Improvement In LVEF Research Articles

Spontaneous QRS complex narrowing predicts left ventricle reverse remodeling in CRT patients

Mechanical cardiac dyssynchrony is an important component of cardiac remodeling during heart failure with reduced ejection fraction. Furthermore, echocardiographic assessment of left ventricle reverse remodelingrepresents the major tool to evaluate cardiac resynchronization therapy (CRT) response. In contrast, according to major randomized trialsmechanical dyssynchrony assessment failed and electrocardiographic proof of dyssynchrony is needed to indicate CRT, therefore; electrical reverse remodeling was suggested by few clinical studies conducted with a small number of patients. Additional information is required on the relationship between electrical (ERR) and structural reverse remodeling (SRR) in patients treated with cardiac resynchronization therapy. We investigated whether ERR defined as narrowing of the native electrocardiographic QRS duration after CRT might predict improvement in echocardiographic outcome. We collected 75 patients who underwent successful CRT device implantation in our department. Clinical, electrocardiographic and echocardiographic parameters were collected before implantation and after a variable duration of follow up in the outpatient clinic. SRR was defined as an improvement of LVEF > 5% and/or a reduction in LVESV > 15%. ERR was defined as a decrease in native QRS duration > 10 milliseconds (was recorded after switching off biventricular pacing). After a mean follow up duration of 69 months from the time of implantation, 51 patients had an echocardiographic response (SRR) and among 45 patients who had demonstrated an electrocardiographic response (ERR), 75% developed SRR (vs. 55% for those without ERR P = 0.07) and only 7.5% of them were ischemic cardiomyopathy. Mean QRS reduction was at 16 milliseconds in patients with SRR versus 8 milliseconds in patients without SRR (P = 0.02). Reversal electric remodeling as assessed by native QRS narrowing was associated with greater improvements in mean LVEF (16% vs. 10%, P = 0.1), mean LVEDV (85 mL vs. 35 mL, P = 0.04) and mean LVESV (77 mL vs. 37 mL, P = 0.1). Native QRS narrowing after initiation of CRT in patients with HFrEF was positively correlated tostructural reverse remodeling parameters assessed by echocardiography and consequently to the echocardiographic outcome.

PO-03-014 LONG-TERM OUTCOMES OF CONDUCTION SYSTEM PACING IN LEFT VENTRICULAR DYSFUNCTION USING STYLET-DRIVEN LEADS: A COMPARISON WITH LUMEN-LESS LEADS

Long-term outcomes of conduction system pacing (CSP) using stylet-driven leads (SDL) among patients with left ventricular systolic dysfunction (LVSD) have neither been studied nor been compared with lumen-less leads (LLL). The study’s objective was to compare stylet-driven (SDL) leads with lumen-less (LLL) in terms of feasibility, pacing characteristics, and long-term outcomes. Retrospective analysis of single-centre data of consecutive patients with LVEF < 50% undergoing a successful CSP implant using SDLs and LLLs between Jan 2020 to Aug 2022. Indications for CSP implant were Resynchronization therapy, bradycardia indication with LVEF < 50% with anticipated to require > 20% ventricular pacing and Pacing-induced Cardiomyopathy (PICMP). Among 114 patients (age 62.2 ± 11.3 years, 65 males) with LVEF < 50% (mean 29.2 ± 7.7%) undergoing CSP, LLLs and SDLs were used in 65 and 49 patients respectively. 9 LLL and 7 SDL implants used HBP; the remaining implants were LBBAP or LOT-CRT. CRT, bradyarrhythmia with LV dysfunction, and PICMP were the indications for CSP in 77, 32, and 5 patients, respectively. CRT indication (n = 70) was treated with LLL-LBBAP/LOT-CRT, SDL-LBBAP/LOT-CRT, LLL-HBP, and SDL-HBP, respectively. LLL-LBBAP/LOT-CRT, SDL-LBBAP/LOT-CRT, LLL-HBP, and SDL-HBP were used in 8, 13, 5, and 6 patients with bradyarrhythmia-CSP, respectively. At a median follow-up of 494 days (IQR: 208–636) for LLLs and 235 days (IQR: 122–333) for SDLs, LBBAP, unlike HBP, had similar lead parameters for both LLLs and SDLs with few complications. Four fatalities (three non-cardiac) occurred among the 112 patients accessible for follow-up. QRS narrowing (LLL: 168.8 ± 15.7 to 114.3 ± 16.5 ms, SDL: 166.3 ± 16.7 to 115.0 ± 14.2 ms), LVEF improvement (LLL: 26.7 ± 6 to 48.4 ± 8.0%, SDL: 25.7 ± 6.7 to 46.7 ± 8.0%), and NYHA class improvement (LLL: 2.8 ± 0.9 to 1.1 ± 0.3, SDL: 2.6 ± 0.8 to 1.2 ± 0.4) were similar between LLLs and SDLs for patients with LBBB undergoing LBBAP/LOT-CRT. Paced QRS duration (LLL:126.3 ± 14.2 ms, SDL:120.5 ± 7.5 ms) and LVEF stabilization (LLL:34.6 ± 6 to 40.1 ± 10.1%, SDL: 38.2 ± 7.5 to 45.8 ± 7%) was comparable across LLLs and SDLs for patients undergoing LBBAP/LOT-CRT for pacing. In this largest series of SDLs in LV dysfunction and the only direct comparison of SDLs vs. LLLs among patients with LVSD, both leads showed equal and good long-term performance when used for conduction system pacing.

