Recovery Of Left Ventricular Function Research Articles

ST-segment depression and left ventricular systolic function recovery post-atrial fibrillation ablation in heart failure.

Catheter ablation (CA) of atrial fibrillation (AF) improves left ventricular ejection fraction (LVEF) in patients with heart failure with reduced ejection fraction (HFrEF). The impact of ST-segment depression before CA on LVEF recovery and clinical outcomes remains unknown. In the present study, we aimed to investigate the relationship between ST-segment depression during AF rhythm before CA and improvement in the LVEF and clinical outcomes in persistent atrial fibrillation (PerAF) patients with HFrEF. The present study included 122 PerAF patients (male; 98 patients, 80%, mean age: 69 [56, 76] years) from the Osaka Rosai Atrial Fibrillation ablation (ORAF) registry who had LVEF<50% and underwent an initial ablation. The patients who underwent percutaneous coronary intervention or coronary artery bypass grafting within the past 1month were not included in the enrolled patients. We assigned the patients based on the presence of ST-segment depression before CA during AF rhythm and evaluated improvement in the LVEF (LVEF≥15%) 1year after CA and the relationship between ST-segment depression and heart failure (HF) hospitalization/major adverse cardiovascular events (MACE), which are defined as a composite of HF hospitalization, cardiovascular death, hospitalization due to coronary artery disease, ventricular arrhythmia requiring hospitalization and stroke. The percentage of patients with improvement in the LVEF 1year after CA was significantly lower in the patients with ST-segment depression than those without (58.6% vs. 79.7%, P=0.012). Multiple regression analysis showed ST-segment depression was independently and significantly associated with improvement in the LVEF 1year after CA (HR: 0.35; 95% CI: 0.129-0.928, P=0.035). Kaplan-Meier analysis showed that the patients with ST-segment depression significantly had higher risk of HF hospitalization and MACE than those without (log rank P=0.022 and log rank P=0.002, respectively). Multivariable Cox proportional hazards analysis showed that ST-segment depression was independently and significantly associated with a higher risk of MACE (HR: 2.82; 95% CI: 1.210-6.584, P=0.016). ST-segment depression before CA during AF rhythm was useful prognostic predictor of improvement in the LVEF and clinical outcomes including HF hospitalization and MACE in PerAF patients with HFrEF.

Outcome of Patients Presenting with Peripartum Cardiomyopathy in a Tertiary Care Center of Nepal

Purpose: Peripartum cardiomyopathy is a rare life-threatening cardiomyopathy of unknown etiology with significant maternal morbidity and mortality. It causes heart failure due to left ventricular systolic dysfunction with or without left ventricular dilatation in the last month of pregnancy up to 5 months postpartum in previously healthy women. We aimed to determine short-term outcomes of peripartum cardiomyopathy clinically as well as in terms of left ventricular systolic function and to study the clinical profile and associated risk factors. Patients and methods: A prospective observational study was carried out in the Department of Cardiology of Manmohan Cardiothoracic Vascular and Transplant Center, Institute of Medicine, Kathmandu, Nepal, from July 2018 to January 2022. All the patients with peripartum cardiomyopathy who presented to the department of cardiology were enrolled in the study and re-evaluated with echocardiography at 6 months. Results: A total of 68 women met the inclusion criteria. The mean age was 28.38 ± 5.5 years (range 19 to 44 years). The most common clinical presentation was dyspnea followed by lower limb edema. Six (8.8%) patients presented during the last month of pregnancy whereas 62 (91.2%) patients presented in the postpartum period. The mean left ventricular ejection fraction on presentation was 30.01 ± 8.54. A full recovery was observed among 60.29% at 6 months. The mortality rate was 4.41%. Conclusion: Timely diagnosis and management of peripartum cardiomyopathy with standard therapy for heart failure leads to better recovery of left ventricular systolic function.

