with reduced LVEF (trend p-value &amp;lt;0.0001). The risk of ST was more than doubled in both mid-range LVEF (HR 2.30, 95% CI: 1.30–4.06, p=0.004) and reduced LVEF patients (HR 2.18, 95% CI: 1.11–4.28, p=0.02), as compared with normal LVEF. Conclusion The presence of an even mild degree of LVEF impairment confers an increased risk of ischemic events, including ST, among females undergoing PCI with DES. Funding Acknowledgement Type of funding sources: None. Figure 1

WALK-IN VT AND PRESERVED EJECTION FRACTION - DO THESE PATIENTS RECEIVE THERAPIES FROM AN ICD?

<h3>BACKGROUND</h3> Implanted cardioverter defibrillators (ICDs) clearly improve survival in patients with prior cardiac arrest without reversible cause, and in those with sustained ventricular tachycardia (VT) with significantly impaired left ventricular ejection fraction (EF). This ‘secondary prevention' approach is well supported by evidence from large clinical trials. However, it is not clear from the evidence whether patients with a minimally reduced ejection fraction (35-50%) who experience sustained VT that is hemodynamically tolerated benefit from ICD therapy. ICD implant entails some risk and these devices can malfunction or become infected in a small proportion of patients, making the comparison of benefit to risk clinically important to ICD decision making. We set out to describe a cohort of patients that have received an ICD in London for 'walk-in' VT with preserved ejection fraction, and assess whether they have received therapy from their ICD for ventricular arrhythmias. <h3>METHODS AND RESULTS</h3> We queried our clinical database to identify patients who received an ICD from May 2015 to December 2019 for treatment of a hemodynamically stable episode of VT with ejection fraction minimally impaired at 35-50%. Patient demographics, medications and comorbidities were recorded, along with their history of ICD therapy for ventricular arrhythmias. The timing and nature of ICD therapies was documented. A blanking period was applied to the 7 days after ICD implant to ensure that the presenting episode of VT had subsided was not counted as a follow-up event. Local REB approval was obtained for this project. Among 423 ICDs implanted for secondary prevention during this time period, 64 patients met the enrollment criteria and were included. Average age was 68 (±12) and ejection fraction at time of implant 40%(±4.4). 28 patients (44%) were taking sotalol or amiodarone during follow-up. Over a mean follow-up time of 961 days (±589, range 14-3025) ICD therapy was delivered to 36 (56%) patients. ICD shocks were delivered to 18 (28%) patients over a mean 370 (±347, range 12-1080) days. ATP was delivered to 32 (50%) patients over a mean 239 (±277, range 11-933) days. <h3>CONCLUSION</h3> ICD therapies are delivered to approximately half of patients with a minimally reduced ejection fraction and an ICD for hemodynamically well tolerated VT, over a period of several years after implant. Guidelines are unclear on ICD indication for these patients due to lack of trial data. Our findings suggest that further study is warranted.

Predictors of Right ventricular Pacing induced Left Ventricular dysfunction in Pacemaker Recipients with Preserved Ejection Fraction

Abstract Background Pacemaker (PM) has been an effective treatment in the management of patients with brady-arrhythmias. Chronic RV pacing may cause electrical and mechanical dyssynchrony which lead finally to reduced left ventricular ejection fraction (LVEF). This deterioration of LVEF has been defined as pacemaker induced cardiomyopathy (PICM). The incidence of PICM was described by many studies and ranged between 10% to 26%. The predictors for PICM have not been well studied. These studies were limited by variation in follow-up period and definition of PICM. Objective to study the incidence and predictors of PICM in patients who underwent pacemaker implantation in Ain shams University hospital. Patients and Methods This retrospective study included 160 patients who underwent single or dual chamber pacemaker implantation in Ain shams university hospital between 2010 and 2017 with the mean period 4.7±2.0 years. Implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) patients were excluded. Individuals who had baseline transthoracic echocardiography (TTE) with normal LVEF ≥ 50% before implantation were included. Results This study included 160 patients who had single or dual chamber pacemaker implantation between 2010 and 2017. 45% were males and 55% were females, mean age was 55.5 years. It showed that the incidence of PICM is 7.5%. Wider native QRS durations, particularly &amp;gt;140 ms (p &amp;lt; 0.001), wider pQRS duration &amp;gt;150 ms (p &amp;lt; 0.001), Low normal ejection fraction &amp;lt;56 % preimplantation (p = 0.023) and increased LVEDD&amp;gt;53 mm and LVESD&amp;gt;38 mm (p &amp;lt; 0.001) are predictors for the development of PICM. Female gender was independent predictor for PICM (p = 0.058). There was no association between burden of right ventricular pacing (p = 0.782) or pacing site (p = 0.876) with the risk of development of left ventricular dysfunction. Conclusion The incidence of right ventricular pacing-induced left ventricular dysfunction is not uncommon, with an observed incidence of 7.5% in the current study. Wider native and paced QRS durations, Low normal ejection fraction (&amp;lt; 56 %) pre-implantation and increased LVEDD /LVESD post implantation are the most important predictors for the development of PICM. List of abbreviations PM= pacemaker, RV= Right ventricle, PICM = pacemaker induced cardiomyopathy, TTE= transthoracic echocardiography, DM= Diabetes Mellitus, HTN= Hypertension, BMI= Body Mass index, pQRSd= Paced QRS duration, SWMA= segmental wall motion abnormality, AF= Atrial fibrillation, SSS= Sick sinus syndrome, CHB= Complete heart block, AVB= Atrioventricular block, LVEF = left ventricular ejection fraction, LVEDD= Left ventricular end diastolic diameter, LVESD= Left ventricular end systolic diameter, ms= milli second.