PO-03-080 OPTIMIZING POST-IMPLANT CRT MANAGEMENT

Implementing a post-implant cardiac resynchronization therapy (CRT) clinic using a combined electrophysiology (EP) & heart failure (HF) advanced practice provider (APP) model may improve subspecialty collaboration & prevent delays in device & medical optimization. Some previously described models evaluate patients 6 months post-procedure. Early follow-up post-implant may further improve response. To determine if a 1 month post-implant device interrogation provides actionable data to improve CRT response at 6 months using a dual-APP multidisciplinary model. We designed a multidisciplinary clinic to formally evaluate patients after CRT device implant. The team involves an advanced HF APP, an EP APP & a HF nurse. Standard device clinic follow up is maintained with the addition of a device interrogation at 1 month to evaluate device function & CRT pacing. Interventions are made at 1 month as necessary. Patients are then seen in the multidisciplinary clinic 6 months following implant & undergo device interrogation, ECG, echocardiogram, & 6-minute walk test. Patients are simultaneously seen by the APPs & a unified plan of care is developed. The electronic medical records were reviewed prospectively for clinical characteristics pre-implant & at 1 & 6 months post-implant, which were summarized with descriptive statistics, including correlation between 1 month data & 6 month CRT response. CRT responders at 6 months were defined as having an LVEF improvement of ≥5% & a reduction in LVESVi ≥10%. Ninety-six patients seen in the clinic from September 2020 to April 2022 were evaluated. The mean age was 70 years; 66 (69%) were male; 40 (42%) had ischemic cardiomyopathy; 53 (56%) had no documented arrhythmia history prior to device implant; 13 (13.5%) were considered to have permanent atrial fibrillation (AF). Of these patients, 52 (54%) were considered CRT responders at 6 months. One month CRT pacing >95% correlated with 6 month CRT response (coefficient of 0.11, std error 0.04, p= 0.01). PVC burden >5% negatively correlated with CRT response (coefficient of 0.15, std error 0.15, p=.02). AF burden did not correlate with CRT response (coefficient of 0.01, std error 0.01, p=0.14). Multivariate analysis did not show these variables to be independently predictive of CRT response. An APP-led, early post-implant evaluation of CRT patients may provide an opportunity to improve six-month CRT response.

A Young Patient Presenting with Dilated Cardiomyopathy and Renal Infarction during Treatment with Isotretinoin: Mere Coincidence or Serious Side Effect of a Drug Commonly Used in Adolescence?

Isotretinoin or 13-cis-retinoic acid (RA) is one of the most effective and widely used drugs for the treatment of severe acne vulgaris. Despite being deemed safe, no definite consensus has been reached on the cardiovascular risk of RA derivatives. We report a case of heart failure due to dilated cardiomyopathy (DCM) and concomitant renal infarction occurring after 5 months of isotretinoin use in a previously healthy 18-year-old male. The patient, with a history of acne vulgaris, presented to our emergency department with left iliac fossa pain and effort dyspnea. A trans-thoracic echocardiogram showed DCM and severely reduced left ventricle ejection fraction (LVEF: 29%). During hospitalization, a total body computed tomography (CT) showed an ischemic lesion in the left kidney. Ischemic, autoimmune, infective, and heritable causes of DCM were ruled out. Cardiac magnetic resonance (CMR) evidenced LV circumferential mid-wall late gadolinium enhancement. Heart failure therapy was promptly started and up-titrated, but only poor LVEF improvement was detected overtime. Our case aims to raise awareness on rare life-threatening cardiovascular events possibly associated with isotretinoin use. To the best of our knowledge, this is the first described case of renal thromboembolism and severe DCM leading to implantable cardioverter-defibrillator (ICD) implantation occurring during isotretinoin treatment.

Corticosteroid in anti-inflammatory treatment of pediatric acute myocarditis: a systematic review and meta-analysis

BackgroundTo evaluate the efficacy of corticosteroids in anti-inflammatory treatment of pediatric acute myocarditis.MethodsWe searched PubMed, Embase and Cochrane library and included studies before October 2022 for clinical trials, observational studies and retrospective studies which reported on children with acute myocarditis treated with corticosteroid anti-inflammatory therapy. The quality of the clinical trials was assessed by Jadad score as an exclusion criterion.ResultsThis systematic review included 6 studies involving 604 pediatric patients with acute myocarditis. Corticosteroid therapy was not associated with reduced risk of mortality due to acute myocarditis (P = 0.53; RR = 0.87; 95% CI = 0.58 to 1.33) compared to anti-failure treatment. There was a significant improvement in pediatric patients’ left ventricular function measured by left ventricular ejection fraction in the group on corticosteroid anti-inflammatory treatment (P = 0.0009; MD = 11.93%; 95% CI = 4.87% to 18.99%). No conclusion can be drawn due to the high heterogeneity in meta-analyses of risk of getting to a clinical endpoint (death or heart transplantation) and changes in left ventricular end-diastolic diameter (LVEDD).ConclusionsCorticosteroid anti-inflammatory therapy in pediatric acute myocarditis patients showed no significant improvement in reducing the risk of mortality, but showed significant improvement in LVEF.

