Left Ventricular Ejection Fraction Recovery Research Articles

CMR characterisation of patients with heart failure and Left Bundle Branch Block

Abstract Aims We aimed to identify the distinctive cardiovascular magnetic resonance (CMR) features of patients with left bundle branch block (LBBB) and heart failure with reduced ejection fraction (HFrEF) of presumed non-ischaemic aetiology. The secondary aim was to determine whether these individuals exhibit characteristics that could potentially serve as predictors of left ventricular ejection fraction (LVEF) recovery as compared to patients without LBBB. Methods We prospectively recruited patients with HFrEF (LVEF ≤40%) on echocardiography who were referred for early CMR examination. Patients with an established diagnosis of coronary artery disease and known structural or congenital heart disease were excluded. LV recovery was defined as achieving ≥10% absolute improvement to ≥40% in LVEF between baseline evaluation to CMR. Results A total of 391 patients were recruited including 115 (29.4%) with LBBB. Compared to HF patients without LBBB, those with LBBB exhibited larger left ventricles and smaller right ventricles, but no differences were observed with respect to LVEF (35.8 ± 12 vs. 38 ± 12 %, p=0.105). The overall rate of LV recovery from baseline echocardiogram to CMR (70 [42 - 128] days) was not significantly different between LBBB and non-LBBB patients (27.8% vs. 31.5%, p=0.47). Reduced LVEF remained an independent predictor of LV non-recovery only in patients with LBBB. Conclusion Patients presenting with HFrEF and LBBB had larger LV cavities and smaller RV cavities than those without LBBB but no difference in prevalence of scar or ischaemia. The rates of LV recovery were similar between both groups, which supports current guidelines to defer device therapy until 3-6 months of GDMT, rather than early CMR and device implantation.

LONG–TERM FUNCTIONAL LIMITATIONS ON CARDIOPULMONARY EXERCISE TESTING IN A COHORT OF PATIENTS WITH EMOTIONS–TRIGGERED TAKOTSUBO SYNDROME

Abstract Background In patients with prior Takotsubo syndrome (TTS), long lasting functional cardiac limitations were described as compared with normal subjects. Emotions–triggered Takotsubo syndrome (E–TTS) has more favorable outcomes than TTS preceded by a physical trigger or by no identifiable factors. The aim of the present study was to assess long–term cardiac functional limitations in a cohort of asymptomatic E–TTS patients. Methods We enrolled n=39 asymptomatic patients with a diagnosis of E–TTS. Cardiopulmonary exercise tests (CPET) were performed at 30 [12–40] months median follow–up from the acute event. A cohort of n=39 individuals matched for age, sex, body mass index and comorbidities served as control. Results Despite recovery of left ventricular ejection fraction, patients with prior E–TTS had lower peak VO2 and percentage of predicted peak VO2 (17.8 ± 3.6 vs 22.5 ± 6.5; P < 0.001 and 75.2 ± 14.1 % vs 100.6 ± 17.1%, P <0.001), VO2 at anaerobic threshold (AT) (11.1 [10.1–12.9] vs 14.4 [12.5–18.7]; P <0.001), peak O2 pulse (9.7 ± 2.5 vs 13.1 ± 3.5; P <0.001) and higher VE/VCO2 slope (30.4 ± 3.7 vs 27.2 ± 3.5; P <0.001) compared with matched controls. We found no statistically significant differences in heart rate reserve (HRR), respiratory equivalent ratio (RER), mean blood pressure and peak PetCO2 between patients and controls. Conclusions Despite their overall favorable outcome, asymptomatic patients with E–TTS were found to have long–term subclinical functional cardiac impairments. CPET proved to be a useful tool in the long–term evaluation of E–TTS patients after recovery of LVEF. Further studies are needed to fully clarify the origin of the detected CPET abnormalities as well as their prognostic relevance in patience with recovered E–TTS.

Abstract PO3-09-02: Identifying risk factors for trastuzumab-induced cardiotoxicity among multi-ethnic women with HER2-positive early-stage breast cancer

Abstract Introduction: While trastuzumab, a HER2-targeted therapy for patients with HER2-positive breast cancer, has been shown to improve disease-free and overall survival rates, it also confers the risk of significant morbidity in the way of trastuzumab-induced cardiotoxicity (TIC). TIC may present as asymptomatic decline in left ventricular ejection fraction (LVEF) or as symptomatic heart failure. Given that racial/ethnic minorities are at higher risk for cardiovascular disease (CVD) compared to non-Hispanic Whites, our objective was to assess racial/ethnic differences in TIC and LVEF recovery among multi-ethnic patients with HER2-positive early-stage breast cancer. Methods: We conducted a retrospective cohort study including patients diagnosed with stage I-III HER2-positive breast cancer between 2007-2022 who had received adjuvant trastuzumab therapy at Columbia University Irving Medical Center (CUIMC) in New York, NY. TIC was defined as >10% decrease in LVEF to an overall LVEF< 50% and was confirmed by a minimum of two serial echocardiograms, whereas LVEF recovery was defined as a return to a LVEF >50%. Descriptive statistics, univariate and multivariate logistic regression analyses were conducted to estimate odds ratios (OR) and 95% confidence intervals (CI) for the associations between sociodemographic factors, tumor characteristics, treatment regimens, and CVD risk factors with the main outcome of TIC. Results: In the final cohort (N=500), median age was 53 years (IQR: 45.0-62.0) with 36.6% non-Hispanic White (NHW), 15.8% non-Hispanic Black (NHB), 27.8% Hispanic, and 19.8% Asian/Pacific Islander/Other. About 68.2% of patients received adjuvant radiation therapy, 30.2% were treated with anthracyclines, 37.8% with pertuzumab, 4.6% with T-DM1 and 69.0% with endocrine therapy. Fifty-three (10.6%) patients developed TIC, half of which experienced LVEF recovery. Compared to NHW, NHB patients had a higher rate of TIC (9.3% vs. 17.7%, respectively) and lower rate of LVEF recovery (70.6% vs. 21.4 % in those with TIC, respectively). On multivariable analysis, increasing age, lower LVEF at baseline, anthracycline exposure, and coronary artery disease (CAD) were associated with TIC (see Table). We found no association between TIC and use of pertuzumab or T-DM1. Discussion: In our racially/ethnically diverse study population, we found an incidence of TIC comparable to previous clinical studies. NHB patients had double the incidence of TIC and a lower incidence of LVEF recovery when compared to NHW patients. Given the observed racial disparities in TIC and LVEF recovery, NHB patients may require closer cardiac monitoring and restricted use of anthracyclines with adjuvant trastuzumab treatment. More research on cardiotoxicity associated with newer forms of HER2-targeted therapies is necessary. Table: Multivariable logistic regression model with outcome of TIC Citation Format: Leila Mishalani, Anna Vaynrub, Katherine Crew. Identifying risk factors for trastuzumab-induced cardiotoxicity among multi-ethnic women with HER2-positive early-stage breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-09-02.