IDENTIFYING SOCIODEMOGRAPHIC, CLINICAL, AND ECHOCARDIOGRAPHIC PROFILES RELATED TO LEFT VENTRICULAR THROMBI FORMATION IN A SAFETY NET HOSPITAL

TOPIC: Cardiovascular Disease TYPE: Original Investigations PURPOSE: Left ventricular thrombus (LVT) formation is associated with significant morbidity and mortality owing to the risk of thromboembolism. LVT has been studied extensively in relation to myocardial infarction (MI); however, few studies have identified the clinical, sociodemographic, and echocardiographic risk factors associated with clot formation. We aimed to identify and compare sociodemographic, clinical, and echocardiographic risk factors associated with LVT formation in a safety net hospital. METHODS: A database of 30,468 transthoracic echocardiogram (TTE) reports were surveyed retrospectively for the word "clot," "thrombus," "thrombi," from 2012-2018. Indications for TTE included suspicion of LVT and comorbidities often associated with LVT including myocardial infarction (MI), cardiac arrhythmias (i.e. atrial fibrillation, atrial flutter), cerebrovascular accidents (i.e. stroke, transient ischemic attacks). Several sociodemographic, clinical, and echocardiographic criteria were compiled based on availability and analyzed via t-tests for normal distributions, Mann-Whitney u test for non-normal distributions, and chi-squared tests for categorical variables comparing those with and without thrombi. Multivariate analysis was then used to identify independent risk factors. RESULTS: We identified 224 patients that were being investigated for LVT, of which 5 cases were excluded due to workup of right ventricular thrombus. Out of 219 patients, 72 patients had LVT while the other 147 did not have LVT, and were used as our control group. Patients with LVT were predominantly male (88% vs. 64%, p<0.001), undomiciled (15% vs. 5%, P=0.006), had a history of MI (44% vs. 16%, p<0.001), or a history of methamphetamine use (17% vs. 9%, p=0.087). A majority of patients with non-ischemic cardiomyopathy (NICM) did not have LVT formation (49% vs. 59%, p<0.001) whereas individuals with ischemic cardiomyopathy (ICM) tended to have higher rates of LVT formation (47% vs. 22%, p=0.002). LVT was noted primarily in patients with left ventricular ejection fraction (LVEF) < 40% (89% vs. 34% p<0.001) and regional wall motion abnormalities (32% vs. 14%, p<0.001) among other echocardiographic findings, patients with LVT had differences in mean end diastolic diameter (p=0.001), mean stroke volume (p=0.001), and mean mitral valve E/A ratio (p<0.001). Using multivariate analysis, male gender and moderate or severe impairment of LVEF were independently associated with LVT. CONCLUSIONS: Male sex, moderate and severe left ventricular systolic dysfunction, regardless of etiology are independently associated with LVT in a cohort of patients seen at a safety net hospital. The current study adds to the data available on potential risk factors that may portend LVT formation. CLINICAL IMPLICATIONS: Identification of clinical, echocardiographic and sociodemographic risk factors of left ventricular thrombus and patients at risk for screening DISCLOSURES: No relevant relationships by Rahul Ahuja, source=Web Response No relevant relationships by Shahad Al Chalaby, source=Web Response No relevant relationships by Sophie Barbant, source=Web Response No relevant relationships by Ghita Bouzarif, source=Web Response No relevant relationships by Steve Kong, source=Web Response No relevant relationships by Saba Lahsaei, source=Web Response No relevant relationships by Katherine leger, source=Web Response No relevant relationships by Kala Mehta, source=Web Response No relevant relationships by Marina Trilesskaya, source=Web Response

Prospective evaluation of health status, quality of life and clinical outcomes following implantable defibrillator generator exchange.

