Median Ejection Fraction Research Articles

The problem of pulmonary arterial hypertension in end-stage renal disease: can peritoneal dialysis be the solution

BackgroundPulmonary arterial hypertension (PAH) in the setting of end-stage renal disease (ESRD) has important prognostic and therapeutic consequences. We estimated the prevalence of PAH among patients with ESRD treated with automated peritoneal dialysis (APD), investigated the effect of different variables and compared pulmonary artery pressure and cardiac function at the beginning and end of the study.MethodsThis is a 5-year study in which 31 ESRD patients on APD were recruited after fulfilling inclusion criteria. Blood samples were collected from all patients for the biochemical and hematological data at the beginning of the study and every month and at the study termination. Total body water (TBW) and extracellular water (ECW) were calculated using Watson’s and Bird’s calculation methods. All patients were followed-up at 3-month interval for cardiac evaluation. Logistic regression analysis was used to assess the relation between different variables and PAH.ResultsThe mean age of the study population (n = 31) was 51.23 ± 15.24 years. PAH was found in 24.2% of the patients. Mean systolic pulmonary artery pressure (sPAP) and mean pulmonary artery pressure (mPAP) were significantly higher in the APD patients at study initiation than at the end of the study (40.75 + 10.61 vs 23.55 + 9.20 and 29.66 + 11.35 vs 18.24 + 6.75 mmHg respectively, p = 0.001). The median ejection fraction was significantly lower in patients with PAH at zero point than at study termination [31% (27-34) vs 50% (46-52), p = 0.002]. Hypervolemia decreased significantly at the end of study (p < 0.001) and correlated positively with the PAP (r = 0.371 and r = 0.369), p = 0.002). sPAP correlated with left ventricular mass index, hemoglobin level, and duration on APD.ConclusionsLong term APD (> 1 years) seemed to decrease pulmonary arterial pressure, right atrial pressure and improve left ventricular ejection fraction (LVEF). Risk factors for PAH in ESRD were hypervolemia, abnormal ECHO findings and low hemoglobin levels. Clinical and echocardiographic abnormalities and complications are not uncommon among ESRD patients with PAH. Identification of those patients on transthoracic echocardiography may warrant further attention to treatment with APD.

10-year single center experience of catheter ablation of focal atrial tachycardia.

Focal atrial tachycardias (ATs) represent 5-15% of sustained supraventricular tachycardias (SVTs). Characteristic distribution of sites of origin and detailed electrophysiologic characterization of AT from specific sites of origin (SOO) have been described. Acute success and recurrence are less favorable than for other SVTs. In this series, we present our experience of focal AT ablation over a 10-year period. We undertook a retrospective review of an electronically maintained database of all patients undergoing AT ablation at our institution between January 2011 and December 2020. Demographic, procedural, and outcomes data were reviewed. A total of 293 distinct atrial tachycardias were treated during 279 procedures in 256 patients, including 207 first AT ablations. Acutely successful AT suppression was achieved in 91% of first-time ablations. Acute success was dependent on SOO of AT with lowest rates of acute suppression in the para-Hisian region and the crista terminalis (CT). The most common reason for failure to acutely suppress the AT was proximity to a critical structure (phrenic nerve, sinus node, and AV node). 8.9% of patients in this series presented with a tachycardia-mediated cardiomyopathy (TCM). 48% of TCM patients underwent an ablation attempt during an acute medical admission. Among the TCM group, median LV ejection fraction increased from 25% (range 10-50%) to 55% (range 35-65%) with successful treatment of AT. Five patients undergoing a repeat procedure had planned pericardial access for displacement of the phrenic nerve to permit ablation of the AT, which was successful in all cases. Among patients without a pre-existing diagnosis of AF, peri-procedural AF was not associated with a higher incidence of a subsequent diagnosis of AF (odds ratio 1.169, 95% CI 0.4058-3.475, p = 0.7628). Median duration of follow-up was 832days. By Kaplan-Meier estimate, recurrence-free survival was 78% (95% CI 67-88%). In this series, focal AT ablation is associated with good acute results and a low rate of complications, but outcomes remain less favorable than previously reported for other forms of SVT.

Abstract 10151: Detection of Cardiac Involvement in Eosinophilic Granulomatosis With Polyangiitis (EGPA) With Multiparametric Cardiovascular Magnetic Resonance (CMR)

