Nonischemic Chronic Heart Failure Research Articles

The influence of alcohol dependence on the course of chronic heart failure in patients with HIV infection

Introduction. Alcohol dependence is a condition, the consequences of which are severe in persons with cardiovascular diseases and immunodeficiency. The purpose of the study is to evaluate the influence of alcohol dependence on the course of chronic heart failure (CHF) in persons infected with human immunodeficiency virus (HIV). Materials and methods. A clinical study including 240 HIV-infected patients, 160 of them were diagnosed with CHF, 72 had alcohol dependence. AUDIIT scale was used for diagnostics of alcohol dependence. All patients underwent echocardiography, NT-proBNP concentration was determined in blood plasma, serum - content of SRB, transferrin, ferritin, iron, potassium, sodium, bilirubin, creatinine, urea, uric acid, AST, ALT, GGTP activity. Statistical calculations: Kolmogorov-Smirnov, Mann-Whitney methods, odds ratios and risks. Results. Congestion, lower heart rate prevailed in the group of patients with alcohol dependence. On the background of alcohol dependence in blood serum there was a decrease in the level of total cholesterol, transferrin, potassium, an increase in total bilirubin and GGTP activity, a decrease in the number of platelets. Increase in NT-proBNP concentration was found in blood plasma. Discussion. Alcohol is characterized by cardiotoxic effect, and regular ethanol consumption is associated with the development of non-ischemic dilated cardiomyopathy and CHF. Echocardiographic findings suggest a predominance of right atrial and left ventricular dilatation in the group of patients with alcohol dependence among all patients with CHF infected with HIV due to the formation of cardiomyopathy. Conclusion. Alcohol dependence is a condition aggravating the course of CHF in HIV-infected patients, which is manifested by higher values of blood plasma NT-proBNP, with CHF more often acquiring a congestive character. The course of CHF in HIV-infected patients against the background of alcohol dependence is accompanied by liver dysfunction - 3.5 times increase the chance of cholestasis development, 2.5 times increase the chances of death within 2 months after admission to hospital.

Circulating H-FABP as a biomarker of frailty in patients with chronic heart failure.

Increased vulnerability to physiologic stressors, termed frailty, is a common occurrence in patients with chronic heart failure (CHF). However, the definite biomarkers to assess frailty in CHF patients are not known. Here, we assessed the frailty phenotype and its potential association with heart failure (HF) markers in CHF patients. We categorized controls (n = 59) and CHF patients (n = 80), the participants, into robust, pre-frail, and frail based on the cardiovascular health study (CHS) frailty index. The plasma levels of HF markers, including tumorigenicity 2 (s-ST2), galectin-3, and heart-type fatty acid binding protein (H-FABP), were measured and correlated with frailty phenotype and cardiac function. The levels of plasma s-ST2, galectin-3, and H-FABP were profoundly elevated in CHF patients. Conversely, the frailty index scores were significantly lower in ischemic and non-ischemic CHF patients versus controls. Of the assessed HF markers, only H-FABP was positively correlated (r2 = 0.07, P = 0.02) with the frailty score in CHF patients. Collectively, these observations suggest that circulating H-FABP may serve as a biomarker of frailty in CHF patients.

Impact of heart failure on all-cause mortality in COVID-19: findings from the Eurasian International Registry.

To study all-cause mortality in patients hospitalized with COVID-19 with or without chronic heart failure (CHF) during hospitalization and at 3 and 6months of follow-up. The international registry Analysis of Comorbid Disease Dynamics in Patients with SARS-CoV-2 Infection (ACTIV) was conducted at 26 centres in seven countries: Armenia, Belarus, Kazakhstan, Kyrgyzstan, Moldova, Russian Federation, and Uzbekistan. The primary endpoints were in-hospital all-cause mortality and all-cause mortality at 3 and 6months of follow-up. Of the 5616 patients hospitalized with COVID-19, 917 (16.3%) had CHF. Total in-hospital mortality was 7.6%. In-hospital mortality was higher in patients with CHF than in patients without a history of CHF [17.7% vs. 4.0%, P<0.001; odds ratio (OR) 4.614, 95% confidence interval (CI) 3.633-5.859; P<0.001]. The risk of in-hospital all-cause mortality correlated significantly with the severity of CHF; specifically, the risk of in-hospital all-cause mortality was greater for patients in New York Heart Association functional classes III and IV (OR 6.124, 95% CI 4.538-8.266; P<0.001 vs. patients without CHF) than for patients in functional classes I and II (OR 2.446, 95% CI 1.831-3.267, P<0.001 vs. patients without CHF). The risk of mortality in patients with ischemic CHF was 58% higher than in patients with non-ischaemic CHF [OR 1.58 (95% CI 1.05-2.45), P=0.030]. In the first 3months of follow-up, the all-cause mortality rate in patients with CHF was 10.32%, compared with 1.83% in patients without CHF (P<0.001). At 6months of follow-up, NYHA classes II-IV was a strong risk factor for all-cause mortality [OR 5.343 (95% CI 2.717-10.508); P<0.001]. Hospitalized COVID-19 patients with CHF have an increased risk of in-hospital all-cause mortality, which remains high 6months after discharge.