BACKGROUNDLittle is known about health status and quality of life (QoL) after implantable cardioverter-defibrillator (ICD) generator exchange (GE).METHODSWe prospectively followed patients undergoing first-time ICD GE. Serial assessments of health status were performed by administering the 36-Item Short Form Survey (SF-36).RESULTSMean age was 67.5 ± 14.3 years, left ventricle ejection fraction (LVEF) was 36.5% ± 15.0% and over 40% of the cohort had improved LVEF to > 35% at the time of GE. SF-36 scores were significantly worse in physical/general health domains compared to domains of emotional/social well-being ( P < 0.001 for each comparison). Physical health scores were significantly worse among those with medical comorbidities including diabetes, chronic obstructive pulmonary disease and atrial fibrillation. Mean follow-up was 1.6 ± 0.5 years after GE. Overall SF-36 scores remained stable across all domains during follow-up. Survival at 3 years post-GE was estimated at 80%. Five patients died during follow-up and most deaths were adjudicated as non-arrhythmic in origin. Four patients experienced appropriate ICD shocks after GE, three of whom had LVEF which remains impaired LVEF (i.e., < 35%) at the time of GE. CONCLUSIONPatients undergoing ICD GE have significantly worse physical health compared to emotional/social well-being, which is associated with the presence of medical comorbidities. In terms of clinical outcomes, the incidence of appropriate shocks after GE among those with improvement in LVEF is very low, and most deaths post-procedure appear to be non-arrhythmic in origin. These data represent an attempt to more fully characterize the spectrum of QoL and clinical outcomes after GE.

Trimetazidine Attenuates Heart Failure by Improving Myocardial Metabolism via AMPK.

Energic deficiency of cardiomyocytes is a dominant cause of heart failure. An antianginal agent, trimetazidine improves the myocardial energetic supply. We presumed that trimetazidine protects the cardiomyocytes from the pressure overload-induced heart failure through improving the myocardial metabolism. C57BL/6 mice were subjected to transverse aortic constriction (TAC). After 4 weeks of TAC, heart failure was observed in mice manifested by an increased left ventricular (LV) chamber dimension, an impaired LV ejection fraction evaluated by echocardiography analysis, which were significantly restrained by the treatment of trimetazidine. Trimetazidine restored the mitochondrial morphology and function tested by cardiac transmission electron microscope and mitochondrial dynamic proteins analysis. Positron emission tomography showed that trimetazidine significantly elevated the glucose uptake in TAC mouse heart. Trimetazidine restrained the impairments of the insulin signaling in TAC mice and promoted the translocation of glucose transporter type IV (GLUT4) from the storage vesicle to membrane. However, these cardioprotective effects of trimetazidine in TAC mice were notably abolished by compound C (C.C), a specific AMPK inhibitor. The enlargement of neonatal rat cardiomyocyte induced by mechanical stretch, together with the increased expression of hypertrophy-associated proteins, mitochondria deformation and dysfunction were significantly ameliorated by trimetazidine. Trimetazidine enhanced the isolated cardiomyocyte glucose uptake in vitro. These benefits brought by trimetazidine were also removed with the presence of C.C. In conclusion, trimetazidine attenuated pressure overload-induced heart failure through improving myocardial mitochondrial function and glucose uptake via AMPK.

Optimal echocardiographic assessment of myocardial dysfunction for arrhythmic risk stratification in phospholamban mutation carriers.