Background: EGPA is a rare small-vessel vasculitis. Cardiovascular (CV) involvement is an important predictor of adverse outcomes but is challenging to detect. CMR is as an excellent tool to detect cardiac EGPA but is not widely available. It is unknown who would benefit most from comprehensive CV assessment with CMR. We aimed to determine the prevalence of cardiac EGPA with multiparametric CMR and to identify potential clinical/biochemical predictors of CV involvement. Methods: This single-center study was performed in EGPA patients who underwent CMR as part of routine clinical evaluation including comprehensive tissue characterization with T1 mapping, T2-STIR, T2 mapping, and late gadolinium enhancement imaging, in accordance with SCMR guidelines. Results: Sixty-three EGPA patients were included (Table 1). CV involvement (defined by typical LGE, LV dysfunction or pericardial inflammation) was seen in 37%. The median LV and RV ejection fraction was 58% and 57%. Two (3%) patients demonstrated increased T2 signal and mapping values, suggesting acute cardiac injury. LGE was present in 18 (29%) patients with a predominant pattern of subendocardial fibrosis. Patients with CV involvement were younger when diagnosed with EGPA, had higher NT-pro-BNP level (sensitivity 30%, specificity 98%) and lower EF (sensitivity 48%, specificity 100%) (Table 1). Troponin levels were not predictive of CV involvement (Table 1) as defined by positive CMR. Conclusion: Clinical and biochemical markers had low sensitivity for detecting cardiac involvement which was present in over a third of patients. CMR is necessary to detect cardiac involvement and should be considered part of the baseline evaluation of patients with EGPA.

Abstract 15243: Incidence and Predictors of Chemotherapy-Induced Cardiomyopathy in African Americans: A Single-Center Experience

Introduction: African Americans (AA) have largely been under-represented in randomized clinical trials investigating chemotherapy-induced cardiomyopathy (CICM) associated with doxorubicin and trastuzumab. Limited and conflicting evidence has linked higher incidence of CICM among AA patients to a higher prevalence of underlying co-morbidities. Hypothesis: African Americans have a higher incidence of CICM which is associated with higher prevalence of underlying co-morbidities in these patients. Methods: We retrospectively identified and included AA patients who underwent treatment with doxorubicin and trastuzumab at our institution. CICM was defined as a decline in ejection fraction (EF) to &lt;50% OR &gt;/=10% decline in baseline EF post-treatment. A univariate analysis was performed to study the association of common co-morbidities with CICM. JMP software (SAS v 9.4) was used for statistical analysis. Results: A total of 121 patients were included for analysis, out of which, 52.1% (63/121) and 47.9% (58/121) were treated with trastuzumab and doxorubicin respectively. Majority (85.1%, 103/121) were females and the mean age was 62.4±5.2 years. Median EF pre- and post-treatment were 65% (IQR 60%,65%) and 60% (IQR 55%,65%) respectively. The cumulative incidence of CICM in our cohort was 24% (29/121). There was no statistically significant association of CICM with female sex [OR=0.79 (0.25-2.99), p=0.68], age [OR=0.99 (0.96-1.02), p=0.88], pre-treatment EF [OR=1.09 (0.96-1.94), p=0.27], hypertension [OR=1.27 (0.51-3.18), p=0.60], diabetes [OR=1.91 (0.89-4.95), p=0.13], hyperlipidemia [OR=1.19 (0.44-2.92), p=0.78] or coronary artery disease [OR=1.93 (0.68-5.93), p=0.21]. Conclusions: Per existing literature, the incidence of CICM in our cohort of AA patients is higher than general population. As historically postulated, CICM was not found to be associated with pre-existing co-morbidities. Further clinical and translational research is needed to study genetic and pathophysiological mechanisms driving CICM in AA patients.

Survival and readmission among patients with advanced cardiomyopathy undergoing transcatheter edge-to-edge mitral valve repair:Are we applying COAPT findings too broadly?

Transcathether edge-to-edge mitral valve repair (TEER) has been shown to be an effective treatment for secondary mitral regurgitation (MR). However, the outcomes of TEER in patients with severe cardiomyopathy is less clear. The objective of this study is to determine the outcomes of such patients who underwent TEER at our institution. A retrospective review of patients with severe cardiomyopathy, defined as ejection fraction ≤30% or the requirement of inotropic support preoperatively, undergoing TEER for secondary MR at our institution from 11/2016 to 11/2020 was performed. Univariate analysis associating preoperative characteristics with our primary endpoint of 1-year death or orthotopic heart transplant (OHT) was performed. Kaplan-Meier analysis was conducted for the composite outcome of death or OHT, as well as for heart failure-related readmission. Finally, an assessment of changes in MR severity from the preoperative, to immediate postoperative period, to 30-day postoperative period was conducted. There were 48 patients identified. Median age was 74.5 years (IQR 65.5-79.5), median ejection fraction was 21.5% (IQR 16.0-27.5), and 81.4% of patients had severe or torrential mitral regurgitation preoperatively. The composite endpoint of 1-year mortality or OHT occurred in 15 of 48 patients (31.3%, 14 deaths and 1 OHT). One-year heart failure readmission rate was 47.9%. Mortality or OHT at 2 years occurred in 45.8%. Patients at extremes of heart failure who underwent TEER had poor outcomes when assessed at 1-year. Our study may suggest that the results of cardiovascular outcomes assessment of the mitraclip percutaneous therapy for heart failure patients with secondary mitral regurgitation may not be applicable to patients with severe cardiomyopathy.