USE OF SGLT2–INHIBITORS IN THE TREATMENT OF ANTHRACICLINE CARDIOTOXICITY

Abstract The survival rate of cancer patients has significantly increased in the last 25 years thanks to the extraordinary advances in anti-tumor therapies. However, many chemotherapeutic agents are potentially cardiotoxic. In particular, anthracycline-induced cardiotoxicity is a clinical condition caused by chemotherapy drugs that lead to morpho-functional alterations and cell death of cardiomyocytes; the most typical clinical manifestation of this cardiotoxicity is the development of left ventricular dysfunction, which over time can evolve towards full-blown heart failure. It is therefore characterized by a reversible asymptomatic stage that progresses to an irreversible stage, often difficult to treat. For an early individualization of this toxicity, a dedicated clinic has been established in our center for the monitoring of patients undergoing treatment with cardiotoxic chemotherapy. We describe the case of a 53-year-old patient with preserved biventricular systolic function undergoing neoadjuvant treatment for breast cancer, who at the end of the second infusion of anthracyclines presented with mild exertional dyspnoea associated with radiological signs of pulmonary congestion and an increase in the indices of myocardionecrosis and BNP. The echocardiogram revealed a sudden worsening of the left ventricular systolic function which was 48%. It was therefore decided to hospitalize the patient and initiate infusional diuretic therapy with a rapid clinical and instrumental response. An SGLT2 inhibitor with indication for the treatment of heart failure with moderately reduced ejection fraction was also added to the therapy. At the one-month check-up, there was an almost complete recovery of left ventricular function and a clear symptomatic benefit with associated normalization of laboratory markers of myocardial damage and heart failure, with the possibility for the patient to undergo surgery to remove the left ventricle. tumor mass. This clinical case could represent a starting point to start considering therapy with SGLT2 inhibitors for the prevention and early treatment of cardiac toxicities from some chemotherapeutics, in order to avoid the process of irreversibility of myocardial damage with subsequent poor response to anti-inflammatory therapies. – conventional compensation.

TAKOTSUBO SYNDROME PRECEDING THE INDEX EVENT: A DANGEROUS CLINICAL SETTING

Abstract We describe the case of a 68–year–old patient who presented to the Emergency Department following an unwitnessed syncopal episode with slow recovery of consciousness. On admission, the patient had dyspnoea together with physical signs of pulmonary congestion. Cardiac ultrasound showed severe left ventricular dysfunction with an ejection fraction of 30%, and apical and paraapical akinesis. The admission electrocardiogram showed sinus tachycardia and diffuse repolarization abnormalities, hs TnI was elevated and BNP vl blood gas analysis were unremarkable. During observation in the Emergency Department, the patient experienced epileptic seizure, promptly resolved by intravenous Midazolam. Contrast–enhanced chest CT ruled out aortic dissection disclosing a clinically irrelevant subsegmental pulmonary embolism. A non–contrast CT scan of the brain yielded negative results. In consideration of the atypical clinical presentation and scattered evidence of an acute coronary syndrome, the patient was admitted to our Cardiac Intensive Care Unit (CICU) for additional diagnostic workup delaying coronary angiography in the presence of stable TnI elevation. Three hours after admission the patient continued showing altered consciousness and a subsequent brain CT was performed, demonstrating an intraparenchymal hemorrhagic spreading. Repeat ECGs showed precordial T wave inversion and prolongation of the QT interval. These data, together with LV apical dysfunction, raised the suspicion of Takotsubo syndrome secondary to an acute cerebrovascular event. During the hospital stay, recovery of consciousness, spontaneous absorption of the cerebral hemorrhagic spread and complete recovery of left ventricular function at repeat cardiac ultrasound examinations were observed, confirming the almost unequivocal diagnosis of Takotsubo syndrome. The patient was discharged uneventfully and was scheduled for an outpatient coronary CT scan. This case underscores the crucial importance of a thorough clinical assessment in the management of complex patients in the presence of nonunivocal clinical signs and misleading blood test and imaging data. Moreover, Takotsubo syndrome is a protean clinical entity that can precede the index event as in our patient, i.e. cerebral hemorrhage. Misclassification of these patients as having an acute coronary syndrome could have led to the initiation of antithrombotic therapy, with potential fatal outcomes for the patient.

A COMPLEX POST CARDIAC–ARREST SYNDROME: FROM UNCERTAIN NEUROLOGICAL OUTCOME TO HEMORRHAGIC COMPLICATION

Abstract A 49–years–old woman with type II diabetes mellitus, hypothyroidism and Churg–Strauss syndrome experienced chest pain with loss of consciousness. Emergency service was called and CPR promptly started. Cardiac arrest with shockable rhythm was documented, DC–shock performed with sign of anterior STEMI after ROSC, then refractory cardiac arrest appeared. The patient was centralized in our hospital and VA–ECMO was positioned through a percutaneous femoral access in cath–lab. Coronary angiography showed acute occlusion of the mid–proximal LAD and subocclusive stenosis of the dominant Cx for which PCI with DES was performed, then intra–aortic balloon pump (IABP) was implanted. At ICCU admission the patient was supported by ECMO and IABP with MAP 65 mmHg and lactates 3.5 mmol/L. Echocardiography and chest X–ray showed severe biventricular dysfunction and pulmonary overload (Fig 1). She was ventilated via ECMO circuit and mechanical ventilation setting protective TV values of 6 ml/kg. Diuresis was good with low dose of furosemide, lactates progressively decreased. Temperature control was set within 36°C with the cooling system of the ECMO circuit. Cardioaspirin, ticagrelor and bivalirudin were administered. At early neurological stratification EEG documented absence of epileptiform anomalies, responsiveness to painful stimuli, SSPE showed normal and symmetrical morphology, NSE at 48 h was 59 ng/mL, she opened eyes and performed simple orders. Levosimendan was administered with partial recovery of the right ventricular dysfunction leading to ECMO removal on 5th day. Due to poor consciousness recovery despite sedation reduction, percutaneous tracheostomy was performed on 8th day, IABP removed and the following day all vasopressors suspended. Neurological improvement allowed transition to spontaneous breathing and weaning from mechanical ventilation; on 19th day tracheostomy was removed. Massive enterorrhagia appeared after ECMO removal (figure 2). The colonoscopy showed ischemic pancolitis, therefore ticagrelor was suspended. On 18th day clopidogrel was reintroduced based on hemoglobin stability and endoscopic improvement. She was discharged from the cardiology department after a total length of stay of thirty days, with normal neurological status, no motor deficits, recovery of left and right ventricular function, stable hemoglobin levels.