Aims Phospholamban (PLN) p.Arg14del mutation carriers are at risk of developing malignant ventricular arrhythmias (VAs) and/or heart failure. Currently, left ventricular ejection fraction (LVEF) plays an important role in risk assessment for VA in these individuals. We aimed to study the incremental prognostic value of left ventricular mechanical dispersion (LVMD) by echocardiographic deformation imaging for prediction of sustained VA in PLN p.Arg14del mutation carriers.Methods and resultsWe included 243 PLN p.Arg14del mutation carriers, which were classified into three groups according to the ‘45/45’ rule: (i) normal left ventricular (LV) function, defined as preserved LVEF ≥45% with normal LVMD ≤45 ms (n = 139), (ii) mechanical LV dysfunction, defined as preserved LVEF ≥45% with abnormal LVMD >45 ms (n = 63), and (iii) overt LV dysfunction, defined as reduced LVEF <45% (n = 41). During a median follow-up of 3.3 (interquartile range 1.8–6.0) years, sustained VA occurred in 35 individuals. The negative predictive value of having normal LV function at baseline was 99% [95% confidence interval (CI): 92–100%] for developing sustained VA. The positive predictive value of mechanical LV dysfunction was 20% (95% CI: 15–27%). Mechanical LV dysfunction was an independent predictor of sustained VA in multivariable analysis [hazard ratio adjusted for VA history: 20.48 (95% CI: 2.57–162.84)].Conclusion LVMD has incremental prognostic value on top of LVEF in PLN p.Arg14del mutation carriers, particularly in those with preserved LVEF. The ‘45/45’ rule is a practical approach to echocardiographic risk stratification in this challenging group of patients. This approach may also have added value in other diseases where LVEF deterioration is a relative late marker of myocardial dysfunction.

Immediate evaluation of global longitudinal strain at initiation of trastuzumab treatment in breast cancer patients.

Global longitudinal strain (GLS) is recommended to detect subclinical changes preceding reduced left ventricular ejection fraction (LVEF) in trastuzumab related cardiotoxicity. Since the possibility to detect signs of acute myocardial deterioration at treatment initiation is not clarified, the objective of this study was to assess changes in GLS and biomarkers within the first 2weeks of trastuzumab treatment. In a prospective cohort study, 45 patients with non-metastatic breast cancer (age 54, LVEF 62.8%, GLS -19.9%, 40% hypertension) scheduled for trastuzumab treatment were included. Echocardiography and measurement of troponin and NT-proBrain-Natriuretic-Peptide were conducted before initiation of trastuzumab, at days 3, 7, and 14 and after 3, 6, and 9 months. A significant deterioration in LVEF from 62.8% (SD±3.6) to 58.4% (SD±4.1) (p<0.0001), GLS from -19.9 (SD±2.1) to -18.1 (SD±2.5) (p=0.004), s' (p<0.0001), e' septal (p=0.008), and s' RV (p<0.0001) occurred at 9 months and was preceded by significant changes in these parameters within the first 14 days. After 14 days, 12 patients (27%) had a ≥10% deterioration in GLS, which was associated with significantly lower LVEF at 55.2% (SD±4.1) at 9months compared to patients with<10% early deterioration in GLS (LVEF=59.5% (SD±3.5) (p=0.001)). No difference in plasma concentrations of biomarkers was observed between the two groups. In this study deteriorations in key echocardiographic parameters within normal limits were detected during the first 2weeks of trastuzumab treatment, and an early ≥10% deterioration in GLS was associated with a lower LVEF at 9months.

Clinical characteristics and therapeutic strategy of frequent accelerated idioventricular rhythm

BackgroundAccelerated idioventricular rhythm (AIVR) is often transient, considered benign and requires no treatment. This observational study aims to investigate the clinical manifestations, treatment, and prognosis of frequent AIVR.MethodsTwenty-seven patients (20 male; mean age 32.2 ± 17.0 years) diagnosed with frequent AIVR were enrolled in our study. Inclusion criteria were as follows: (1) at least three recordings of AIVR on 24-h Holter monitoring with an interval of over one month between each recording; and (2) resting ectopic ventricular rate between 50 to 110 bpm on ECG. Electrophysiological study (EPS) and catheter ablation were performed in patients with distinct indications.ResultsAll 27 patients experienced palpitation or chest discomfort, and two had syncope or presyncope on exertion. Impaired left ventricular ejection fraction (LVEF) was identified in 5 patients, and LVEF was negatively correlated with AIVR burden (P < 0.001). AIVR burden of over 73.8%/day could predict impaired LVEF with a sensitivity of 100% and specificity of 94.1%. Seventeen patients received EPS and ablation, five of whom had decreased LVEF. During a median follow-up of 60 (32, 84) months, LVEF of patients with impaired LV function returned to normal levels 6 months post-discharge, except one with dilated cardiomyopathy (DCM). Two patients died during follow-up. The DCM patient died due to late stage of heart failure, and another patient who refused ablation died of AIVR over-acceleration under fever.ConclusionsFrequent AIVR has unique clinical manifestations. AIVR patients with burden of over 70%, impaired LVEF, and/or symptoms of syncope or presyncope due to over-response to sympathetic tone should be considered for catheter ablation.