Microvascular obstruction identifies a subgroup of patients who benefit from stem cell therapy following ST-elevation myocardial infarction

Microvascular obstruction (MVO) is associated with greater infarct size, adverse left-ventricular (LV) remodeling and reduced ejection fraction following ST-elevation myocardial infarction (STEMI). We hypothesized that patients with MVO may constitute a subgroup of patients that would benefit from intracoronary stem cell delivery with bone marrow mononuclear cells (BMCs) given previous findings that BMCs tended to improve LV function only in patients with significant LV dysfunction. We analyzed the cardiac MRIs of 356 patients (303 M, 53 F) with anterior STEMIs who received autologous BMCs or placebo / control as part of 4 randomized clinical trials that included the Cardiovascular Cell Therapy Research Network (CCTRN) TIME trial and its pilot, the multicenter French BONAMI trial and SWISS-AMI trials. A total of 327 patients had paired imaging data at 1 year. All patients received 100 to 150 million intracoronary autologous BMCs or placebo / control 3 to 7 days following primary PCI and stenting. LV function, volumes, infarct size and MVO were assessed prior to infusion of BMCs and 1 year later. Patients with MVO (n = 210) had reduced LVEF and much greater infarct size and LV volumes compared to patients without MVO (n=146) (P < .01). At 12 months, patients with MVO who received BMCs had significantly greater recovery of LVEF compared to those patients with MVO who received placebo (absolute difference=2.7%; P < .05). Similarly, left-ventricular end-diastolic (LVEDVI) and end-systolic volume indices (LVESVI) demonstrated significantly less adverse remodeling in patients with MVO who received BMCs compared to placebo. In contrast, no improvement in LVEF or LV volumes was observed in those patients without MVO who received BMCs compared to placebo. The presence of MVO on cardiac MRI following STEMI identifies a subgroup of patients who benefit from intracoronary stem cell therapy.

Reversal of pacing-induced cardiomyopathy after left bundle branch area pacing: a case report

BackgroundConventional right ventricular apex (RVa) pacing increases the risk of pacing-induced cardiomyopathy (PICM), especially in elderly patients with a higher ventricular pacing burden. Left bundle branch area pacing (LBBAP) has been suggested as an alternative to conventional RVa pacing. However, there is a lack of evidence that LBBAP may reverse PICM. We report a case of a reversal of PICM after LBBAP.Case presentationAn 81-year-old woman with a history of complete atrioventricular block and baseline QRS duration of 142 ms received permanent pacemaker implantation with dual pacing. The ventricular lead was placed at the apical direction and paced QRS duration was 146 ms. After 8 months, the patient visited with acute heart failure. The patient’s ventricular pacing burden was > 99%, and echocardiography found severe depression of left ventricular ejection fraction (LVEF, 30%), left ventricular dyssynchrony, and global hypokinesia. Despite 3 months of optimal medical management of heart failure, there was minimal improvement in LVEF (35%) and ventricular dyssynchrony persisted. The patient's presentation was consistent with PICM. LBBAP was performed with a stylet-driven lead and a delivery sheath (Biotronik Selectra 3D, Biotronik, Berlin, Germany). The lead was placed at the area of the left bundle branch trunk and non-selective LBBAP was achieved with a left ventricular activation time of 71 ms, paced QRS duration of 110 ms, and bipolar stimulation to QRS end of 136 ms. After a month, echocardiography found improved LVEF (53%) and N-terminal Pro-B-Type natriuretic peptide was decreased from 1011 to 645 pg/mL. The patient was relieved from dyspnea.ConclusionsWe report a case that PICM was resolved after LBBAP. LBBAP could be a rescue therapy for PICM induced by conventional RVa pacing.

Catheter ablation improved ejection fraction in persistent AF patients: a DECAAF-II sub analysis.