Predictors of systolic function recovery after atrial fibrillation ablation in heart failure patients

Introduction and objectivesAtrial fibrillation (AF) and heart failure (HF) often coexist. AF catheter ablation improves left ventricular ejection fraction (LVEF), but its impact varies between patients. We aimed to identify predictors of LVEF improvement in HF patients with impaired LVEF undergoing AF ablation. MethodsWe conducted a retrospective single-center study in HF patients with LVEF <50% undergoing AF catheter ablation between May 2016 and May 2022. The primary endpoint was the LVEF recovery rate (‘responders’). Secondary endpoints were one-year safety and effectiveness. We also aimed to validate a prediction model for LVEF recovery. ResultsThe study included 100 patients (79% male, median age 60 years, 70% with probable tachycardia-induced cardiomyopathy [TIC], mean LVEF 37%, 29% with paroxysmal AF). After a median follow-up of 12 months after catheter ablation, LVEF improved significantly (36±10% vs. 53±10%, p<0.001), with an 82% responder rate. A suspected diagnosis of TIC (OR 4.916 [95% CI 1.166–20.732], p=0.030), shorter QRS duration (OR 0.969 [95% CI 0.945–0.994], p=0.015), and smaller left ventricle (OR 0.893 [95% CI 0.799–0.999], p=0.049) were independently associated with LVEF improvement. Freedom from any documented atrial arrhythmia was 86% (64% under antiarrhythmic drugs), and the rate of adverse events was 2%. The prediction model had a good discriminative performance (AUC 0.814 [95% CI 0.681–0.947]). ConclusionIn AF patients with HF and impaired LVEF, suspected TIC, shorter QRS duration, and smaller LV diameter were associated with LVEF recovery following AF catheter ablation.

Biomarkers to predict improvement of left ventricular ejection fraction after atrial fibrillation ablation

BackgroundAtrial fibrillation (AF) and heart failure frequently coexist. Prediction of left ventricular ejection fraction (LVEF) recovery after catheter ablation (CA) for AF remains difficult. ObjectiveThe purpose of this study was to evaluate the value of biomarkers, alone and in combination with the Antwerp score, to predict LVEF recovery after CA for AF. MethodsPatients undergoing CA for AF with depressed LVEF (<50%) were included. Plasma levels of 13 biomarkers were measured immediately before CA. Patients were categorized into “responders” and “nonresponders” in a similar fashion to the Antwerp score derivation and validation cohorts. The predictive power of the biomarkers alone and combined in outcome prediction was evaluated. ResultsA total of 208 patients with depressed LVEF were included (median age 63 years; 19% female; median indexed left atrial volume 42 mL/m2; median LVEF 43%). At a median follow-up time of 30 months, 161 (77%) were responders and 47 (23%) were nonresponders. Of 13 biomarkers, 4—angiopoietin 2 (ANG2), growth differentiation factor 15 (GDF15), fibroblast growth factor 23, and myosin binding protein C3—were significantly different between responders and nonresponders (P ≤ .001) and combined could predict the end point with an area under the curve of 0.72 (95% confidence interval [CI] 0.64–0.81) overall, 0.69 (95% CI 0.59–0.78) in heart failure with mildly reduced ejection fraction, and 0.88 (95% CI 0.77–0.98) in heart failure with reduced ejection fraction. Only ANG2 and GDF15 remained significantly associated with LVEF recovery after adjustment for age, sex, and Antwerp score and significantly improved the accuracy of the Antwerp score predictions (P < .001). The area under the curve of the Antwerp score in the outcome prediction improved from 0.75 (95% CI 0.67–0.83) to 0.78 (95% CI 0.70–0.86). ConclusionA biomarker panel (ANG2 and GDF15) significantly improved the accuracy of the Antwerp score.

Predictors of improvement in left ventricular systolic function after catheter ablation in patients with persistent atrial fibrillation complicated with heart failure

AimsThe current management of patients with atrial fibrillation (AF) and concomitant heart failure (HF) remains a significant challenge. Catheter ablation (CA) has been shown to improve left ventricular ejection fraction (LVEF) in these patients, but which patients can benefit from CA is still poorly understood. The aim of our study was to determine the predictors of improved ejection fraction in patients with persistent atrial fibrillation (PeAF) complicated with HF undergoing CA.Methods and resultsA total of 435 patients with persistent AF underwent an initial CA between January 2019 and March 2023 in our hospital. We investigated consecutive patients with left ventricular systolic dysfunction (LVEF < 50%) measured by transthoracic echocardiography (TTE) within one month before CA. According to the LVEF changes at 6 months, these patients were divided into an improved group (fulfilling the ‘2021 Universal Definition of HF’ criteria for LVEF recovery) and a nonimproved group. Eighty patients were analyzed, and the improvement group consisted of 60 patients (75.0%). In the univariate analysis, left ventricular end-diastolic diameter (P = 0.005) and low voltage zones in the left atrium (P = 0.043) were associated with improvement of LVEF. A receiver operating characteristic analysis determined that the suitable cutoff value for left ventricular end-diastolic diameter (LVDd) was 59 mm (sensitivity: 85.0%, specificity: 55.0%, area under curve: 0.709). A multivariate analysis showed that LVDd (OR = 0.85; 95% CI: 0.76–0.95, P = 0.005) and low voltage zones (LVZs) (OR = 0.26; 95% CI: 0.07–0.96, P = 0.043) were significantly independently associated with the improvement of LVEF. Additionally, parameters were significantly improved regarding the left atrial diameter, LVDd and ventricular rate after radiofrequency catheter ablation (all p < 0.05).ConclusionsThe improvement of left ventricular ejection fraction (LVEF) occurred in 75.0% of patients. Our study provides additional evidence that LVDd < 59 mm and no low voltage zones in the left atrium can be used to jointly predict the improvement of LVEF after atrial fibrillation ablation.