Significance of QRS scoring system in left ventricular function recovery after acute myocardial infarction.

The Selvester scoring system has been derived from ECG parameters for estimating infarct size. However, there is still a lack of evidence for Selvester score as an alternative to cardiac magnetic resonance (CMR) myocardial injury makers for risk stratification and prediction of left ventricular function (LVF) recovery among patients with ST-segment elevation myocardial infarction (STEMI). This multicentre observational study enrolled 328 STEMI patients (88.4% men, 57.3±10.6years of age) undergoing CMR examination 1week post-reperfusion therapy. Patients with baseline left ventricular ejection fraction (LVEF)<50% underwent a follow-up CMR 6months later, categorized into baseline normal LVF (ejection fraction [EF]≥50% at baseline, n=155); recovered LVF (EF<50% at baseline and ≥50% after 6months, n=69); and reduced LVF (EF<50% at baseline and after 6months, n=104). The median follow-up was 4 (3-4) years for all patients, with 61 patients experiencing major adverse cardiovascular event (MACEs). Patients with reduced LVF had a higher risk of MACEs than those with baseline normal LVF (P=0.01), while the recovered LVF group had no significant difference (P>0.05). A Selvester score >10 doubled the risk of MACEs in patients with systolic dysfunction (1.91 [1.02 to 3.58], P=0.04). Additionally, Selvester score, baseline LVEF, transmural infarction, and peak CK-MB were independent predictors of recovered LVF, with Selvester score providing incremental predictive value to peak CK-MB in predicting recovered LVF (∆AUC=0.07, P<0.05). The Selvester score improves risk stratification among STEMI patients beyond LVEF and provide independent and incremental information to clinical parameters in predicting recovered LVF.

Recovery of left ventricular systolic function in peripartum cardiomyopathy: an observational study from rural Tanzania

BackgroundThe aim of this study was to evaluate the recovery rate of the left ventricular systolic function of women diagnosed with peripartum cardiomyopathy receiving specialized care in rural Tanzania.MethodsIn this observational study, women diagnosed with peripartum cardiomyopathy at a referral center in rural Tanzania between December 2015 and September 2021 were included. Women diagnosed between February and September 2021 were followed prospectively, those diagnosed between December 2015 and January 2021 were tracked back for a follow-up echocardiography. All participants received a clinical examination, a comprehensive echocardiogram, and a prescription of guideline-directed medical therapy. The primary outcome was recovery of the left ventricular systolic function (left ventricular ejection fraction > 50%).ResultsMedian age of the 110 participants was 28.5 years (range 17–45). At enrolment, 49 (45%) participants were already on cardiac medication, 50 (45%) had severe eccentric hypertrophy of the left ventricle, and the median left ventricular ejection fraction was 30% (range 15–46). After a median follow-up of 8.98 months (IQR 5.72–29.37), 61 (55%) participants were still on cardiac medication. Full recovery of the left ventricular systolic function was diagnosed in 76 (69%, 95% CI 59.6–77.6%) participants. In the multivariate analysis, a higher left ventricular ejection fraction at baseline was positively associated with full recovery (each 5% increase; OR 1.7, 95% CI 1.10–2.62, p = 0.012), while higher age was inversely associated (each 10 years increase; OR 0.40, 95% CI 0.19–0.82, p = 0.012).ConclusionLeft ventricular systolic function recovered completely in 69% of study participants with peripartum cardiomyopathy from rural Tanzania under specialized care.