The fate of patients after failed epicardial ablation of atrial fibrillation

BackgroundMuch debate is still going on about the best ablation strategy—via endocardial or epicardial approach—in patients with atrial fibrillation (AF), and evidence gaps exist in current guidelines in this area. More specifically, there are no clear long-term outcome data after failed surgical AF ablation.MethodsSince June 2008, 549 surgical AF ablation procedures through a right minithoracotomy were performed at our institution. From 2008 to 2011, a unipolar radiofrequency device was used (151 patients), whereas from 2011 to 2020 a bipolar radiofrequency device was used (398 patients). Patients were scheduled for surgery on the basis of the following criteria: recurrent episodes of paroxysmal or persistent lone AF refractory to maximally tolerated antiarrhythmic drug dosing and at least one failed cardioversion attempt. Besides the recommended follow-up by the local cardiologist, starting from 2021, surviving patients were asked to undergo assessment of left ventricular function and to complete a questionnaire addressing quality of life and predisposing factors for recurrent AF.ResultsAt a mean follow-up of 77 months, the rate of AF recurrence was 20.7% (n = 114). On multivariate analysis, impaired left ventricular ejection fraction (58 patients, 51%, p = 0.002), worsening of European Heart Rhythm Association (EHRA) symptom class (37 patients, 32%, p = 0.003) and cognitive decline or depression (23 patients, 20%, p = 0.023) during follow-up were found to be significantly associated with AF recurrence.ConclusionsSurgical AF ablation through a right minithoracotomy is safe, but a better outcome could be achieved using a hybrid approach. Patients after initial failed surgical AF ablation show worsening of cardiac function, clinical status and quality of life at follow-up compared to patients with successful AF ablation.

Heart failure is associated with accumulation of long chain acylcarnitines in children suffering from cardiomyopathy

Cardiac failure in adults is associated with down regulation of fatty acid beta oxidation and accumulation of long chain (LC) fatty acid derivatives such as LC acylcarnitines [1] , [2] . These lipidomic disturbances have been shown to impair cardiac function [3] . No data are available concerning metabolic modification in heart failure in children. We retrospectively collected acylcarnitines profiles, NT pro BNP, clinical and echographical data and MRI performed in children explored for a non-metabolic cardiomyopathy in our centre from 2015 to 2021. Eighteen children aged from 1 month to 16 years old (median 2.7 years old) met the inclusion criteria. Thirteen were diagnosed for a dilated cardiomyopathy (DCM) [with normal left ventricular ejection fraction (LVEF) for 5 of them], 4 had a hypertrophic cardiomyopathy and 1 suffered from a restrictive cardiomyopathy. Seven children had clinical symptoms of cardiac insufficiency, and nine showed elevation of NT pro BNP. Considering first only children with DCM, sum of total acylcarnitines and sum of LC acylcarnitines were significantly enhanced in patients with impaired LVEF compared to those with normal LVEF (40.0 ± 16.8 vs. 16.2 ± 5.7 μM, P < 0.01, and 4.8 ± 1.6 vs. 3.1 ± 0.7 μM, P < 0.05, respectively). Similarly, considering the whole patients with cardiomyopathy, children with an elevation of NT pro BNP level displayed accumulation of total acylcarnitines and LC acylcarnitines compared to those with a normal NT pro BNP level (38.9 ± 16.9 vs. 15.5 ± 8.2 μM, P < 0.01, and 5.2 ± 2.4 vs. 2.8 ± 1.1 μM, P < 0.01, respectively). Our results suggest alteration of fatty acid oxidation in children with cardiomyopathy and impaired LVEF or elevated NT pro BNP. This metabolic modification needs to be confirmed with a larger scale study. Such lipidomic alteration could worsen heart function, and may suggest considering a metabolic treatment of heart failure in children.