Abstract 6298: The value of routine trastuzumab-related cardiac toxicity monitoring in gastrointestinal cancers

Abstract Background: It is a common practice to monitor trastuzumab-related cardiac toxicity (TRCT) using left ventricular ejection fraction (LVEF) in patients who receive trastuzumab-containing therapy for human epidermal growth factor receptor 2 (HER2)-positive cancers. However, this monitoring approach does not appear cost effective in patients with HER2-positive gastrointestinal (GI) cancers given poor overall survival (OS). Here, we aim to examine the incidence of clinically significant TRCT in this target population. Methods: This is a retrospective cohort study of patients with advanced HER2-positive GI cancers who received trastuzumab-containing therapies (trastuzumab +/- pertuzumab, chemotherapy +/- immunotherapy + trastuzumab, trastuzumab deruxtecan) between 2011 and 2023. HER2 status was determined by immunohistochemistry, fluorescent in situ hybridization, and/or next generation sequencing. LVEF was estimated by serial transthoracic echocardiograms (TTE). Continuous variables were summarized as median and interquartile range (IQR). Paired Wilcoxon signed rank test was used to compare serial LVEF. OS was estimated using Kaplan-Meier method. Results: A total of 243 patients were included in this study with a median age of 64 (IQR: 55-70) years. 139 (57%) patients had esophageal or GEJ adenocarcinoma; 45 (19%) patients had gastric cancer; 37 (15%) patients had colorectal cancer; and the rest had other GI cancers. Median follow-up time was 18.6 (IQR: 9.2-36) months. Median OS from cancer diagnosis and the first dose of trastuzumab-containing therapy were 24.1 (95%CI: 20.2-30.2) and 11.7 (95%CI: 10.4-15.6) months, respectively. Patients received a median of 13 cycles of trastuzumab-containing therapy for a median duration of 4.1 (IQR: 1.4-10.1) months. The median number of TTE each patient had throughout therapy was 2 (IQR: 1-4). Median baseline LVEF was 61% (IQR: 56-65%) which was significantly higher (p&amp;lt;0.001) than the median lowest LVEF of 58% (IQR: 53-62%) during therapy, but not different (p=0.14) from the most recent median LVEF of 60% (IQR: 56-64%) after discontinuation of trastuzumab. Among 176 patients with serial LVEF data, 16 (9%) had &amp;gt; 10% LVEF drop; 7 (44%) of these 16 patients had LVEF recovery. None of the cardiovascular risk factors prior to trastuzumab treatment including hypertension, diabetes, hyperlipidemia, peripheral arterial disease, coronary artery disease, and stroke were significantly associated with the development of TRCT. Conclusion: The incidence of clinically significant LVEF drop appears low in patients with advanced GI cancers as post-treatment LVEF recovery to baseline was observed at the population level. The value of using TTE to monitor TRCT in these patients with short OS should be further assessed in the perspective of cost effectiveness. Citation Format: Samual R. Kosydar, Matteo Castrichini, Mojun Zhu, Hao Xie. The value of routine trastuzumab-related cardiac toxicity monitoring in gastrointestinal cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6298.

Predictive Value of Global Longitudinal Strain on the Recovery of Left Ventricular Function Following ST-Segment Elevation Myocardial Infarction

Background: Identifying reliable predictors for ventricular recovery at the outset is crucial for patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI). Objectives: This study aimed to evaluate the role of baseline global longitudinal strain (GLS) in predicting myocardial recovery following an acute infarction. Methods: We enrolled 60 consecutive patients diagnosed with STEMI and admitted to Al-Zahra Hospital for PCI from March 2022 to March 2023. Echocardiography was performed on all patients within 48 hours after revascularization to measure baseline parameters, including left ventricular ejection fraction (LVEF) and GLS. Follow-up echocardiography was conducted 6 months later to reassess LVEF. Results: At the 6-month follow-up, 38 (63.3%) patients showed a ≥ 5% improvement in LVEF, indicating ventricular recovery. The change in GLS was significantly different between the groups (recovered: -4.72 ± 2.00, not recovered: -2.41 ± 2.15, P &lt; 0.001). A baseline GLS ≤ -4.5 and &gt; -14.8 was predictive of either failure to recover or successful recovery of LVEF with 100% negative and positive predictive values, respectively. Baseline GLS values &gt; -9.2 were predictive of LV recovery with 50% sensitivity and 83.3% specificity (P = 0.0002, AUC (95% confidence interval) = 0.697 (0.594, 0.799)). The type of revascularization was linked to better prediction outcomes, with patients undergoing primary and rescue PCIs more likely to recover during the follow-up period compared to those receiving deferred PCI after 24 hours (P = 0.032). Conclusions: While certain baseline GLS value thresholds may serve as predictors of LVEF recovery in patients with STEMI undergoing primary PCI, further prospective studies with larger cohorts are needed to establish more precise cut-off values.

The Prognostic Impact of Follow-up Cardiac MIBG Imaging on LV trajectory After Acute Decompensation.