The Impact of Microvascular Resistance Reserve on the Outcome of Patients With STEMI

BackgroundMicrovascular resistance reserve (MRR) can characterize coronary microvascular dysfunction (CMD); however, its prognostic impact in ST-segment elevation myocardial infarction (STEMI) patients remains undefined. ObjectivesThis study sought to investigate the prevalence of CMD in STEMI patients and to elucidate the prognostic performance of MRR. MethodsThis prospective cohort study enrolled 210 STEMI patients with multivessel disease who underwent successful revascularization and returned at 3 months for coronary physiology assessments with bolus thermodilution. The prevalence of CMD (MRR <3) and the association between MRR and major adverse cardiovascular and cerebrovascular events (MACCEs) at 12 months were investigated. ResultsThe median age of patients was 65 years, and 59.5% were men. At the 3-month follow-up, 56 patients (27%) had CMD (MRR <3.0). The number of MACCEs at 12 months was higher in patients with vs without CMD (48.2% vs 11.0%; P < 0.001). MRR was independently associated with 12-month MACCEs (HR: 0.45 per unit increase; 95% CI: 0.31-0.67; P < 0.001) and with stroke, heart failure, and poorer recovery in left ventricular systolic function. The areas under the receiver-operating characteristic curves for predicting MACCEs at 12 months with fractional flow reserve, coronary flow reserve (CFR), the index of microvascular resistance (IMR), and MRR were 0.609, 0.762, 0.781, and 0.743, respectively. The prognostic performance of CFR, IMR, and MRR were all comparable. ConclusionsThe novel parameter MRR is a prognostic marker of MACCEs in STEMI patients with a comparable performance to CFR and IMR. (Impact of TMAO Serum Levels on Hyperemic IMR in STEMI Patients [TAMIR]; NCT05406297)

Effect of residual myocardial ischemia on recovery of left ventricular function after primary percutaneous coronary intervention

BackgroundIt is unknown whether the existence of severe bystander damage will affect left ventricular (LV) healing following primary percutaneous coronary intervention (PPCI).The aim of the present analysis was to follow LV recovery using 2D speckle tracking echocardiography (2-D STE) in cases with single versus multiple vessel disease with acute myocardial infarction (AMI) who underwent PPCI and to assess major adverse cardiovascular events (MACEs) within 3 months.Patients and methodsThis work was conducted at Assiut University Heart Hospital. Of 1026 screened subjects with AMI needing PPCI and assessed for eligibility, only 89 cases fulfilled the inclusion criteria. They were classified into Group A: single vessel and Group B: multiple vessel (≥ 2 vessels) disease. Their data were obtained on admittance and after 90 days.ResultsIn group A compared to group B, there was a statistically preferable value at baseline in the global longitudinal strain- Apical 2 chamber (GLS-A2C) (-12.05 ± 3.57 vs. -10.38 ± 3.92, P = 0.039). At follow-up, the improvement was in all 2-D STE variables, including GLS-long axis (GLS-LAX) (-13.09 ± 3.84 vs.-10.75 ± 3.96, P = 0.006), GLS- apical 4 chamber (GLS-A4C) (-13.23 ± 3.51 vs.-10.62 ± 4.08, P = 0.002), GLS-A2C (-13.85 ± 3.41 vs-10.93 ± 3.97, P < 0.001) and GLS- average (GLS-AVG, P = 0.001). There was a considerable negative correlation between the recovery of LV performance and the existence of multi-vessel lesions (P = 0.009). There was no variance between the groups regarding MACEs.ConclusionsPatients with single vessel lesions who underwent PPCI to the culprit lesion had better recovery of LV function than those with multi-vessel (≥ 2 vessels) lesions who underwent PPCI to the culprit lesion only. The presence of multivessel involvement was an independent risk factor for deterioration in GLS.Trial RegistrationRegistered in clinical trial, clinicalTrial.gov ID NCT04103008 (25/09/2019). IRB registration: 17,100,834 (05/11/2019).

Left ventricular recovery after total arterial coronary artery bypass grafting versus conventional coronary artery bypass grafting in patients with multivessel coronary artery disease and reduced left ventricular ejection fraction.

We compared total arterial revascularization (TAR) versus conventional revascularization (CR) in terms of left ventricular function recovery in patients with multivessel coronary artery disease (CAD) and reduced left ventricular ejection fraction (LVEF). We conducted a retrospective cohort study of 162 consecutive patients with multivessel CAD and reduced LVEF who underwent isolated coronary artery bypass grafting at our institution between January 2013 and July 2022. We assessed left ventricular function by transthoracic echocardiography at admission, before discharge, and at follow-up of 3, 6, and 12months, using LVEF, global longitudinal peak strain, end-diastolic volume index, and end-systolic volume index. We also evaluated mitral valve regurgitation and graft patency rate at 1 year. The TAR group had a significantly higher increase in LVEF and global longitudinal peak strain, and a significantly lower decrease in end-diastolic volume index and end-systolic volume index than the CR group at 6 and 12months after surgery. The TAR group also had a significantly lower degree of mitral valve regurgitation than the CR group at all-time points within 12months after surgery. The TAR group had a significantly higher graft patency rate than the CR group at 12months. There was no significant difference in hospital mortality or repeat revascularization between the groups. TAR was associated with better recovery of left ventricular function than CR in patients with multivessel CAD and reduced LVEF. Further studies are needed to confirm these findings in this high-risk population.