The association between non-HDL cholesterol and SYNTAX score in premature heart disease

&lt;b&gt;Aim: &lt;/b&gt;This study aimed to estimate the association of coronary artery disease complexity with non-HDL-C levels in premature CAD.&lt;br /&gt; &lt;b&gt;Background: &lt;/b&gt;Primary prevention has utmost importance in terms of minimizing the number of patients who had premature coronary artery disease (CAD). Non-high density lipoprotein cholesterol (non-HDL-C) contains potentially atherogenic lipoprotein fractions.&lt;br /&gt; &lt;b&gt;Material and methods&lt;/b&gt;: Coronary angiographic recordings of two hundred acute coronary syndrome patients were evaluated by two cardiologists. Clinical, demographic and lipid parameters of the patients were compared with SYNTAX score.&lt;br /&gt; &lt;b&gt;Results&lt;/b&gt;: Median age of the study group was 41 (18-45) years. One hundred eighty five (90.5%) of them were male, nineteen (9.5%) of them were female. Median SYNTAX score and ejection fraction of the patients were 17 (4.5-39) and 50 (33-68), respectively. SYNTAX score of the male patients was significantly higher compared to females [17 (4.5-39) vs 12 (8-26), p=0.048), similarly, diabetic patients had higher values of syntax score compared to non-diabetic patients [19 (10-39) vs 16 (4.5-37), p=0.005), There were no differences of SYNTAX score with respect to presence of hypertension, smoking status and family history of CAD. &amp;nbsp;There were very strong positive correlation between SYNTAX score and non-HDL-C, TC and LDL-C levels (r=0.958, r=0.946 and r=0.921, respectively, p&amp;lt;0.001 for all).&amp;nbsp;&amp;nbsp; HgA1c levels showed positive correlation, whereas HDL-C showed negative correlation with SYNTAX score (r=0.793 and r=-0.620, respectively, p&amp;lt;0.001 for both).&lt;br /&gt; &lt;b&gt;Conclusion&lt;/b&gt;: non-HDL-C was a valuable tool in assessing the complexity of atherosclerotic cardiovascular disease in young patients.

Exercise-induced changes in pulmonary artery wedge pressure in adults post-Fontan versus heart failure with preserved ejection fraction and non-cardiac dyspnoea.

Despite their universal predisposition, diagnosing diastolic dysfunction in patients post-Fontan palliation is challenging. Our aim was to compare exercise haemodynamics between adults post-Fontan and patients with heart failure with preserved ejection fraction (HFpEF) and non-cardiac dyspnoea (NCD). Twenty-four adults (age ≥18 years) post-Fontan palliation with resting and exercise pulmonary artery wedge pressure (PAWP) measured during supine biking were identified. Forty-eight patients with HFpEF and 48 with NCD diagnosed at catheterization were selected for comparison. Mean age for Fontan patients was 30.3 ± 7.5 years; median ventricular ejection fraction was 52.5% (45-55.8), being <50% in 37.5%. Resting PAWP among Fontan patients was 10.2 ± 3.5 mmHg (>12 mmHg in 25%); PAWP was lower in Fontan patients than in HFpEF but higher than NCD. During exercise, PAWP was lower in the Fontan group than HFpEF (22.5 mmHg [19.3-28] vs. 28.2 ± 6.3; p=0.0006) but higher than NCD (11.2 ± 4.2, p ≤ 0.0001). However, there were no differences in ΔPAWP/ΔQs between Fontan and HFpEF patients (4.0 [2.1-7.3] vs. 2.7 [1.6-4.4]; p=0.10) with the ratio being higher post-Fontan than in NCD (0.6 [0.2-1.2]; p < 0.0001). ΔPAWP/ΔQs remained similar between HFpEF and Fontan patients even when those with ejection fraction <50% were excluded (2.7 [1.6-4.4] vs. 2.7 [1.0-5.8]; p=0.97). There were no differences in ΔPAWP/ΔQs ratios between post-Fontan and HFpEF patients, supporting markedly abnormal single ventricle compliance despite lower resting and exercise PAWP. Therefore, exercise invasive haemodynamics may represent a novel tool for the diagnosis of diastolic dysfunction in Fontan patients.

Noninvasive Cardiac Radioablation for Ventricular Tachycardia: Results of the STARNL-1 Trial