The aim of our study was to assess differences in post-ablation atrial fibrillation (AF) recurrence and burden and to quantify the change in LVEF across different congestive heart failure (CHF) subcategories of the DECAAF-II population. Differences in the primary outcome of AF recurrence between CHF and non-CHF groups was calculated. The same analysis was performed for the three subgroups of CHF and the non-CHF group. Differences in AF burden after the 3-month blanking period between CHF and non-CHF groups was calculated. Improvement in LVEF was calculated and compared across the three CHF groups. Improvement was also calculated across different fibrosis stages. There was no significant differences in AF recurrence and AF burden after catheter ablation between CHF and non-CHF patients and between different CHF subcategories. Patients with heart failure with reduced ejection fraction (HFrEF) experienced the greatest improvement in EF following catheter ablation (CA, 16.66% ± 11.98, P < 0.001) compared to heart failure with moderately reduced LVEF, and heart failure with preserved EF (10.74% ± 8.34 and 2.00 ± 8.34 respectively, P-value < 0.001). Moreover, improvement in LVEF was independent of the four stages of atrial fibrosis (7.71 vs. 9.53 vs. 5.72 vs. 15.88, from Stage I to Stage IV respectively, P = 0.115). Atrial fibrillation burden and recurrence after CA is similar between non-CHF and CHF patients, independent of the type of CHF. Of all CHF groups, those with HFrEF had the largest improvement in LVEF after CA. Moreover, the improvement in ventricular function seems to be independent of atrial fibrosis in patients with persistent AF.

Prognostic role of pulmonary hemodynamics before transcatheter aortic valve replacement among patients with severe aortic stenosis.

Pulmonary hypertension (PH) frequently co-exists in patients with severe aortic stenosis (AS). In this study, we sought to identify the implications of invasive pulmonary hemodynamics on major adverse cardiac events (MACE), biventricular function and NYHA functional class after transcatheter aortic valve replacement (TAVR). Invasive hemodynamics via right heart catheterization (RHC) were performed pre-TAVR. Patients were stratified per mean PA pressure (mPAP), diastolic pulmonary gradient (DPG) and pulmonary vascular resistance (PVR), and followed at 1-month and 1-year intervals up to 6 years. MACE outcomes included cardiovascular death and heart failure hospitalizations post-TAVR. Among 215 patients, Kaplan-Meir estimates demonstrated an increased 1-year risk of MACE from 8% among those without pre-TAVR PH to 27% among patients with pre-existing PH. Specifically, the MACE risk was 32% among PH patients with PVR ≥ 3WU (p=.04) and 53% among PH patients with DPG ≥ 7 mm Hg (p < .01). On univariate Cox regression, RV stroke work index (RVSWI) (HR,1.02; p=.02), and pulmonary hemodynamic index (PHI) (HR,1.27; p=.047) were identified as additional predictors of MACE post-TAVR. On multivariable Cox regression analysis, SvO2 (HR, 0.95; p=.01) and PVR (HR, 1.2; p=.04) were demonstrated as predictive of MACE post-TAVR. A significant improvement in LVEF (2-Factor ANOVA, p < .01) and RV fractional area change (RVFAC%) (p < .01) was noted as assessed at baseline, 1-month and 1-year follow up post-TAVR. There was a significant interaction between pre-TAVR PH status and time post procedure with respect to NYHA functional class (p=.03), that is, the manner and degree of change in NYHA class over time depended on pre-TAVR PH status. Defining invasive pulmonary hemodynamics, such as mPAP, PVR, and DPG among patients with severe AS undergoing TAVR has significant prognostic implications. Routine risk stratification by utilizing invasive hemodynamics can better identify patients who will have functional improvement and improved outcomes post-TAVR.

Comparison of his bundle pacing versus biventricular pacing in heart failure: a systematic review and meta-analysis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Despite optimal medical treatment, the 5-years mortality and HF readmission rate was 75.3% and 48.5%, respectively. The current guidelines recommended cardiac resynchronization therapy (CRT) by implanting biventricular pacing (BVP) for specific group of patients with HF with reduced ejection fraction (HFrEF) in order to reduce the mortality and the risk of HF events by 34%. However, 20% to 40% patients might not respond or even get clinical deterioration after receiving such device. To overcome the non-responders, His bundle pacing (HBP) emerges recently as one of the therapeutic options. His bundle pacing implantation potentially results in the narrower QRS duration as well as more improvement in left ventricle (LV) function compared with BVP in patients with LBBB. On top of that, HBP might become a more cost-effective solution, compared to CRT, particularly for the majority of developing countries in Asia. Purpose We aim to elaborate the clinical efficacy of HBP in specific patients with HF, compared to BVP. This HBP was implanted either as a primary therapeutic strategy for CRT candidates or as a rescue strategy for BVP non-responders. Methods This study is registered. A structured search was conducted in Pubmed, Embase, and Clinicaltrial.gov. Inclusion criteria were: Age &amp;gt;18 years old, NYHA II-IV, QRS duration ≥120 milliseconds, and left (LBBB) or right bundle branch block (RBBB) morphology. The primary endpoints were change in QRS duration, improvement in LVEF, improvement in NYHA class, and cardiovascular (CV) event. Results A total of 8 final articles involving 361 HF patients were included for analysis, with a male preponderance. The QRS duration was significantly narrower in HBP (MD: -23.44; 95%CI -34.92 to -11.97; P&amp;lt;0.001) compared to BVP. There was no statistically significant LVEF improvement between HBP group and BVP group in HF patients who were CRT candidates (MD: 4.63; 95%CI -4.47 to 13.74; P=0.32). The improvement in NYHA class varied between studies. One study reported comparable improvement between HBP and BVP, while another study reported better improvement in HBP compared to BVP. In terms of CV outcome, there was no significant difference in CV hospitalization and mortality rate. Heart failure hospitalization occurred both in HBP and BVP group, but the difference was not significant between groups. Improvement in QRS duration, LVEF, and NYHA class occurred in both LBBB and RBBB. Conclusion(s) HBP provides better electrical resynchronization compared to BVP. Additionally, some degree of reverse LV remodelling was also observed in HBP group of patients with either LBBB and RBBB patterns. However, the benefits of HBP in reducing HF hospitalization and CV mortality remain indeterminate. Further RCTs with large samples are still required to evaluate the superiority of HBP, compared to BVP for CRT, in reducing mortality and HF hospitalization.