Peripartum Cardiomyopathy: A Case Report

Background: Peripartum cardiomyopathy (PPCM) is a type of dilated cardiomyopathy of unknown origin. Predisposing factors for PPCM are multiparity, family history, ethnicity, smoking, diabetes, hypertension, preeclampsia, malnutrition, and advanced age in pregnant women or teenage pregnancy.&#x0D; Case presentation: A 29-year-old female patient was treated in the internal medicine department of Dr. M. Djamil General Hospital Padang on March 18th, 2023, with the main complaint of shortness of breath. On physical examination, signs of congestion were found. ECG shows sinus tachycardia, QT prolongation, and T inversion in V3-V6, II, III, and aVF. The patient is established with peripartum cardiomyopathy, community-acquired pneumonia, nonsevere low-risk MDR, hypochromic microcytic mild anemia et causa chronic disease, high-risk VTE, h hypokalemia et causa diuretic.&#x0D; Conclusion: Education regarding recurrent recurrence of PPCM in subsequent pregnancies is 30-50%. The prognosis depends on the recovery of left ventricular function; 30% of patients can return to baseline ventricular function within 6 months, and 50% of patients have an improvement in symptoms and ventricular function. Contraception is recommended that does not pose a risk of thromboembolism, such as a uterine device (IUD) and subcutaneous progesterone.

Irreversible myocardial injury attenuates the benefits of sacubitril/valsartan in heart failure patients

BackgroundDespite the established benefits of angiotensin receptor-neprilysin inhibitor (ARNI) in heart failure with reduced ejection fraction (HFrEF) across various etiologies, there are controversies regarding the effects of ARNI in patients with irreversible myocardial injury. The aim of this study is to investigate the impact of irreversible myocardial injury on the benefits of ARNI treatment in patients with HFrEF, consisted of both ischemic and non-ischemic etiologies. Methods and resultsWe conducted a retrospective single-center study including 409 consecutive patients with HFrEF treated with ARNI between March 2017 and May 2020. Irreversible myocardial injury was defined as nonviable myocardium without contractile reserve, which suggests a limited potential for recovery of left ventricular function and geometry. At baseline, irreversible myocardial injury was observed in 129 (31.5%) patients. Composite outcome was cardiovascular death or hospitalization for heart failure, which occurred in 56 (43.4%) and 61 (21.8%) patients with and without irreversible myocardial injury, respectively. On multivariable analysis, irreversible injury presence, but not ischemic etiology, was an independent predictor of composite outcome (hazard ratio 2.16, 95% confidence interval 1.33–3.49). Mediation analysis revealed that the increased risk of the composite outcome due to irreversible myocardial injury was mediated by attenuated LV reverse remodeling (Z value = 2.02, P = 0.043). ConclusionsThe presence of irreversible myocardial injury was significantly associated with the response to ARNI treatment in patients with HFrEF, regardless of etiology.

Endocardial pacing compared to epicardial left ventricle pacing and right ventricle pacing: A single-center long-term experience in a pediatric population

Background and aimsPediatric pacing is usually performed as epicardial pacing in small children in need of pacemaker therapy. Epicardial pacing compared with transvenous pacing for pediatric complete atrioventricular block (CAVB) has different strengths and weaknesses. The epicardial left ventricular wall position of the lead has been considered superior, in terms of contraction pattern, compared to a transvenous right ventricular stimulation. We aimed to compare QRS duration and cardiac function before and after the switch from epicardial to transvenous pacing in a pediatric population. MethodsPediatric patients with congenital or acquired CAVB, who underwent a switch from epicardial-to transvenous pacing at our center from 2005 to 2021, were identified through the national ICD- and Pacemaker Registry. Data regarding clinical status, ECG, and echocardiography before and after the switch and at last follow-up were collected. ResultsWe included 15 children. The median age at the switch was 6.7 (4.4–11.7) years with a median weight of 21 (15–39) Kg. The median QRS duration with the transvenous systems was 136 (128–152) ms vs. a QRS duration during epicardial stimulation of 150 (144–170) ms with a median difference in QRS duration of 14 (6–20) ms. Children with a post-surgical AV block had a broader QRS duration, both with epicardial and endocardial stimulation. Before the switch, there was one patient with impaired left ventricular function (LVF) but with normal left ventricular end-diastolic diameters. After the switch, one patient developed symptomatic LV dysfunction with the recovery of LVF at the last follow-up after being implanted with a cardiac resynchronization therapy device. ConclusionsOur report of pediatric patients after switching from epicardial to transvenous pacing shows how transvenous pacing is not inferior to epicardial pacing in terms of QRS duration and no significant deterioration of cardiac function was detectable.