<h3>Purpose/Objective(s)</h3> Radioablation or stereotactic arrhythmia radiotherapy is a promising new last-resort treatment modality for patients with recurrent ventricular tachycardia (VT) who are considered therapy refractory. Experience with radioablation is steadily growing worldwide as result of promising efficacy and safety results. Prospective trials are needed to confirm these results. The STARNL-1 study was designed to prospectively evaluate the efficacy and safety of cardiac radioablation in patients with therapy-refractory ventricular tachycardia. <h3>Materials/Methods</h3> The prospective STARNL-1 trial is a single-arm, pre-post, intervention study. In 6 patients, the pro-arrhythmic cardiac region was identified and treated with a single stereotactic radiotherapy fraction of 25 Gy. Patients who were considered therapy-refractory, with recurrences after (multiple) VT ablations and high doses of class 1-3 anti-arrhythmic drugs, were included. For this analysis, the number of treated VT-episodes 6-months before and after treatment, excluding events in the 6-week blanking period, were compared. Safety analysis included evaluation of (serious) adverse events, echocardiography and lung function tests. <h3>Results</h3> All six patients (6/6, 100%) included in the STARNL-1 trail completed the 6-month follow-up. All patients were male (age range 55-83 years) and had an ischemic cardiomyopathy (median ejection fraction: 38% [range 24-52]. The median planning target volume was 187ml (range 93-372.2) and radiation beam-on times were all below 7 minutes. There were no significant alterations in hs-Troponin-T as a marker for myocardial injury comparing baseline (2-3h before treatment) to 3h (+9.7% [-2.3;31.1], p=0.34), 12h (+13.3 [-2.1;17.8], p=0.22) and 24h (+8.0% [9.8;53.3], p=0.40) post-treatment. The median number of treated VT episodes significantly reduced from 24 (range: 6-107) in the 6 months before treatment to 3 (range 0-15) after treatment, p=0.028. The median reduction percentage was 88.0% (range 85-100%). No serious treatment related adverse events occurred during follow-up. Comparing 3 months after treatment with baseline, the median change in ejection fraction was +12% (range: -27 to +33) and the median reduction in 1 second forced expiratory volume (FEV1) and diffusion capacity (DLCO) were both below <15%. <h3>Conclusion</h3> The results of the prospective STARNL-1 evaluating cardiac radioablation for therapy-refractory VT patients are very promising with regards to efficacy and safety.

PTX3 as a novel inflammatory biomarker in patients with myocarditis

Abstract Background Pentraxin-3 (PTX3) is an acute phase protein, which plays pivotal roles in innate immunity and inflammation. Among cardiovascular diseases, PTX3 was found to be elevated in acute myocardial infarction, chronic heart failure, and cardiac arrest. So far, however, PTX3 has never been investigated in the context of myocarditis. Purpose To evaluate PTX3 as a circulating marker of inflammation in patients with suspected myocarditis. Methods We enrolled 30 consecutive inpatients with new diagnosis of myocarditis, proven both by the updated Lake Louise criteria on cardiac magnetic resonance (CMR), and by the Dallas criteria on endomyocardial biopsy (EMB) (100%). Circulating serum PTX3 was assessed at the time of EMB, by ELISA technique using a commercial kit. Normal values for PTX3 were considered as &amp;lt;2 ng/mL, as in previous studies. A normal control group (n=10) was used for results validation of PTX3. Results In our cohort (77% males, age 50±18 y; median left ventricle ejection fraction [LVEF] 50%, IQR 30–59%), PTX3 levels were assessed in 30 patients. PTX3 levels were elevated in 26/30 (87%) patients with myocarditis (median 4,36 ng/mL, IQR 2,44–6,72, range 1,20–40,0), and in none (0/10) among healthy controls (median 1,28 ng/mL, IQR 1,04–1,36, range 0,77–1,94) (p=0,001). In the study group, the yield of other cardiac biomarkers was lower: 12/30 (40%) for C-reactive protein, 23/30 (77%) for T-troponin, and 20/30 (67%) for NTproBNP. PTX3 was constantly elevated in patients presenting with heart failure (HF) (16/16, 100%), compared with those presenting with acute coronary syndrome-like (8/10, 80%), or arrhythmias (2/4, 50%) (p=0,024). In particular, elevated PTX3 was associated with systolic dysfunction (LVEF &amp;lt;50%) at discharge (16/16 vs. 10/14, p=0,022). Conclusion Our preliminary data suggest PTX3 as a novel biomarker with potential diagnostic and prognostic value for myocarditis and inflammatory cardiomyopathy. Funding Acknowledgement Type of funding sources: None.

Cardiac radioablation does not worsen cardiac function: preliminary safety results of the prospective STARNL-1 trial

Abstract Background Cardiac radioablation for ventricular tachycardia (VT) appears to be highly effective and safe in patients with recurrent VT despite anti-arrhythmic therapy and catheter ablation(s), although global experience is currently very limited. Detailed echocardiographic strain analysis could provide important insights in (subclinical) functional safety. Importantly, current stereotactic cardiac radioablation techniques includes irradiation of the VT substrate but, inherently, also includes irradiation of the VT border zone and some healthy cardiac tissue. The latter particularly may result in detoriation of cardiac function after cardiac radioablation. Purpose To evaluate functional echocardiographic safety of cardiac radioablation. Methods The STARNL-1 trial is a prospective, monocenter, single-arm, pre-post intervention study. Six patients with recurrent VT despite high dose anti-arrhythmic drugs, after (single or multiple) conventional catheter ablation and deemed unsuited for repeat catheter ablation, were treated with a single fraction 25 Gy radiotherapy dose. Per protocol, patients underwent echocardiograms at baseline, 24 hours after treatment, and 3 months after treatment. Echocardiograms were analysed using 2D-speckle tracking. Mean radiotherapy dose per segment was calculated according to the AHA 17-segment model. Echocardiographic parameters were compared between baseline, 24 hours and 3 months, and correlated to radiotherapy dose. Results Patients were all male (age 55–83 years), all suffered from ischaemic cardiomyopathy, and all completed 3 month follow-up. At baseline, median left ventricle ejection fraction (LVEF) was 38% [30; 47] and median global longitudinal strain (GLS) −8% [−12; −5]. Interestingly, LVEF significantly improved 24 hours after treatment (42% [36; 49], p=0.046) but GLS did not change (−7% [−12; −5], p=0.833). At 3 months, both LVEF and GLS were unchanged compared to baseline (LVEF 39% [33; 49%], p=0.463; GLS −6% [−12; −5], p=0.893). The difference in longitudinal strain per segment before and after treatment did not correlate with the mean radiotherapy dose per segment, both 24 hours after treatment (Pearson coefficient −0.082, p=0.410) and 3 months after treatment (Pearson coefficient −0.005, p=0.957). In Figure 1 an illustrative case is presented. Conclusion(s) Cardiac radioablation for VT does not worsen (subclinical) cardiac function within the first 3 months after treatment. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation

SODIUM-GLUCOSE TRANSPORT PROTEIN 2 INHIBITOR ELIGIBILITY FOR PATIENTS HOSPITALIZED WITH ACUTE HEART FAILURE

SODIUM-GLUCOSE TRANSPORT PROTEIN 2 INHIBITOR ELIGIBILITY FOR PATIENTS HOSPITALIZED WITH ACUTE HEART FAILURE

Real-world use patterns of angiotensin receptor-neprilysin inhibitor (sacubitril/valsartan) among patients with heart failure within a large integrated health system.

BACKGROUND: Sacubitril/valsartan is a first-in-class angiotensin receptor-neprilysin inhibitor (ARNI) that is now preferred in guidelines over angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) for patients with heart failure with reduced ejection fraction (HFrEF). However, it has not been broadly adopted in clinical practice. OBJECTIVE: To characterize ARNI use within a large diverse real-world population and assess for any racial disparities. METHODS: We conducted a cross-sectional study within Kaiser Permanente Southern California. Adult patients with HFrEF who received ARNIs, ACEIs, or ARBs between January 1, 2014, and November 30, 2020, were identified. The prevalence of ARNI use among the cohort and patient characteristics by ARNIs vs ACEIs/ARBs use were described. Multivariable regression was performed to estimate odds ratios and 95% CIs of receiving ARNI by race and ethnicity. RESULTS: Among 12,250 patients with HFrEF receiving ACEIs, ARBs, or ARNIs, 556 (4.54%) patients received ARNIs. ARNI use among this cohort increased from 0.02% in 2015 to 7.48% in 2020. Patients receiving ARNIs were younger (aged 62 vs 69 years) and had a lower median ejection fraction (27% vs 32%) compared with patients receiving ACEIs/ARBs. They also had higher use of mineralocorticoid antagonists (24.1% vs 19.8%) and automatic implantable cardioverterdefibrillators (17.4% vs 13.3%). There were no significant differences in rate of ARNI use by race and ethnicity. CONCLUSIONS: Within a large diverse integrated health system in Southern California, the rate of ARNI use has risen over time. Patients given ARNIs were younger with fewer comorbidities, while having worse ejection fraction. Racial minorities were no less likely to receive ARNIs compared with White patients. DISCLOSURES: Dr Huang had stock ownership in Gilead and Pfizer. Dr Liang received support for article processing and medical writing.

Catheter ablation in patients with ventricular fibrillation by purkinje de-networking.

BackgroundVentricular fibrillation (VF) is a leading cause of cardiovascular death worldwide. However, recurrence rates of arrhythmia are high leading to mortality and morbidity. Recently, Purkinje fibers have been identified as potential sources of VF initiation and maintenance.AimThe study analyzes the feasibility and effectiveness of catheter ablation in patients with recurrent VF by specific Purkinje de-networking (PDN).MethodsConsecutive patients with recurrent VF undergoing PDN were included in this observational study. The procedural endpoint was the non-inducibility of sustained ventricular arrhythmia. A three-dimensional -anatomical mapping was conducted, and the specific cardiac conduction system and Purkinje fibers were tagged. All detectable Purkinje signals were ablated in the left ventricle (LV). Additional right ventricular (RV) PDN was performed in case of VF inducibility after LV ablation. Follow-up was performed by patient visits at our outpatient clinic including device interrogation and by telephone interviews.ResultsEight patients were included in the study. Six patients were females (75%); the median age during the procedure was 43 [37;57] years and the median body mass index was 24 [23;33] kg/m2. Four patients (50%) had known structural heart disease with two cases of ischemic cardiomyopathy and two cases of dilated cardiomyopathy. In four patients (50%), no underlying structural heart disease could be identified. The median LV ejection fraction was 42 ± 16.4%. All patients had an implantable cardioverter-defibrillator (ICD) prior to ablation with documentation of recurrent VF. The median number of ICD shocks before the ablation was 5 [3;7]. LV PDN was performed in all patients. In two patients (25%), an additional RV PDN was performed. Non-inducibility of any ventricular arrhythmia was achieved in all patients after PDN. Two patients showed complete left bundle branch block post-ablation. The median follow-up duration was 264 [58;421] days. Two patients (25%) experienced ventricular arrhythmia recurrence with recurrent ICD-shock delivery. One patient died during follow-up with an unknown cause of death. Six patients (75%) experienced no arrhythmia recurrence during follow-up.ConclusionPurkinje de-networking represents a novel treatment option for patients with recurrent VF without arrhythmia substrate or specific arrhythmia triggers with promising results in terms of efficiency and feasibility. Larger and more prospective studies are needed for a systematic evaluation.