Cardiac metaiodobenzylguanidine (MIBG) imaging provides prognostic information in patients with heart failure. Recently, the trajectory of left ventricular ejection fraction (LVEF) has been a focus in patients with reduced LVEF admitted for acute decompensated heart failure (ADHF). We sought to investigate the prognostic value of follow-up cardiac MIBG imaging in ADHF patients with reduced LVEF in relation to LVEF trajectory. We prospectively studied 145 ADHF patients with reduced LVEF<40%. The cardiac MIBG heart-to-mediastinum ratio (late HMR) was measured on the delayed image at discharge and at the 6-month follow-up (6FUP). At 6 months after discharge, 54 (37%) patients had complete recovery of LVEF≥50% (HFcorEF), and 43 (30%) patients had partial recovery of LVEF: 40%-50% (HFparEF), while the remaining 48 (33%) patients had no functional recovery of LVEF (HFnorEF). The late HMR at 6 FUP in HFcorEF patients was significantly greater than that in HFparEF and HFnorEF patients. During a follow-up period of 4.3 ± 2.6 years, 43 patients had cardiac events, defined as the composite of readmission for worsening HF and cardiac death. Patients with lower late HMR at 6 FUP had a greater risk of cardiac events than those with higher late HMR at 6 FUP in the group with recovered LVEF, especially HFparEF, which was not observed in the HFnorEF subgroup. Follow-up MIBG imaging after discharge could provide additional prognostic information in ADHF patients with recovered left ventricular function.

Left atrial diastasis strain slope is a marker of hemodynamic recovery in post-ST elevation myocardial infarction: the Laser Atherectomy for STemi, Pci Analysis with Scintigraphy Study (LAST-PASS).

Left atrial (LA) mechanics are strongly linked with left ventricular (LV) filling. The LA diastasis strain slope (LADSS), which spans between the passive and active LA emptying phases, may be a key indicator of the LA-LV interplay during diastole. This study aimed to investigate the LA-LV interdependencies in post-ST elevation myocardial infarction (STEMI), with particular focus on the LADSS. Patients with post-anterior STEMI who received primary percutaneous coronary intervention underwent contrast cardiac magnetic resonance imaging (MRI) during acute (5-9 days post-STEMI) and chronic (at 6 months) phases. The LADSS was categorized into three groups: Groups 1, 2, and 3 representing positive, flat, and negative slopes, respectively. Cross-sectional correlates of LADSS Group 2 or 3 compared to Group 1 were identified, adjusting for demographics, LA indices, and with or without LV indices. The associations of acute phase LADSS with the recovery of LV ejection fraction (LVEF) and scar amount were investigated. Sixty-six acute phase (86.4% male, 63.1 ± 11.8 years) and 59 chronic phase cardiac MRI images were investigated. The distribution across LADSS Groups 1, 2, and 3 in the acute phase was 24.2%, 28.9%, and 47.0%, respectively, whereas in the chronic phase, it was 33.9%, 22.0%, and 44.1%, respectively. LADSS Group 3 demonstrated a higher heart rate than Group 1 in the acute phase (61.9 ± 8.7 vs. 73.5 ± 11.9 bpm, p < 0.01); lower LVEF (48.7 ± 8.6 vs. 41.8 ± 9.9%, p = 0.041) and weaker LA passive strain rate (SR) (-1.1 ± 0.4 vs. -0.7 [-1.2 to -0.6] s-1, p = 0.037) in the chronic phase. Chronic phase Group 3 exhibited weaker LA passive SR [relative risk ratio (RRR) = 8.8, p = 0.012] than Group 1 after adjusting for demographics and LA indices; lower LVEF (RRR = 0.85, p < 0.01), higher heart rate (RRR = 1.1, p = 0.070), and less likelihood of being male (RRR = 0.08, p = 0.058) after full adjustment. Acute phase LADSS Groups 2 and 3 predicted poor recovery of LVEF when adjusted for demographics and LA indices; LADSS Group 2 remained a predictor in the fully adjusted model (β = -5.8, p = 0.013). The LADSS serves both as a marker of current LV hemodynamics and its recovery in post-anterior STEMI. The LADSS is an important index of LA-LV interdependency during diastole. https://clinicaltrials.gov/, identifier NCT03950310.

Severity of Left Ventricular Dysfunction in Patients With Tachycardia-Induced Cardiomyopathy: Impacts on Remodeling After Atrial Flutter Ablation

Tachycardia-induced cardiomyopathy is defined as a reversible left ventricular (LV) systolic dysfunction (SeD) resulting from a sustained fast heart rate. LV remodeling in patients with severe LV dysfunction at diagnosis remains poorly understood. In this retrospective cohort study, we described LV remodeling in 50 patients who underwent atrial flutter ablation. These patients were divided into severe LV SeD (LV ejection fraction [EF] ≤30%) and LV nonsevere SeD (LVEF 31% to 50%) at baseline. All continuous variables are expressed as median and interquartile range. LVEF was 18% (13 to 25) and 38% (34 to 41) in the SeD (n=29) and LV nonsevere SeD (n=21) groups, respectively. At baseline, patients with SeD had higher LV end-diastolic diameter (56 [54 to 59] vs 49mm [47 to 52], p<0.01), LV end-systolic diameter (48 [43 to 51] vs 36mm [34 to 41], p<0.01), LV end-diastolic volume (71 [64 to 85] vs 56ml/m2 [46 to 68], p<0.01), LV end-systolic volume (56 [53 to 70] vs 36ml/m2 [27 to 42], p<0.01), and lower tricuspid annular plane systolic excursion (12 [10 to 13] vs 16mm [13 to 19], p<0.01). At last follow-up, LVEF was not statistically significantly different between groups. However, LV end-systolic diameter (36 [34 to 39] vs 32mm [32 to 34], p=0.01) and LV end-systolic volume (29 [26 to 35] vs 25ml/m2 [20 to 29], p=0.02) remained larger in the SeD group. Seven patients (14%), all from the SeD group, had a LVEF ≤35% 2months after rhythm control, and reverse remodeling was observed up to 9months. In conclusion, more than half of patients with tachycardia-induced cardiomyopathy and atrial flutter had LVEF ≤30% at baseline. LVEF recovery and LV remodeling were observed beyond 2months, highlighting the importance of rhythm control and early guideline-directed medical therapy in these patients.