Impact of thrombus aspiration on left ventricular remodeling and function in patients with ST-segment elevation myocardial infarction: A meta-analysis of randomized controlled trials

BackgroundRoutine thrombus aspiration (TA) does not improve clinical outcomes in patients with ST-segment-elevation myocardial infarction (STEMI), although data from meta-analyses suggest that patients with high thrombus burden may benefit from it. The impact of TA on left ventricular (LV) functional recovery and remodeling after STEMI remains controversial. We aimed to pool data from randomized controlled trials (RCTs) on the impact of TA on LV function and remodeling after primary percutaneous coronary intervention (pPCI). MethodsPubMed and CENTRAL databases were scanned for eligible studies. Primary outcome measures were: LV ejection fraction (LVEF), LV end diastolic volume (LVEDV), LV end systolic volume (LVESV) and wall motion score index (WMSI). A primary pre-specified subgroup analysis was performed comparing manual TA with mechanical TA. ResultsA total of 28 studies enrolling 4990 patients were included. WMSI was lower in TA group than in control (mean difference [MD] -0.11, 95% confidence interval [CI] -0.19 to −0.03). A greater LVEF (MD 1.91, 95% CI 0.76 to 3) and a smaller LVESV (MD -6.19, 95% CI -8.7 to −3.6) were observed in manual TA group compared to control. Meta regressions including patients with left anterior descending artery (LAD) involvement showed an association between TA use and the reduction of both LVEDV and LVESV (z = −2.13, p = 0.03; z = −3.7, p < 0.01) and the improvement in myocardial salvage index (z = 2.04, p = 0.04). ConclusionTA is associated with improved LV function. TA technique, total ischemic time and LAD involvement appears to influence TA benefit on post-infarction LV remodeling.

Artificial intelligence-derived ECG bio-index as a tool for predicting the prognosis of patients with ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention

Abstract Background/Introduction Electrocardiogram (ECG) changes after primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients, such as the recovery of ST elevation, are associated with prognosis, but quantifying them is challenging. Deep-learning algorithms (DLA) can diagnose STEMI and quantify the probability as a bio-index. However, the prognostic value of this index has yet to be well studied. Purpose This study aims to investigate the feasibility of predicting the prognosis of patients with STEMI by analyzing serial ECGs post-primary PCI using an DLA designed to detect AMI and STEMI. Methods We developed a DLA to detect acute myocardial infarction (AMI) and STEMI using 12-lead ECGs from hospital A. The DLA was based on convolutional neural network and presented the index for probability of AMI and STEMI as a number between 0 and 1. We subsequently analyzed serial ECGs from hospital B, taken more than one month prior to the STEMI event (baseline), at pre-PCI (at emergency department [ED]), immediate post-PCI, 6h, 24h, 1 month after PCI, using the DLA. The primary endpoint was a post-STEMI heart failure defined as left ventricular ejection fraction (LVEF) less than 50%. Results A total of 22,259 ECGs (13,916 ECGs of non-AMI and 8,343 ECGs of AMI) from 15,113 patients were used to develop and validate the DLA. The area under the curve (AUC) of the final DLA was 0.950 for AMI and 0.954 for STEMI. Serial ECGs of 639 STEMI patients were analyzed. The mean index value at different time points were as follows: 0.061 ± 0.158 in baseline ECG, 0.801 ± 0.333 in ECG at ED, 0.525 ± 0.429 in immediate post-PCI, 0.467 ± 0.425 in 6-hour, 0.482 ± 0.423 in 24-hour, and 0.273 ± 0.348 in 1-month after PCI (ANOVA P-value &amp;lt;0.001). To evaluate the predictive value of the DLA index, we stratified the study population into low, intermediate, and high-risk group based on the DLA index, with thresholds of 0.03 and 0.45 of the immediate post-PCI AI indices. The mean LVEF was 53.0 ± 10.1% in the low-risk group, 49.6 ± 10 %, and 47.4 ± 10.2 % in the intermediate and the high-risk group (ANOVA P-value &amp;lt; 0.001). The prevalence of post-STEMI heart failure was 30.6%, 46.4%, and 60.6%, respectively (P &amp;lt; 0.001). Furthermore, the DLA index was significantly associated with the recovery of left ventricular function. The prevalence of heart failure in 3-month follow-up echocardiography was highest in the high-risk group (15.4% vs. 27.1% vs. 31.8%, respectively, P = 0.022). Conclusion Our study shows that the DLA-derived bio-index is an effective tool to quantify ECG changes after primary PCI in STEMI patients and predict post-AMI heart failure. The DLA index is also associated with left ventricular function recovery, indicating its potential as a prognostic marker. Further studies are needed to validate our results and explore the use of the DLA index in assessing myocardial reperfusion after primary PCI.