Treating Pediatric Myocarditis with High Dose Steroids and Immunoglobulin.

There is considerable variability in practice among pediatric centers for treatment of myocarditis. We report outcomes using high dose steroids in conjunction with IVIG. This is a single center retrospective study of children < 21 years of age diagnosed with myocarditis and treated with high dose steroids and IVIG from January 2004-April 2021. Diagnostic criteria for myocarditis included positive endomyocardial biopsy, cardiac magnetic resonance (CMR) imaging meeting Lake Louise criteria, or strictly defined clinical diagnosis. Forty patients met inclusion criteria. Median age at diagnosis was 11.6 years (0.7–14.6). Diagnosis was made clinically in 70% of cases (N = 28), by CMR in 12.5% (N = 5) and by biopsy in 17.5% (N = 7). Median ejection fraction (EF) at diagnosis was 35% (IQR 24–48). Median duration of IV steroids was 7 days (IQR 4–12) followed by an oral taper. Median cumulative dose of IV immunoglobulin (IVIG) was 2 g/kg. There were no serious secondary bacterial infections after steroid initiation. Ten patients (25%) required mechanical circulatory support. Overall transplant free survival was 92.5% with median follow-up of 1 year (IQR 0–6 years). Six patients required re-admission for cardiovascular reasons. By 3 months from diagnosis, 70% of patients regained normal left ventricular function. High dose steroids in conjunction with IVIG to treat acute myocarditis can be safe without significant infections or long-term side effects. Our cohort had excellent recovery of ventricular function and survival without transplant. Prospective comparison of a combination of high dose steroids with IVIG versus other therapies is needed.

Volatile versus Total Intravenous Anesthesia for Coronary Artery Bypass Graft Surgery: Analysis of 1586 MYRIAD Trial Patients Managed with the Same Perioperative Protocol.

This study investigated the influence of volatile anesthesia (VA) on major complications and mortality in patients undergoing coronary artery bypass graft surgery (CABG). This post-hoc analysis included 1586 patients from the MYRIAD trial managed using the same perioperative protocol at a single institution. Patients were randomized to receive either volatile anesthesia (sevoflurane, isoflurane, or desflurane) or total intravenous anesthesia (TIVA). The assessed study outcomes were the rate of complications, including: myocardial infarction, stroke, acute kidney injury, prolonged ventilation ( 24 h), receipt of high-dose inotropic support (inotropic score 10), and need for mechanical circulatory support. The duration of intensive care unit (ICU) stay, length of hospitalization, hospital readmission during follow-up, 30-days and 1-year mortality were also analyzed. 1586 patients were enrolled between September 2014-September 2017 and randomly assigned to the volatile anesthesia group (n = 794) and the TIVA group (n = 792). The median patient age was 63 years, with a median ejection fraction of 60%. There were no significant differences in the rates of major complications, duration of ICU stay, and hospitalization between the groups. The median total dose of fentanyl was 12.0 mcg/kg in volatile group and 14.4 mcg/kg in TIVA group (p 0.001). One-year mortality rates were 2.5% (n = 20) and 3.2% (n = 25) in the volatile and TIVA groups, respectively. Two patients were lost at the 30-day and 1-year follow-ups in the volatile group compared to four patients in TIVA group. Regression analysis showed that cardiopulmonary bypass (CPB) duration, fentanyl dose, and baseline serum creatinine level were associated with 30-days mortality, while ejection fraction was associated with 1-year mortality. The use of VA in patients undergoing CABG did not result in a reduction in major complications or mortality compared with TIVA. A higher dose of fentanyl was used in the TIVA group and was associated with an increase in the 30-days mortality. These findings warrant further investigation. ClinicalTrials.gov (NCT02105610).

Left Ventricular Diastolic Dysfunction and Progression of Chronic Kidney Disease: Analysis of KNOW-CKD Data.

BackgroundFew studies have examined the association between the early diastolic mitral inflow velocity/early diastolic mitral annulus velocity ratio (E/e’) and chronic kidney disease progression.Methods and ResultsWe reviewed data from 2238 patients with nondialysis chronic kidney disease from the KNOW‐CKD (Korean Cohort Study for Outcome in Patients With Chronic Kidney Disease); data from 163 patients were excluded because of missing content. A >50% decrease in estimated glomerular filtration rate from baseline, doubling of serum creatinine, or dialysis initiation and/or kidney transplantation were considered renal events. At baseline, median (interquartile range) ejection fraction and E/e’ were 64.0% (60.0%–68.0%) and 9.1 (7.4–11.9), respectively. Proportions of ejection fraction <50% and E/e’ ≥15 were 1.3% and 9.6%, respectively. More than one quarter of patients (27.2%) had an estimated glomerular filtration rate <30 mL/min per 1.73 m2. During the mean 59.1‐month follow‐up period, 724 patients (34.9%) experienced renal events. In multivariable Cox proportional hazard regression analysis, the hazard ratio with 95% CI per 1‐unit increase in E/e’ was 1.027 (1.005–1.050; P=0.016). Penalized spline curve analysis yielded a suggested threshold of E/e’ for renal events of 12; in our data set, the proportion of E/e’ ≥12 was 4.1%.ConclusionsIncreased E/e’ was associated with an increased hazard of renal events, suggesting that diastolic heart dysfunction is a novel risk factor for chronic kidney disease progression.