Left ventricular systolic dysfunction during acute pulmonary embolism

BackgroundHeart failure increases the risk of death in acute pulmonary embolism (PE). The role of the left ventricle (LV) in acute PE is not well defined. ObjectiveTo identify the prevalence of LV systolic dysfunction, morphology, and prognosis of the LV during an acute PE. MethodsRetrospective study (26-months) of patients diagnosed with an acute PE presenting with LV systolic dysfunction at the University of Maryland. ResultsAmong 769 acute PE patients, 78 (10.5 %) had LV systolic dysfunction and 42 (53.8 %) had history of cardiac disease. Patients without history of cardiac disease were younger (mean age [SD] 54.9 [16.8] vs. 62.6 [16.6]; p = 0.04), had a higher BMI (31.2 [12.2] vs. 29.2 [7.7]; p = 0.005), and less hypertension (20 [34.5 %] vs. 38 [65.5 %]; p = 0.0005).A massive PE was most common in patients without history of cardiac disease (8[22.2 %] vs. 2[4.7 %], p = 0.02). There was no difference in clot burden, but right ventricular strain was more frequently seen in patients without history cardiac disease in the initial CT (p = 0.001). The median troponin and lactate were similar in both groups.In 41 patients with follow-up echocardiograms, improvement in LVEF% was observed in patients without cardiac history (median Δ LVEF% [IQR]; 20 [6.2–25.0]). While patients with cardiac disease did not demonstrate similar changes (median Δ LVEF% [IQR]; 0 [−5–17.5]; p = 0.01). In hospital mortality was 12.8 % with no difference between both groups (p = 0.17). ConclusionPulmonary embolism can be associated with LV systolic dysfunction, even in patients without history of cardiac disease.

Levosimendan in outpatients with advanced heart failure: Single-center experience of 200 intermittent perfusions

IntroductionPatients with advanced heart failure (HF) have high morbidity and mortality, with only a small proportion being eligible for advanced therapies. Intermittent outpatient levosimendan infusion has been shown to provide symptomatic relief and reduce the rate of HF events. Our aim was to assess the safety and efficacy of outpatient levosimendan administration in an advanced HF population. MethodsThis is a report of a single-center experience of consecutive advanced HF patients referred for intermittent intravenous outpatient administration of levosimendan, between January 2018 and March 2021. Baseline and follow-up evaluation included clinical assessment, laboratory tests, transthoracic echocardiography and cardiopulmonary exercise testing. Baseline and clinical follow-up data were compared using the Wilcoxon signed-rank test. ResultsA total of 24 patients (60.8 years, 83% male, mean left ventricular ejection fraction [LVEF] 24%), with a median of 1.5 HF hospitalizations in the previous six months, were referred for outpatient levosimendan pulses, the majority as a bridge to transplantation or due to clinical deterioration. At six-month follow-up there was a significant reduction in HF hospitalizations to 0.4±0.7 (p<0.001). NYHA class IV (52.2% to 12.5%, p=0.025) and NT-proBNP (8812.5 to 3807.4 pg/ml, p=0.038) were also significantly reduced. Exercise capacity was significantly improved, including peak oxygen uptake (p=0.043) and VE/VCO2 slope (p=0.040). LVEF improved from 24.0% to 29.7% (p=0.008). No serious adverse events were reported. ConclusionRepeated levosimendan administration in advanced HF patients is a safe procedure and was associated with a reduction in HF hospitalizations, functional and LVEF improvement, and reduction in NT-proBNP levels during follow-up.

Resynchronization effects and clinical outcomes during left bundle branch area pacing with and without conduction system capture.