Haematopoietic loss of KDM6A impairs cardiac recovery post myocardial infarction via pro-inflammatory myeloid cells

Abstract Background Ischaemic heart failure (IHF) remains a leading cause of death worldwide. Clonal haematopoiesis has emerged as a major risk factor for IHF and patients with CH have worse outcomes after acute myocardial infarction (AMI). CH is characterized by clonal expansion of a haematopoietic stem cell that carries a leukaemogenic mutation. Recently, acquired loss-of-function mutations in the histone demethylase KDM6A were identified as CH-drivers in IHF patients. KDM6A is frequently mutated in human cancer and acts as a tumour suppressor in acute myeloid leukaemia. However, the role of KDM6A in the regulation of cardiac damage after MI is not understood. Purpose Investigate the effect of leukocyte specific loss of KDM6A in the development of IHF after AMI in mice and humans. Methods/Results A mouse model of haematopoietic specific loss of Kdm6a (VaviCre-Kdm6aflox) combined with a model of myocardial injury was employed to investigate the role of Kdm6a in leukocytes in post-MI cardiac recovery. Firstly, following 28 days (D) post-MI, mice lacking Kdm6a in haematopoietic cells (KDM6A KO) showed significantly worse cardiac ejection fraction compared to controls (controls 43.98 ± 2.55 % vs KDM6A KO 31.86 ± 3.23 % recovery from baseline, P=0.009). This was accompanied by an increase in cardiac scar size at D28 post-MI (controls 22.46±5.25% vs KDM6A KO 56.83±11.1 % area, P&amp;lt;0.0001). Moreover, KDM6A KO mice showed peripheral blood monocytosis (controls 33793±5644 vs KDM6A KO 76227±14035 monocytes/ml blood, P =0.008) at D3 post-MI, which was accompanied by an increased influx of CD11b+ myeloid cells in the injured heart (7804±1023 vs 11444±1436 CD11b+ cells/mg tissue, P=0.05), as well as by an increased expression of pro-inflammatory marker TNF-α (controls 1.01±0.14 vs KDM6A KO 2.16±0.45 fold change, P=0.04) in the ischaemic myocardium. These data were corroborated by single-cell RNA sequencing (scRNA-seq) profiling of CD45+ cardiac leukocytes 3D post-MI. Here, transcriptomically distinct subsets of macrophages/monocytes showed upregulation of pro-inflammatory markers such as Il1-β, Nlrp3, Cxcl2, and Nfkb1 (P &amp;lt; 0.05, Bonferroni correction). Finally, scRNA-seq of circulating blood cells from IHF patients carrying KDM6A CH-driver mutations showed elevated levels of pro-inflammatory genes such as IL32, IL7R and CCL5 in CD14+ classical monocytes (P &amp;lt; 0.05, Bonferroni correction) compared to non-carriers. Conclusions In summary, this study shows that loss of KDM6A in myeloid cells amplifies acute cardiac inflammation and impairs recovery of left ventricular function after AMI accompanied by increased pro-inflammatory myeloid cells in the heart. Further interrogation of genes identified in the aforementioned murine and human sequencing data and subsequent in vitro mechanistic studies will be essential to identify the mechanism by which loss of KDM6A results in altered leukocyte function and worse HF prognosis post-MI.

Predicting poor left ventricular function recovery in Peripartum cardiomyopathy

Introduction Peripartum cardiomyopathy (PPCM) is a rare type of cardiomyopathy that manifests as acute heart failure associated with pregnancy. Delays in early identification result in poor recovery of left ventricular (LV) function; however, no risk prediction model exists. We sought to yield a scoring system known as the Padjadjaran Peripartum CardioMyopathy Recovery (PPCM recovery) score to predict the probability of poor LV function recovery in PPCM patients. Methods All baseline and clinical parameters were prospectively collected from a cohort of patients with PPCM admitted to Dr. Hasan Sadikin General Hospital in Bandung, Indonesia between January 2014 and December 2021. Logistic regression analyses were performed to investigate the relationship between each variable and the risk of poor LV function recovery in PPCM patients. Results This prospective cohort study included 113 patients with PPCM (84 recovered and 29 non-recovered patients). Significant mitral regurgitation (MR), left ventricular ejection fraction (LVEF) <30%, left ventricular end-diastolic diameter (LVEDD) ≥56 mm, and New York Heart Association functional class (NYHA FC) IV were all strong predictors of poor LV function recovery. These variables were integrated into the PPCM recovery score (AUC of 0.85). Patients with a score of ≥8 were nearly 18 times more likely to have poor LV function recovery (sensitivity 57%, specificity 93%). Conclusion PPCM recovery score is a convenient scoring system based on clinical and echocardiography assessment that may assist in distinguishing which patients are more likely to develop poor LV function recovery; therefore, these patients should be immediately referred to a tertiary referral hospital.