Incremental prognostic value of speckle tracking echocardiography and early follow-up echo assessment in predicting left ventricular recovery after reperfusion for ST-segment elevation myocardial infarction (STEMI).

Up to 50% of patients do not achieve significant left ventricular ejection fraction (LVEF) recovery after primary percutaneous intervention (PPCI) for STEMI. We aimed to identify the echocardiographic predictors for LVEF recovery and assess the value of early follow-up echocardiography (Echo) in risk assessment of post-myocardial infarction (MI) patients. One hundred one STEMI patients undergoing PPCI were enrolled provided EF below 50%. Baseline echocardiography assessed LVEF, volumes, wall motion score index (WMSI), global longitudinal strain (GLS), global circumferential strain (GCS), and E/e'. Follow-up echocardiography after 6weeks reassessed left ventricular volumes, LVEF and GLS.GCS was not assessed at follow up. Patients were classified into recovery and non-recovery groups. Predictors of LVEF recovery and major adverse cardiovascular events (MACE) at 6 months were analysed. The mean change of EF was 8.04±3.32% in group I versus -.39±5.09 % in group II (p<.001). Recovered patients had better baseline GLS, baseline GCS, E/e', and follow-up GLS. Multivariate regression analysis revealed E/e', GCS, and follow-up GLS after 6weeks to be strong independent predictors for LVEF recovery. Composite MACE was considerably higher in group II (32.7% vs. 4.1%, p<.001) mainly driven by higher heart failure hospitalisation Multivariate regression analysis revealed baseline GLS, E/e', and ejection fraction (EF) percentage recovery as strong independent predictors for MACE. Multiparametric echocardiographic approach incorporating LVEF, strain parameters, and diastolic function could allow early optimal risk stratification after STEMI treated with PPCI. Follow-up GLS and LVEF percentage change are the strongest predictors for early LV recovery and long term clinical outcome, respectively.

COVID-19 Associated Myocarditis: A Monocentric Series of 33 Cases

Introduction: Myocarditis is defined by an inflammatory myocardial infiltrate with necrosis of non-ischemic origin in three forms: fulminant, acute and chronic. Diagnosis is guided by clinical presentation, ECG, echocardiography and biology, and confirmed by MRI and myocardial biopsy. The prognosis depends on clinical manifestations, echocardiographic features and serum troponin levels. Management is based on the treatment of heart failure (HF). For two years, the world has been experiencing a pandemic related to SARS-CoV2 that can affect the heart with ischemic or non-ischemic lesions (myocarditis, most often fulminant) whose treatment is non-specific. Trials with corticosteroids and immunosuppressant drugs have yielded discordant results.&#x0D; Objective: To describe the evolutionary modalities of COVID-19 associated myocarditis and identify factors of poor ejection fraction recovery under HF treatment.&#x0D; Method: This observational, retrospective, single-center study, in 2021, included patients with non-fulminant COVID-19 associated myocarditis suspected at echocardiography and biology and confirmed on MRI. Patients with previous HF and reduced left ventricular ejection fraction (LVEF) were excluded (n=06). Patients were divided into two groups according to LVEF three months later (LVEF&gt;50% v. LVEF&lt;50%) and compared to identify factors predicting a poor LVEF recovery.&#x0D; Results: 33 patients (19♂/14♀) aged between 30–61 years with acute non-fulminant COVID-19 associated myocarditis were included. All had ECG repolarization abnormalities. The mean LVEF at baseline was 44.3% +/- 6.3 (30–52%) with an average troponin level 480 times normal (20–2,100). Beta-blocker and RASB treatment was initiated in all patients, spironolactone (37.5 mg) in 13 patients with LVEF &lt;40% and furosemide if congestive signs (17 patients/51.5%). Clinical, electrical, biological and echocardiographic monitoring was performed at one and three months. Eight patients developed uncomplicated pericardial effusion. A significant improvement in LVEF&gt;50% was observed in 29 patients. One patient with LVEF of 38% presented with incessant ventricular tachyarrhythmia that necessitated an ICD. Three patients kept LVEF&lt;50%. Sex, congestive signs, ECG and coronary angiogram abnormalities do not seem to influence the LVEF evolution (p at 0.62, 1.00, 1.00, 0.56, 0.50, and 0.23, respectively). Age &gt;60 years, troponins &gt;1,200 times normal, pericardial effusion and a combined criterion of the three seem to be a good predictor of poor LVEF evolution (p at 0.07, 0.02, 0.035 and 0.01, respectively).&#x0D; Discussion: The absence of fulminant forms in our series explains the absence of mortality at three months (&gt;30% in the literature). Acute non-fulminant COVID-19 associated myocarditis has a good prognosis with LVEF recovery in 87.88%. The factors of poor LVEF recovery are the age &gt;60 years, troponins &gt;1,200 times normal, pericardial effusion, and the combined criterion of the three (p respectively at 0.07, 0.02, 0.035, 0.01). The routine prescription of corticosteroids in the COVID-19 protocol made it impossible to analyze its impact on COVID-19 associated myocarditis.&#x0D; Interpretation: Cardiac manifestations are not uncommon during COVID-19; they can be ischemic or non-ischemic. There is no specific therapy for non-fulminant COVID-19 associated myocarditis and the evolution seems favorable. Patients with predictive factors of poor progress should have longer follow-ups.&#x0D; Informed consent: All participants gave their informed consent to participate in this study and share the results

Predictive role of intracoronary electrocardiography for procedural success in patients with ST-elevation myocardial infarction developing coronary no-reflow