Left bundle branch area pacing (LBBAP) includes left bundle branch pacing (LBBP) and left ventricular (LV) septal myocardial pacing (LVSP). The study aimed to assess resynchronization effects and clinical outcomes by LBBAP in heart failure (HF) patients with cardiac resynchronization therapy (CRT) indications. LBBAP was successfully performed in 29 consecutive patients and further classified as the LBBP-group (N = 15) and LVSP-group (N = 14) based on the LBBP criteria and novel LV conduction time measurement (LV CT, between LBBAP site and LV pacing (LVP) site). AV-interval optimized LBBP or LVSP, or LVSP combined with LVP (LVSP-LVP) was applied. LV electrical and mechanical synchrony and clinical outcomes were assessed. All 15 patients in the LBBP-group received optimized LBBP while 14 patients in the LVSP-group received either optimized LVSP (5) or LVSP-LVP (9). The LV CT during LBBP was significantly faster than that during LVP (p < .001), while LV CT during LVSP were similar to LVP (p = .226). The stimulus to peak LV activation time (Stim-LVAT, 71.2 ± 8.3 ms) and LV mechanical synchrony (TSI-SD, 35.3 ± 9.5 ms) during LBBP were significantly shorter than those during LVSP (Stim-LVAT 89.1 ± 19.5 ms, TSI-SD 49.8 ± 14.4 ms, both p < .05). Following 17(IQR 8) months of follow-up, the improvement of LVEF (26.0%(IQR 16.0)) in the LBBP-group was significantly greater than that in the LVSP-group (6.0%(IQR 20.8), p = .001). LV activation in LBBP propagated significantly faster than that of LVSP. LBBP generated superior electrical and mechanical resynchronization and better LVEF improvement over LVSP in HF patients with CRT indications.

A new composite indicator consisting of left ventricular extracellular volume, N-terminal fragment of B-type natriuretic peptide, and left ventricular end-diastolic volume is useful for predicting reverse remodeling after catheter ablation for atrial fibrillation.

Recently, myocardial extracellular volume (ECV) analysis has been measurable on computed tomography (CT) using new software. We evaluated the use of cardiac CT to estimate the myocardial ECV of left ventricular (LV) myocardium (LVM) to predict reverse remodeling (RR) in cases of atrial fibrillation (AF) after catheter ablation (CA). Four hundred and seven patients underwent CA for AF in our institution from April 2014 to Feb 2021. Of these, 33 patients (8%) with an LVEF ≤ 50% and who had undergone CT were included in our study. We estimated the LVM ECV using commercial software to analyze the CT data. RR was defined as an improvement in LVEF to > 50% after CA. LVEF increased to > 50% in 24 patients (73%) after CA. In all 24 patients, LVM ECV, LV end-diastolic and end-systolic volumes (LVEDV and LVESV), and the n-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP) were significantly lower than in the other nine patients (P = 0.0037, 0.0273, 0.0443, and < 0.0001). On receiver operating characteristic curve analysis, the best cut-off of ECV, LVEDV, LVESV and NT-proBNP for the prediction of RR were 37.73%, 120mL, 82mL, and 1267pg/mL, respectively. We newly defined the ENL (ECV, NT-proBNP, and LVEDV) score as the summed score for the presence or absence (1 or 0; maximum score = 3) of ECV, NT-proBNP, and LVEDV values less than or equal to each best cut-off value, and found that this score gave the highest area under the curve for the prediction of RR (0.9583, P < 0.0001). The ENL score may be useful for predicting RR in patients with AF undergoing CA.

1151 MYOCARDIAL VIABILITY IN PATIENTS WITH ISCHEMIC LEFT VENTRICULAR DYSFUNCTION: A CARDIAC MAGNETIC RESONANCE SINGLE-CENTRE EXPERIENCE

Abstract Background Whether assessment of myocardial viability (MV) by delayed enhancement cardiac magnetic resonance (DE-CMR) can help identify patient with severe ischemic left ventricular (LV) disfunction who might benefit from coronary revascularization has not been yet clearly established. Moreover, although improvement in LV function is one of the heart failure treatment goal, its prognostic implication remains controversial. Methods We retrospectively evaluated all consecutive patients with a LV ejection fraction (EF) of 35% or less and extensive coronary artery disease undergoing DE-CMR for assessment of MV in our Department from November 2013 to December 2020. DE-CMR was routinely prescribed before any heart team indication, either coronary intervention (surgical or percutaneous) plus optimal medical therapy (OMT) or OMT only. Quantification of DE was determined visually by comparing the ratio of the thickness of infarcted myocardium to that of total wall thickness within a given segment. A dysfunctional segment (hypokinetic/akinetic) was considered viable when DE transmurality was ≤50%. Accordingly, a patient was considered to have MV when ≥4 dysfunctional but viable segments were present. The primary end point was death from any cause. Secondary end point was improvement in LVEF during follow-up, defined as an increase in LVEF class compared to baseline. Results Of the 70 patients (64 males, median age 67 years [62-75], median LVEF 27% [21-30]) enrolled, 46 (66%) underwent coronary revascularization, of which 16 with surgery and 30 with percutaneous intervention. Only 16 procedures were considered complete, fully revascularizing all diseased vessels and dysfunctional segments. The baseline clinical characteristics (including age, diabetes, eGFR, peripheral vascular disease, LVEF, LV end diastolic volume, and Syntax score) of revascularized patients did not differ significantly to those receiving OMT only, except for number of viable segments, which were significantly higher in patients undergoing revascularization (p=0.017). Over a median follow-up of 31 months (18-45), 15 patients (21%) died. Revascularization plus OMT was associated with a lower incidence of death from any cause than OMT only group (hazard ratio, 0.26; 95% CI 0.09-0.74; p=0.01). However, no significant interaction was observed between the presence/absence of MV and the beneficial effect of revascularization (p=0.39). Improvement in LVEF was observed only among patients with MV, irrespective of treatment assignment (p=0.02). However, survival did not differ significantly between patients who had improvement in LVEF from those who did not have such improvement (logRank p=0.81) Conclusion Among patients with severe ischemic LV systolic dysfunction, coronary revascularization plus OMT was beneficial in prolonging survival, compared to OMT only. However, this beneficial effect was not driven by MV. Furthermore, although increase in LVEF was more likely to occur among patients with MV, such improvement was not related to long-term survival.