Outcomes of conduction system pacing compared to right ventricular pacing as a primary strategy for treating bradyarrhythmia: systematic review and meta-analysis

BackgroundRight ventricular pacing (RVP) may cause electrical and mechanical desynchrony leading to impaired left ventricular ejection fraction (LVEF). We investigated the outcomes of RVP with His bundle pacing (HBP) and left bundle branch pacing (LBBP) for patients requiring a de novo permanent pacemaker (PPM) for bradyarrhythmia.Methods and resultsSystematic review of randomized clinical trials and observational studies comparing HBP or LBP with RVP for de novo PPM implantation between 01 January 2013 and 17 November 2020 was performed. Random and fixed effects meta-analyses of the effect of pacing technology on outcomes were performed. Study outcomes included all-cause mortality, heart failure hospitalization (HFH), LVEF, QRS duration, lead revision, atrial fibrillation, procedure parameters, and pacing metrics. Overall, 9 studies were included (6 observational, 3 randomised). HBP compared with RVP was associated with decreased HFH (risk ratio [RR] 0.68, 95% confidence interval [CI] 0.49–0.94), preservation of LVEF (mean difference [MD] 0.81, 95% CI − 1.23 to 2.85 vs. − 5.72, 95% CI − 7.64 to -3.79), increased procedure duration (MD 15.17 min, 95% CI 11.30–19.04), and increased lead revisions (RR 5.83, 95% CI 2.17–15.70, p = 0.0005). LBBP compared with RVP was associated with shorter paced QRS durations (MD 5.6 ms, 95% CI − 6.4 to 17.6) vs. (51.0 ms, 95% CI 39.2–62.9) and increased procedure duration (MD 37.78 min, 95% CI 20.04–55.51).ConclusionOf the limited studies published, this meta-analysis found that HBP and LBBP were superior to RVP in maintaining physiological ventricular activation as an initial pacing strategy.

Implications of transient ischaemic dilatation and impaired left ventricular ejection fraction reserve in patients with normal stress myocardial perfusion imaging and elevated coronary artery calcium

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Stress only (SO) instead of stress/rest single photon emission computed tomography myocardial perfusion imaging (MPI) is encouraged if perfusion and left ventricular ejection fraction (LVEF) are normal on SO images. Concurrent coronary artery calcium (CAC) scoring has also been recommended to assess atherosclerotic burden in ‘normal’ MPIs. However, the safety of SO MPI in high CAC cases is unclear as additional rest imaging may show transient ischaemic dilation (TID) and/or impaired LVEF reserve (iLVEFr) which are markers of severe coronary artery disease (CAD) and indicate ‘balanced ischaemia’. Purpose We aim to assess the incidence and outcomes of TID and iLVEFr in stress/rest MPIs with normal SO images and elevated CAC. Methods Retrospective analysis of all normal stress/rest MPIs performed between 1 March 2016 to 31 January 2017 with concurrently measured CAC &amp;gt;300. A SO protocol was not in place then. Prone post stress images were routinely done. Known CAD cases were excluded. A reader reviewed only the post stress supine/prone images and excluded cases ineligible for SO MPI (non-homogenous perfusion, LVEF ≤50%, abnormal wall motion). The remaining cases were assessed for TID (software derived TID ratio &amp;gt;1.20) and iLVEFr (stress LVEF – rest LVEF ≤-5%). Coronary angiography (CAG) and major adverse cardiac events (MACE, defined as cardiac death, non fatal myocardial infarction, revascularisation) within 24 months post MPI were traced using electronic medical records. Results There were 230 cases included (mean age 71, 56.5% male) of which 43 (18.7%) had TID and/or iLVEFr (9 TID, 22 iLVEFr, 12 both). There were no significant differences in baseline characteristics, CAC and aspirin/statin use between cases with or without TID and/or iLVEFr (Table 1). More patients in the TID and/or iLVEFr group underwent elective CAG [10 (23.3%) vs 10 (5.3%), p = 0.001] although CAG diagnosis of severe CAD (left main, 3-vessel or 2-vessel disease with proximal left anterior descending involvement) was not different [4/6 (40.0%) vs 5/10 (50.0%), p = 1.000). MACE was significantly higher in the TID and/or iLVEFr group [10 (23.3%) vs 16 (8.6%), p = 0.013], driven by higher elective revascularisation [8 (18.6%) vs 8 (4.3%), p = 0.003] with no significant differences in cardiac death or non fatal myocardial infarction (Table 2). Conclusion TID and/or iLVEFr is seen in &amp;lt;20% of cases eligible for SO MPI with high CAC, suggesting that routine rest scan in these cases exposes the majority to unnecessary radiation. Identification of TID and/or iLVEFr is associated with higher 24 month MACE, driven by higher elective revascularisation from more CAG referral. Approximately half of cases in each group had revascularisation for non severe CAD not typically associated with TID and/or impaired LVEFr. Overall cardiac death and non fatal myocardial infarction rates were low and not significantly different between groups with or without TID and/or iLVEFr.