Abstract Background The no-reflow phenomenon (NRP) is associated with increased mortality and development of heart failure in patients with ST-segment elevation myocardial infarction (STEMI). Although there is no definitive method for NRP treatment in current guidelines, methods to predict the success of procedures with NRP are also limited. There is a need for a practical, real-time method for predicting the outcome of procedures in NRP patients. Intracoronary electrocardiography (ic-ECG) which is simple, cost-effective, and a bedside indicator of myocardial ischemia, is proposed as a potential solution in this study. Purpose The aim of this study was to examine the potential of ic-ECG in predicting the success of primary percutaneous intervention (pPCI) in patients with STEMI and the development of coronary no-reflow. Methods This was a prospective investigation that included 71 patients diagnosed with acute anterior STEMI and underwent pPCI between November 2021 and May 2022. The patients were separated into two groups based on the Thrombolysis in Myocardial Infarction (TIMI) flow grade criteria, with those having a grade of less than 3 defined as NRP. The NRP group was further analyzed to determine the relationship between the percentage of ST-segment resolution (STR) in the ic-ECG records taken during pPCI and short-term major adverse cardiovascular events rates and left ventricular ejection fraction (LVEF) recovery status. Results A total of 71 patients, with a mean age of 56.8 years and 76.1% of them being male, were included in the study. Of these patients, 26 were found to have developed NRP, while TIMI-3 flow was observed in 45 patients. In the NRP group, various parameters were found to be associated with LVEF recovery, such as peak troponin value (6267.8±2488.4 ng/ml vs 3244.6±3183 ng/ml, p=0.013) basal low-density lipoprotein cholesterol (LDL-C) (138.8±29.9 mg/dl vs 104.5±40 mg/dl, p=0.021), total cholesterol value (222.7±69.2 mg/dl vs 167.5±44.5 mg/dl, p=0.024), and ic-ECG STR level (21±22.3% vs 65.5±17%, p&amp;lt;0.001). The results of the multivariate analysis and subsequent ROC analysis showed that an ic-ECG STR ratio greater than 42% (sensitivity 100%, specificity 84.6%) was an independent predictive factor for LVEF improvement (Table 1). Conclusions The results showed that the STR rate measured by ic-ECG was significantly associated with LVEF recovery and was an independent predictive factor for LVEF recovery with a sensitivity of 100% and specificity of 84.6%. The study highlights the usefulness of ic-ECG in predicting pPCI success in NRP patients and supports its integration into clinical practice.

External validation of the Antwerp score: a novel score for predicting responders to catheter ablation of atrial fibrillation in patients with depressed left ventricular function

Abstract Introduction Little exists to identify patients with heart failure (HF) and atrial fibrillation (AF), who will benefit from pulmonary vein isolation (PVI). The Antwerp score was proposed as a new prediction model to identify patients with recovery left ventricular ejection fraction (LVEF) after PVI for AF. Purpose To externally validate the Antwerp score in a large cohort of patients undergoing PVI. Methods Patients with reduced LVEF (&amp;lt; 50%) scheduled to undergo PVI at our hospital were retrospectively analyzed. These were then classified as responders or non-responders to PVI according to the "Universal definition of HF". For each patient, the Antwerp score was calculated, and the performance of the score in predicting LVEF recovery after PVI was evaluated using receiver operating characteristic (ROC) curves and calibration plots. Results Between May 2010 and January 2022, 1665 patients underwent CA for AF at our institution. Of these, 208 patients (median age 63 [IQR 54-69] years, 19% women) had reduced LVEF at presentation and were included in the final analysis (27% with paroxysmal and 73% with persistent AF). The median LVEF at baseline was 43% [IQR 38-46]. At 30 [IQR 20-34] months follow-up after the index procedure, 161 patients (77%) were responders, and 47 patients (23%) were non-responders. The median time to LVEF recovery in responders was 8 [IQR 3-22] months. Between responders and non-responders, differences in AF type were not significant (p = 0.99), while QRS width, absence of known HF etiology and LAVI were significant (p&amp;lt;0.001, p&amp;lt;0.001 and p=0.03). After adjusting for difference in baseline characteristics and procedural outcomes between responders and non-responders, only a QRS duration&amp;lt;120 ms (p=0.002) and absence of known etiology (p&amp;lt;0.001) remained statistically significant with LVEF recovery (Figure). The Antwerp score had an area under the curve (AUC) of 0.75 (95% CI 0.67-0.83). A model containing QRS&amp;lt;120 ms and absence of known etiology performed similarly to the complete Antwerp model (Likelihood Ratio p=0.77). Conclusion The Antwerp score has a moderate ability to identify patients with the recovery of LVEF after PVI in an external population, showing modest rule-in and rule-out capabilities. QRS width and absence of known HF etiology were confirmed as excellent predictors of LVEF recovery.Figure

Incidence of sustained ventricular tachyarrhythmias in patients with non-ischemic cardiomyopathy in a multicenter multinational WCD cohort

Abstract Background Defibrillator use in patients with non-ischemic cardiomyopathy (NICM) and HFrEF remains controversial after the DANISH study. The new ESC guidelines recommend individualized risk stratification in these patients. The wearable cardioverter-defibrillator (WCD) seems to be appropriate to both protect and screen patients with HFrEF at risk for sudden cardiac death (SCD). Puropose: To evaluate the rate of ventricular tachyarrhythmias (VT/VF) in NICM vs. ICM patients receiving a WCD for temporary SCD protection. Methods 1157 patients were included in a multicenter registry from eight European centers. Among these patients, 602 patients received a WCD due to ischemic cardiomyopathy (ICM) and 555 patients for non-ischemic cardiomyopathy (NICM). Incidence of VT/VF and/or appropriate WCD shock discharge during WCD use were evaluated. The mean follow-up (FU) time of the whole cohort was 620.2±607.8 days. Results NICM patients were younger (mean 56.5±14.8a vs 63.9±11.6a; p&amp;lt;0.001) and less often male (75% vs. 87.2%; p&amp;lt;0.001) compared to ICM patients. Heart failure medication at hospital discharge did not differ between the two groups except for a higher prescription rate of aldosterone-antagonists in NICM compared to ICM patients (73.8% vs. 66.7%; p=0.02). The index left ventricular ejection fraction (LVEF) was significantly lower in NICM compared to ICM patients (mean 26.1±9.1% versus 29.5±9.2%; p&amp;lt;0.001). A larger extent of LVEF recovery was detected in NICM patients compared to ICM patients up to the end of WCD use (mean LVEF post WCD: 45.7±35.4% vs. 40.2±11.8%; p=0.02). Average daily WCD wear-time was significantly lower in NICM patients compared to ICM patients (mean 20.7±4.9h vs. 21.6±3.7h; p=0.01). NICM patients had a significantly lower incidence of sustained ventricular tachyarrhythmia (VT/VF) compared to ICM patients (3.4% vs. 6.6%; p=0.02). Consistently, rate of appropriate WCD shock was significantly lower in NICM vs. ICM patients (0.7% vs. 3.7%; p&amp;lt; 0.001), as was rate of re-hospitalization (30.2% vs. 46.1%; p&amp;lt;0.001). Both groups showed a similar mortality rate during FU. Conclusions Patients at risk for SCD with NICM showed a more pronounced LVEF recovery, significantly lower incidence of VT/VF with concomitant shocks and hospitalization, while overall mortality was unchanged compared to ICM patients. These results indicate that WCD use might facilitate individual SCD risk stratification in NICM patients.