941 SARCOIDOSIS: THE IMPORTANCE OF MULTIMODALITY IMAGING

Abstract A 55-years old sporty man, without any cardiovascular risk factors nor previously known cardiological history, presented for a cardiological evaluation due to extra-systolic palpitations and dyspnea. The ECG documented a new onset of right bundle branch block, left anterior fascicular block and first degree of atrio-ventricular block. Echocardiography revealed severe left ventricular (LV) systolic dysfunction (LV ejection fraction -EF- 34%), showing also right ventricular (RV) dilatation and disfunction. A 24-hour Holter monitoring did not show any significant arrhythmias and maximal stress test did not reveal any ECG changes nor arrhythmias. Cardiac magnetic resonance (CMR) confirmed the presence of severe biventricular dysfunction; multiple areas of edema and late gadolinium enhancement (LGE) were observed, with ischemic and nonischemic pattern and extensive involvement of the RV and the interventricular septum. In the suspicion of cardiac sarcoidosis a 18-fluorodeoxyglucose positron emission tomography (PET) was performed, confirming the presence of an inflammatory cardiomyopathy in an active phase. A subsequent endomyocardial biopsy was performed, which demonstrated the presence of non-caseating granulomas, signs of inflammation and fibrosis, consistent with the diagnosis of cardiac sarcoidosis. No signs of extra-cardiac involvement were present. The patient started anti-inflammatory therapy with Prednisone and Metotrexate, along with anti-neurohormonal therapy. However, due to a significant increase in ventricular arrhythmic burden, an implantable cardioverter defibrillator was placed during early follow-up, and Amiodarone therapy was started. After 5 months of medical therapy, PET scan showed a marked reduction of cardiac inflammation and echocardiography showed a significant LVEF improvement (from 34% to 43%). After slow tapering of steroid therapy Prednisone was stopped, whereas Metotrexate, Amiodarone and anti-neurohormonal therapy were maintained. Follow-up is still ongoing without clinical events. Sarcoidosis is a systemic inflammatory disease characterized by the presence of non-caseating granulomas in multiple organs. Cardiac involvement is associated with higher incidence of heart failure, ventricular arrhythmias and all-cause mortality. Isolated cardiac involvement is rare but associated with worse prognosis. Multimodality imaging is of paramount importance for the diagnosis and monitoring therapy.

Beta-blockers and mechanical dyssynchrony in heart failure assessed by radionuclide ventriculography

BackgroundRadionuclide ventriculography (RNVG) can be used to quantify mechanical dyssynchrony and may be a valuable adjunct in the assessment of heart failure with reduced ejection fraction (HFrEF). The study aims to investigate the effect of beta-blockers on mechanical dyssynchrony using novel RNVG phase parameters. MethodsA retrospective study was carried out in a group of 98 patients with HFrEF. LVEF and dyssynchrony were assessed pre and post beta-blockade. Dyssynchrony was assessed using synchrony, entropy, phase standard deviation, approximate entropy, and sample entropy from planar RNVG phase images. Subgroups split by ischemic etiology were also investigated. ResultsAn improvement in dyssynchrony and LVEF was measured six months post beta-blockade for both ischemic and non-ischemic groups. ConclusionsA significant improvement in dyssynchrony and LVEF was measured post beta-blockade using novel measures of dyssynchrony.

Abstract 10573: Left Ventricular Structure, Function, and Clinical Outcomes in Methamphetamine-Associated Heart Failure