C78 PREVALENCE AND MECHANISMS OF SEVERE MITRAL AND TRICUSPID REGURGITATION IN A HEART FAILURE OUTPATIENTS POPULATION

Abstract Introduction Mitral regurgitation (MR) and tricuspid regurgitation (TR) are a known cause of morbidity and mortality in heart failure (HF) patients. Maximal up–titration of guideline–directed medical therapy (GDMT) for HF may not be enough to reduce the severity of the valve’s incompetence and patients’ symptoms. The development and successful results of transcatheter therapies for mitral/tricuspid disease have opened new therapeutic opportunities when surgery is not feasible. Accurate valve regurgitation’s mechanisms evaluation is essential to choose the best treatment option. This study aims at evaluating the prevalence and underlying mechanisms of at least moderate–to–severe (≥3+/4+) MR and/or TR in a cohort of HF outpatients. Methods We retrospectively analyzed the medical records of 1260 outpatients evaluated by our HF unit between January 2020 and June 2021. All patients with echocardiographic evidence of ≥ 3+/4+ MR and/or TR were included (treated ones were excluded), and a thorough echocardiographic images review was conducted. A full collection of patients’ clinical, laboratory and therapy regimens details was performed as well. Results Of the 1260 analyzed patients, 173 (13.7%) exhibited ≥3+/4+ MR and/or TR and were included in the registry. Table 1 shows the main clinical/echocardiographic characteristics. Mean age was 80±7 years, median ejection fraction was 45% (IQR=33–55). All patients were treated with maximal tolerated doses of GDMT and, if appropriate, with cardiac devices/myocardial revascularization. ≥3+/4+ MR and/or TR was observed in 92 (7.3%) and 117 (9.3%) patients, respectively. Patients with isolated significant MR were 56 (4.4%), with isolated significant TR were 81 (6.4%); the remaining 36 (2.8%) had both MR/TR. Among patients with significant MR, 50 (54%) had functional/secondary valvular defect (details in Figure 2): the majority (41,82%) presented a ventricular etiology (asymmetric tethering in 18/41) while 9 (18%) an atrial one (atriogenic tethering in 3/9). Conclusion Despite optimized GDMT, the prevalence of patients with hemodynamically significant valvular defects was considerably high in our HF population. This is the first registry to comprehensively detail atrioventricular valve regurgitations’ mechanisms in a wide real–life cohort of HF outpatients. Further studies are needed to identify reasons for potential undertreatment and patients who would benefit the most from percutaneous correction of their valvular defects.

Prolonged support with Impella 5.0: different pathways of care for acute cardiogenic shock

Abstract Funding Acknowledgements Type of funding sources: None. Background Severe acute cardiogenic shock is a life-threatening condition associated with high in-hospital mortality. Impella 5.0 is a transcatheter left ventricular assist device that ensuring up to 5 L/min of blood flow can provide full hemodynamic support as bridge to recovery, heart transplantation or long term mechanical circulatory support (MCS). Purpose To assess role and outcomes of Impella 5.0 device as tMCS in deep acute cardiogenic shock and describe the results of different pathways of care in these patients. Methods All consecutive patients who underwent Impella 5.0 implantation for cardiogenic shock at our institution between January 2018 and June 2021 were included in the study. Results A total of 40 patients, primarily males (85%) with a median age of 62 (54-70) years, underwent axillary Impella 5.0 implantation for severe cardiogenic shock (SCAI CS stage D: n= 12, 30%; stage E: n= 28, 70%), due to de novo onset acute myocardial infarction in 70% of patients. One third of the patients had been resuscitated and 90% were already on short term mechanical circulatory support (35% on V-A ECMO): median ejection fraction at implantation was 10 (5-20)%. Twenty-eight patients survived to next therapy or recovery (70%). Eleven patients (28%) experienced recovery and were weaned from MCS, 10 underwent LVAD implantation (25%), and seven (17%) were bridged to cardiac transplantation. Median duration of Impella support was 13 days (maximum duration 52 days) ,and, thanks to axillary approach, 33% were successfully mobilized during support. Device complications were limited, the most frequent being major haemolysis (28%), bleeding from cannulation site (13%), and device malfunction requiring replacement (20%),and with other complications incidence &amp;lt; 5%. Hospital survival was 60% overall: 100% in recovery patients, 90% in patients bridged to LVAD and 57% in patients underwent heart transplantation. Main cause of death was multiorgan failure (n=6). "Recovery" patients compared to "non-recovery" (figure 1 and2) had lower SCAI CS stage (p= 0.037), lower diabetes incidence (9% vs 48%, p=0.02) were less likely to be already on MCS support (73% vs 96%, p= 0.025) and had undergone a faster upgrade of support to Impella 5.0 (2 vs 4.5 days, p= 0.04). Conclusions Temporary support with Impella 5.0 proved to have a key role in the management of cardiogenic shock, and showed high survival with low complication rate in these critical patients. Restoring hemodynamic and end-organ perfusion allows to get over the phase of shock and prolonged support allows pathways towards cardiac recovery or next therapies. The early identification of prognostic factors for hemodynamic recovery is crucial, since it may simplify selection for LVAD vs transplantation listing and in the timing of bridging to next therapy.