Left ventricular fibrosis influences the time to recovery in patients with arrhythmia-induced cardiomyopathy

Abstract Background The hallmark of arrhythmia-induced cardiomyopathy (AIC) is reversibility of left ventricular systolic dysfunction (LVSD) following rhythm restoration. Atrial fibrillation and LVSD very frequently co-exist and hence AIC is likely to be under recognized in daily practice. We tested the hypothesis, that left ventricular fibrosis has an influence on the time to recovery (TTR) in patients with AIC. Method We prospectively screened patients hospitalized for newly diagnosed and otherwise unexplainable LVSD (i.e. left ventricular ejection fraction (LVEF) &amp;lt;50%) and coexisting tachyarrhythmia (atrial fibrillation/flutter + heart rate (HR) &amp;gt;100/min). Causes other than tachyarrhythmic for LVSD had to be excluded (e.g. valvular, ischaemic, inflammatory). Left ventricular function was assessed by echocardiography at presentation and at follow-up visits 2, 4, and 6 months after rhythm control. Left ventricular (LV) late gadolinium enhancement (LGE) was measured via magnetic resonance imaging after rhythm restoration. Patients were classified AIC, if LVEF significantly recovered after 6 months (increase by ≥15% or above 50% with an increase of ≥10%) and then correlated with LGE as an indicator for fibrosis. Results 39 patients were included in the LGE analysis, 31 of them recovered and were classified AIC. Although we found no difference in LGE content in AIC vs. non-AIC patients (mean ± SEM 7.7 ± 0.9% vs. 6.5 ± 1.4%; p = 0.542) and contingency analysis of AIC/non-AIC vs. LGE-positive/LGE-negative patients revealed no difference between the groups (p = 0.682), there was a negative correlation of ΔLVEF (month 2 minus baseline) with LGE (Fig. 1) and a positive correlation of the TTR with LGE (Fig. 2) in LGE-positive patients, suggesting an influence of LV fibrosis on the speed of recovery. Conclusion Reliable criteria for recovery of LVEF in patients with newly diagnosed LVSD and coexisting arrhythmia are lacking. We found, that LV LGE correlated with the time to recovery of LVEF in patients with AIC. These results may help to estimate the recovery period and thereby optimize the diagnostic and therapeutic strategy for patients with AIC.Figures 1 and 2.

The prognostic impact of follow-up cardiac Metaiodobenzylguanidine imaging: relation to differential trajectories in left ventricular ejection fraction after acute decompensation

Abstract Background Cardiac metaiodobenzylguanidine (MIBG) imaging provides prognostic information in patients with heart failure (HF). Recently, the trajectory of left ventricular ejection fraction (LVEF) has been focused in patients with reduced LVEF admitted for acute decompensated heart failure (ADHF). We sought to prospectively investigate the prognostic value of the follow-up cardiac MIBG imaging in ADHF patients with reduced LVEF, in relation to LVEF trajectory. Methods We prospectively studied 145 ADHF patients with reduced LVEF&amp;lt;40%. The cardiac MIBG heart-to-mediastinum ratio (late HMR) was measured on the delayed image at the discharge and 6 months’ follow-up (6FUP). HF recovered LVEF (HFrecEF) was defined as those with a second measurement of LVEF at 6FUP of ≥ 40% with a 10-point increase from baseline LVEF, according to the previous report. Furthermore, in the present study, HFrecEF was classified into the two groups; patients with partial recovery of LVEF (≥40%, &amp;lt;50%) (HFparEF) and complete recovery of LVEF (≥50%) (HFcorEF). The endpoint was a cardiac event (CE) defined as a composite of cardiac death and unplanned hospitalization for worsening HF. Results At 6 months after the discharge, HFrecEF was observed in 97 (67%) of 145 study patients and the remaining 48 (33%) patients did not have HFrecEF (HFnorEF). In the subgroup of HFrecEF, 43 (30%) patients had HFparEF and 54 (37%) patients had HFcorEF. Late HMR at 6FUP in HFcorEF patients was significantly greater than those in HFparEF and HFnorEF patients, which was also observed at the discharge with non-significant difference. The change of late HMR significantly correlated with the improvement in LVEF (r=0.33, p&amp;lt;0.001). During a follow-up period of 4.3 ± 2.6 years, 28 patients in HFnorEF, 11 patients in HFparEF and 4 patients in HFcorEF had CEs, respectively. Kaplan-Meier analysis revealed that HFnorEF patients had a significantly higher risk of cardiac events than those with HFparEF and HFcorEF. (58.3% vs 25.6% vs 7.4% P &amp;lt; 0.0001). Patients with lower late HMR at 6FUP had a greater risk of CEs than those with higher late HR at 6FUP in HFrecEF, especially in HFparEF, which was not observed in HFnorEF subgroup. Conclusion The follow-up MIBG imaging after the discharge could provide the additional prognostic information in ADHF patients with recovered LV function.