Introduction: Methamphetamine use and overdose deaths are increasing. People who use methamphetamine are at risk for methamphetamine-associated heart failure (meth-HF). Cardiac fibrosis has been reported in nonischemic cardiomyopathies, but the role of cardiac fibrosis and other factors underlying the pathophysiology and reversibility of meth-HF remain unknown. Methods: Participants with meth-HF were recruited into a prospective cohort at a safety net hospital in San Francisco. Data collection included medical history, clinical outcomes, longitudinal echocardiograms (TTEs), markers of inflammation and fibrosis, and cardiac magnetic resonance imaging (CMR). Outcomes included mortality, changes in LVEF, and hospital readmission. Results: Forty-six participants enrolled: median age 51 years, 83% male, 41% Black, 20% Asian, 33% unstably housed, 76% actively using methamphetamine. Baseline TTEs demonstrated LV dilation (median LVIDd 5.7cm, LVIDs 4.7cm) and severely reduced LV systolic function (LVEF&lt;30% in 62%). After median 9 months follow-up, 13% were deceased. Compared to survivors, baseline LV dimensions were larger (mean LVIDd 6.7 vs 5.5cm, p&lt;0.05; LVIDs 6.1 vs 4.5cm, p&lt;0.05) and LVEF was lower (mean 19% vs 29%, p&lt;0.05) among those who died. At baseline, smaller LV size, higher LVEF, and guideline-directed medical therapy (GDMT) were more common in those with LVEF improvement &gt;10% (Fig). CMRs were often abnormal with late gadolinium enhancement and elevated extracellular volume, but there was no clear association with LV recovery. Conclusions: Despite their young age, the meth-HF population has a high mortality rate and severely reduced LVEF with LV dilation. Smaller LV size, higher LVEF, and GDMT were more common in those with LVEF improvement. These findings suggest that early identification and treatment of heart failure in people who use methamphetamine, along with drug cessation, may be associated with reversibility and improved outcomes.

99mTc-sestamibi and 18F-fluorodeoxyglucose imaging in patients with cardiogenic shock: A pilot study.

Whether perfusion/metabolism imaging differs between matched ST-segment elevation myocardial infarction (STEMI) patients with and without cardiogenic shock (CS) remains unknown. Seventeen STEMI patients with CS (13 men, 60 ± 12 years) and 16 matched STEMI patients without CS (15 men, 54 ± 15 years) were prospectively recruited. All patients underwent baseline 99mTc-sestamibi/18F-fluorodeoxyglucose (FDG) imaging and echocardiography 6 ± 2 days post-infarction. Nine patients with CS and seven without CS had repeated imaging 98 ± 7 days post-infarction. The total perfusion deficit (TPD) and total FDG uptake deficit (TFD) were calculated to assess the percentages of impaired perfusion and metabolism over the left ventricle. Patients were followed up for 337 days (213-505 days) and the major adverse cardiac events (MACE) were recorded. TPD was greater in patient with CS and was independently related to the presence of CS (OR: 4.36, p = 0.013). Both acute- and convalescent TFD were inversely related to the improvement ratio of LVEF (r-values: -0.62, -0.73; both p < 0.05). MACE occurred in 16 patients (10 CS and 6 non-CS), and acute TFD was predictive of MACE in those with CS (HR: 2.06, p = 0.038). In this pilot study, we demonstrated that STEMI patients with CS had a significantly increased TPD, which was relevant to the presence of CS. Acute TFD was associated with improvement in LVEF, and was predictive of MACE in patients with CS.

Abstract 13470: Circulating microRNA-122-5p is Associated With a Lack of Improvement in Left-Ventricular Function After Transcatheter Aortic Valve Replacement and Regulates Viability of Cardiomyocytes via Extracellular Vesicles

Transcatheter aortic valve replacement is a well-established treatment option for high- and intermediate-risk patients with severe symptomatic AVS. However, a specific role for circulating microRNAs in the improvement of cardiac function for patients after TAVR has not yet been investigated. Methods: Circulating EV-associated miRNAs were investigated by using an unbiased Taqman-based human miR array. Several EV-miRNAs were significantly deregulated in AVS patients on day seven after TAVR in comparison to the pre-procedural levels in patients without LVEF-improvement. The higher levels of miR-122-5p were negatively correlated with LVEF improvement at both day seven (r=-0.264 and p=0.015) and at six months (r=-0.328 and p=0.0018). Results: By utilization of patient-derived samples and a murine AVS model, we observed that the expression of miR-122-5p correlates negatively with cardiac function, which is associated with LVEF. Graded wire-injury-induced AVS mice demonstrated a higher level of miR-122-5p, which was related to cardiomyocyte dysfunction. Murine ex vivo experiments revealed that miR-122-5p is highly enriched in ECs in comparison to cardiomyocytes. Co-culture, copy-number analysis, and immunofluorescence demonstrated that miR-122-5p can be shuttled via large EVs from ECs into cardiomyocytes. Gain- and loss-of-function suggested that EV-shuttling of miR-122-5p increases the level of miR-122-5p in recipient cardiomyocytes. Mechanistically, mass spectrometry, miR-pull down, EMSA, and RNA-IP experiments confirmed that miR-122-5p interacts with the RBP, hnRNPU, in a sequence-specific manner to encapsulate miR-122-5p into large EVs. Upon shuttling, miR-122-5p reduces the expression of the anti-apoptotic gene BCL2 , by binding to its 3' untranslated region to inhibit its translation. Conclusion: Increased levels of circulating pro-apoptotic EV-incorporated miR-122-5p are associated with reduced LVEF after TAVR.