Long-term prognostic impact of new-onset atrial fibrillation in patients with preserved and mildly reduced ejection fraction following myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Background/aim It is well known that atrial fibrillation (AF) significantly increases risk of short- and long-term mortality in patients with ST-elevation myocardial infarction (STEMI), especially in those with reduced left ventricular ejection fraction (EF), but its prognostic impact in patients with STEMI and preserved or mildly reduced EF is not well defined. The aim of this study was to analyse the prognostic impact of new-onset AF on long-term mortality in patients with preserved and mildly reduced EF after STEMI. Method we included 1874 consecutive STEMI patients treated with primary percutaneous coronary intervention (pPCI). New-onset AF was defined as electrocardiographic or monitoring evidence of a AF lasting at least 30 seconds in patients with no medical history of previous AF. Echocardiographic examination was performed before discharge, EF was calculated using bi-plane method. Preserved EF was defined as ≥50% and midly reduced EF was defined as EF 41-49%. Patients with cardiogenic shock at admission and patients with previous AF of any form (paroxysmal, persistent or permanent) were excluded. The follow-up period was 6 years. Results Among all analysed patients 491 (26.6%) patients were women and 1375 (73.4%) were men. The median age of all analysed patients was 58 (IQR 46, 69) years and median EF was 52% (IQR 45%, 57%). New-onset AF was registered in 78 (4.2%) patients. Among them 27 (34.6%) patients had AF at admission and 51 (65.4%) patients develop AF later at a median time 4 (IQR 1, 25) hours. Median duration of AF was 17 (IQR 6, 25) hours. All of the analyzed patients with new-onset AF were converted into sinus rhythm with medication (amiodarone) or they converted spontaneously upon myocardial revascularization. As compared with patients without AF, those with AF were older and presented more often with Killip class II and III; they had lower systolic blood pressure and creatinine clearance at admission; they had more often 3-vessel coronary artery disease (at initial angiogram), preprocedural flow TIMI=0 and postprocedural flow TIMI&amp;lt;3. EF values were similar among patients with and without AF 50% (IQR 44%, 55%) and 51% (IQR 45%, 55%) respectively, p=0.93. Six-year mortality was significantly higher in patients with new-onset AF as compared with patients without AF (14.1% vs 2.6%, respectively, p&amp;lt;0.001) as shown in Figure 1. In Cox regression model new-onset AF was an independent predictor of 6-year mortality–HR 4.53 (95% CI 2.29-8.94), p&amp;lt;0.001. Other independent predictors for 6-year mortality were older age, Killip class II and III at admission and baseline creatinine clearance &amp;lt;60ml/min/m2. Conclusion New-onset AF was a strong indepedent predictor for 6-year mortality in analyzed patients with preserved and mildly reduced EF after STEMI.

How to Improve the Outcomes of LVAD Implantation?

Heart transplantation is the treatment of choice for selected patients with end-stage heart failure. Persistent donor organ shortage has resulted in a growing interest in mechanical circulatory support not only as a bridge to transplantation but also as a destination therapy. The aim of the study was to analyze the indications, comorbidities, operative technique, complications, and follow-up of all patients undergoing left ventricular assist device implantation in one of the most experienced clinics in Poland between 2015 and 2020 and state the best timing of the procedure. This study included 78 individuals (72 males, 92%; 6 females, 8%) with a median age of 57 years (range, 50-62 years). The median body mass index was 27.12 (range, 25.2-29.5). The etiology of cardiomyopathy was ischemic (n=31, 39%), dilated cardiomyopathy (n=47, 60%), and others. Sixty-four patients presented with New York Heart Association class IV (82%). Leading heart rhythm was sinus (n=31, 40%) and pacemaker rhythm (n=47, 60%). Sixty-four patients had implantable cardioverter defibrillator implantation (82%). Preoperative echocardiography revealed a median left ventricle ejection fraction of 14.5% (range, 10%-15%) and LV dimension 7.55 cm (range, 6.9-8.275 cm). In 51 patients (65%), imaging confirmed pulmonary hypertension. The intensive care unit stay was 6 days (range, 4.25-11.75 days). Median time to extubation was 25 hours (range, 23.75-70 hours). The median time to discharge was 31.5 days (range, 25-31.85 days). In-hospital mortality was 12 patients (15%). Median follow-up time was 19.5 months (range, 11.25-31 months) months, with the longest follow-up of about 53 months. Appropriate selection of candidates and timing of left ventricular assist device implantation are critical for improved outcomes of destination therapy.