Recovery of left ventricular ejection fraction in Takotsubo Syndrome

Abstract Introduction Takotsubo Syndrome (TTS) is a condition of transient left ventricular dysfunction that is typically triggered by emotional or physical stress. Left ventricular ejection fraction (LVEF) recovery in TTS occurs over a wide-range interval, varying from days to weeks. Purpose Our purpose was to access the prognostic impact of delayed recovery of LVEF in patients with TTS. Methods We performed a retrospective analysis of patients admitted in a single centre between 2008 and 2022 with the diagnosis of TTS, with a LVEF &amp;lt;50% at admission. Patients were divided into two groups: Group A- patients with the recovery of ejection fraction during hospitalization (LV EF ≥ 50% at the pre-discharge echocardiogram) and Group B- patients that had a delay in recovery, with LV EF &amp;lt;50% at the pre-discharge echocardiogram. Major adverse cardiovascular events (MACCE) included heart failure hospitalization, cardiovascular mortality, stroke and TTS recurrence. Results We included 63 pts, 88,9% females, mean age of 69,38 ±12,5 years. Group A included 27 pts, with a median LV EF of 37% (IQR 33-41) and group B included 36 pts with a median LV EF of 36% (IQR 33-38,8), with no statistically significant difference between the two groups (p= 0,347). The median pre-discharge LV EF was 60,0% (IQR 56-65,6) in group A and 42,0% (IQR 37-47) in group B (p&amp;lt;0,005). The hospitalization length (HL)was similar between the two groups (mean HL of 7,9 ±7,8 in group A versus 8,1 ±8,4 days in group B, p= 0,93). The two groups were similar in terms of basal characteristics, with more prevalence of psychiatric disease in group A (13,9% vs 33,3%, p= 0,066). We found no statistically differences in clinical presentation and evolution during hospitalization (Killip class, cardiogenic shock, ventricular arrhythmias) and in the rates of concomitant coronary artery disease (14,8% group A versus 26,5% group B, p= 0,270). Also, the in-hospital medication and at discharge (Angiotensin-converting enzyme inhibitors, beta blockers, spironolactone and aspirin) were identical between the two groups. There was a tendency for more prescription of anticoagulants at discharge in group B (45,7% versus 22,2%, p = 0,055). During a median follow-up of 41,0 months (IQR 14,0-54,5), group B had a higher rate of MACCE (34,4% versus 20,0%, log rank p= 0,033). In a multivariate analysis, after adjusting for possible confounders, delayed recovery of LV EF was an independent predictor of MACCE with a HR 6,1 (95% CI: 1,50-24,9, p= 0,012) (Fig.1). Conclusions In this population, delayed recovery of LV EF in TTS was an independent predictor of major adverse cardiovascular events. These findings suggest that this population should be targeted in clinical trials to investigate possible interventions and these patients should have a closer follow-up.

Impact of pharmacological treatment for heart failure after myocardial recovery in arrhythmia-induced cardiomyopathy

Abstract Introduction There is scarce evidence regarding the optimal medical treatment of patients with heart failure and recovered LVEF. To date, no study has analyzed the efficacy of maintaining neurohormonal blockade in patients with arrhythmia-induced cardiomyopathy (AiCM) after LVEF normalization. Purpose The aim of this study is to analyze impact of pharmacological treatment for heart failure in preventing heart failure relapse after myocardial recovery in AiCM. Methods We analyze data from a single-center cohort of 200 patients admitted for heart failure and ventricular dysfunction initially attributed to AiCM between 2008 and 2020. Myocardial recovery was defined as an improvement in LVEF up to &amp;gt; = 50% (complete recovery) or an increase of &amp;gt; = 10% up to a value of LVEF &amp;gt;= 40% (partial recovery). Heart failure relapse was defined as a decrease in LVEF to &amp;lt;50% in those with previous complete recovery or a decrease of &amp;gt; = 10% in patients with partial recovery, unplanned Emergency Department (ED) visit or hospital admission for heart failure. As drug prescriptions are not constant over follow up, changes in medication have been recorded and time varying covariates were used for statistical analysis. A Fine and Gray competing-risk multivariate regression was performed, adjusting for initial LVEF at admission, degree of myocardial recovery (complete or partial), presence of underlying cardiomyopathy and age, considering death as competing risk. Results Over a median of 6.14 years, most of the patients had a complete myocardial recovery (n = 164; 82.0%). 24 patients (12%) had partial recovery and 12 patients (6.0%) did not show significant improvement in ventricular function. At the moment of myocardial recovery, ACEI/ARB/ARNI were prescribed in 160 patients (85.11%); beta-blockers in 170 (90.43%); ARB in 112 (59.57%); iSGLT2 in 8 (4.26%); antiarrhythmic drugs in 75 (39.89%) and Digoxin in 40 (21.28). From 188 patients with initial LVEF recovery, 64 (34.04%) had a relapse of systolic dysfunction. 65 patients (34.57%) required unplanned Emergency Department (ED) visits and 40 patients (21.28%) needed hospital admission for heart failure. Maintenance of ACEI/ARB/ARNI and beta-blockers after myocardial recovery was associated with a significant lower risk of HF relapse [sHR 0.43 (95% CI 0.26 - 0.73), p 0.002 for ACEI/ARB/ARNI]; [sHR 0.52 (95% CI 0.29 - 0.92), p 0.025 for beta-blockers]. ARM was associated with a non-significant lower risk of HF relapse [sHR 0.67 (95% CI 0.42 - 1.09), p 0.093]. Treatment with antiarrhythmic drugs [sHR 0.90 (95% CI 0.54 - 1.51), p 0.696] and Digoxin [sHR 0.90 (95% CI 0.54 - 1.51), p 0.696] did not show benefit in this study. Conclusions Maintenance of ACEI/ARB/ARNI and beta-blockers after myocardial recovery was associated with a significant lower risk of HF relapse after myocardial recovery in patients with AiCM.Risk of HF relapse - ACEI ARB ARNIRisk of HF relapse - BetaBlockers