Abstract 11320: Sonothrombolysis Leads to Early Improvement of Left Ventricular Function in Acute Coronary Syndromes

Introduction: Acute coronary syndromes (ACS) are among the main causes of death worldwide. Despite important advances in revascularization strategies, there are a considerable number of patients who neither have access to these therapies, or, if so, may experience the no-reflow phenomenon. In STEMI, sonothrombolysis has been shown to restore patency of coronary vessels, especially in the microcirculation, leading to better left ventricular (LV) function recovery, hence emerging as a new adjuvant treatment to reperfusion. Hypothesis: Sonothrombolysis would improve the LV function in ACS. Aim: Compare ejection fraction (EF) and global longitudinal strain (GLS) in patients with ACS randomized to receive sonothrombolysis (therapy group-TG) or conventional treatment (control group-CG). Methods: Patients were randomized from two major clinical trials (NCT04732091 and NCT02410330 - HUBBLE databank). The therapy consists of high-energy intermittent ultrasound pulses associated with ultrasound-enhancing agent infusion (Definity® - Lantheus), initiated immediately after patient admission and continued after PCI or applied only after PCI for a total of 50 minutes. EF and GLS were measured off-line (TomTec Imaging System). Images were acquired immediately post Therapy/PCI or PCI only and 48/72 hours after the patient's inclusion. Comparisons were made using Student t-test, Chi-square test, and Fisher's exact test when indicated. Results: 120 patients were included (CG=60: 51 STEMI, 1 thrombolyzed STEMI, and 8 NSTEMI; TG=60: 53 STEMI, 1 thrombolyzed STEMI e 6 NSTEMI). Demographic characteristics were similar between groups, except for a tendency of higher number of diabetic patients in TG (43% vs. 25%, p=0.054). EF and GLS were similar between TG and CG immediately post-treatment (Therapy/PCI or PCI only) (47±12 vs. 45±11, p=0.393 and 13.2±4.1 vs. 12.5±3.3, p=0.325, respectively). However, after 48/72 hours, patients who received Therapy/PCI had similar values of EF despite higher GLS (49±10 vs. 46±11, p=0.126 and 13.5±3.8 vs. 11.8±3.1, p=0.010, respectively). Conclusions: Preliminary data shows that Sonothrombolysis associated with PCI could be an effective adjuvant treatment for ACS, contributing to the early improvement of LV function.

Abstract 17851: Prevalence and Predictors of Early Left Ventricular Functional Recovery After Transcatheter Aortic Valve Implantation: The TAVI-NOR Study

Introduction: Pre-intervention left ventricular (LV) ejection fraction (LVEF) in aortic stenosis (AS) patients has prognostic value. However, the hemodynamic changes early after TAVI (transcatheter aortic valve implantation) is not fully explored. Hypothesis: To what extent early functional recovery by a clinically significant increase (≥10%) in LVEF is achievable following TAVI, how it differs from baseline patient characteristics, and its potential prognostic impact. Methods: Between 2012 and 2019, 600 consecutive patients (age 81±6years, 49.3% females) with clinically significant AS underwent TAVI. Echocardiography was performed before and within 8 weeks after TAVI. Variables associated with &lt;10% LVEF improvement were identified. End-points were ≥10% LVEF improvement and all-cause mortality. Results: From baseline to follow-up; 28% of patients achieved ≥10% LVEF improvement. A ≥10% LVEF improvement was observed in 25% of patients with normal baseline flow (indexed stroke volume ≥35ml/m 2 ) versus 38% in low-flow (p=0.002). Impaired kidney function, higher blood pressure (BP), higher baseline LVEF and indexed stroke volume, and lower LV mass was more likely in patients with &lt;10% LVEF. In a multivariate logistic regression analysis, higher baseline systolic BP (OR 1.02; 95% CI 1.01-1.03, p=0.004) and lower LV mass (OR 1.25; 95% CI 1.02-1.54, p=0.031), and new pacemaker implantation (OR 1.55; 95% CI 0.99-2.42, p=0.055) were associated with a higher risk, and baseline LVEF &lt;50% with a lower risk (OR: 0.15; 95% CI: 0.09-0.25) for &lt;10% LVEF improvement following TAVI, independent of CKD, baseline troponin T and NT-proBNP. In a univariate Cox regression model, &lt;10% increase in LVEF in early phase after TAVI was not a significant predictor of mortality (HR 1.16; 95% CI 0.90-1.50, p=0.258). Conclusions: Clinically significant early LV functional recovery was evident in nearly one-third of severe AS patients, especially patients with reduced LVEF and more symptoms at baseline. Higher systolic BP, lower LV mass, and the need for new permanent pacemaker, were independently associated with a higher risk of not achieving early LV function recovery after TAVI. In long-term follow-up early LV functional recovery was not associated with all-cause mortality.

TakoTsubo secondary to acute kidney disease.

We report the case of a 62-year-old man who was admitted to the Cardiac Department for TakoTsubo and ACC by torsades de point, secondary to acute kidney disease. We decide to discharge with a portable defibrillator. One month after cardiac magnetic resonance showed a complete recovery of left ventricular function.