Echocardiographic characteristics of patients with ischemic and non-ischemic chronic heart failure with reduced ejection fraction

T The data indicate differences in the adverse outcomes of chronic heart failure (CHF) in both ischemic (ICMP) and non-ischemic origins. The knowledge of the structural and functional myocardial state, especially of the left ventricle (LV), is insufficient for accurate risk stratification of unfavorable events in different etiopathogenetic forms of CHF. Aim . To make a comparative analysis of echocardiographic characteristics of CHF patients with reduced LV ejection fraction (EF) ≤35% depending on the origin of CHF. Material and methods. 498 patients of CHF 3-4 functional class of NYHA (New-York Heart Association) with EF ≤35% taking optimal drug therapy were included in the study. Based on the etiology of CHF, two groups of patients with CHF of ischemic genesis (n=254) and dilated cardiomyopathy (DCMP, n=244) were formed. Two-dimensional echocardiography techniques in Band M-mode, color Doppler, and tissue Doppler imaging were carried out. Results. Patients with ICMP and DCMP had the same pattern of LV remodeling (mainly on the type of eccentric hypertrophy), but they reliably differed in the basic parameters of LV architectonics: endsystolic and end-diastolic dimensions, LV volume, LV myocardial mass and values of these indicators, indexed by body surface area. DCMP patients had a higher value of medial-lateral dimension and volume of left atrial, pathological mitral and tricuspid regurgitation was registered more often. Conclusion. It was found that left heart dimensions and volumes of DCMP patients exceed similar parameters in patients with ICMP. The possible association of the results with future adverse outcomes of CHF demands further research.

The value of cardiac sympathetic activity and mechanical dyssynchrony as cardiac resynchronization therapy response predictors: comparison between patients with ischemic and non-ischemic heart failure

BackgroundImpaired cardiac sympathetic activity and mechanical dyssynchrony (MD) are associated with poor prognosis in patients with heart failure (HF) after cardiac resynchronization therapy (CRT). The study aims to assess the significance of scintigraphic evaluation of cardiac sympathetic innervation and contractility in predicting response to CRT in patients with ischemic and non-ischemic chronic HF. Methods and resultsThe study includes 58 HF patients, who were referred for CRT. Prior to CRT all patients underwent 123I-metaiodobenzylguanidine (123I-MIBG) imaging and gated myocardial perfusion imaging (MPI) using a cadmium-zinc-telluride (CZT) SPECT/CT device. At a one-year follow-up post-CRT, the delayed heart-to-mediastinum 123I-MIBG uptake ratio was an independent predictor of CRT response in non-ischemic HF patients (OR 1.469; 95% CI 1.076-2.007, p = .003). In ischemic HF patients the MD index histogram bandwidth (HBW) obtained by CZT-gated MPI had a predictive value (OR 1.06, 95% CI 1.001-1.112, p = .005) to CRT response. ConclusionCRT response can be predicted by cardiac 123I-MIBG scintigraphy, specifically by the heart-to-mediastinum ratio in non-ischemic HF and by the MD index HBW in ischemic HF. These results suggest the value of a potentially useful algorithm to improve outcomes in HF patients who are candidates for CRT.

Perspectives on the Use of Transthoracic Echocardiography Results for the Prediction of Ventricular Tachyarrhythmias in Patients with Non-ischemic Cardiomyopathy

Aim. To perform a comparative analysis of indicators of transthoracic echocardiography (TE), to establish echocardiographic predictors and their predictive role in the occurrence of stable ventricular tachyarrhythmia (VT) paroxysms in patients with nonischemic chronic heart failure (HF) and cardioverter-defibrillator (ICD) implanted for primary prevention of sudden cardiac death.Material and Methods. A prospective study was carried out, which included 166 patients with nonischemic HF at the age of 54 (49; 59) years with the left ventricle ejection fraction (LV EF) ≤35% and an ICD implanted. The observation time was 24 months. The primary endpoint was the first-ever stable paroxysm of VT (lasting for ≥30 seconds), detected in the «monitor» zone of VT, or paroxysm of VT, which required ICD therapy. A total of 34 TE indicators were evaluated. Chi-square, Fischer, Manna-Whitney, single-factor logistic regression (LR), and multi-factor LR were used for data processing and analysis and for predictive modelling. Model accuracy was estimated using 4 metrics: ROC curve area (AUC), sensitivity, specificity and diagnostic efficiency.Results. During the two-year observation, 32 patients (19.3%) had a primary endpoint. The average time of occurrence of a stable VT episode was 21.6±0.6 months (95% confidence interval [CI] 20.5-22.8 months). The value of LV end-systolic dimension was the only parameter independently associated with VT (odds ratio 2.8 per unit increase, 95% CI 1.04-7.5; p=0.042). The complex analysis of echocardiographic indicators made it possible to identify 5 factors with the greatest predictive potential, which are linearly and nonlinearly related to occurrence of VT. These included the LV end-diastolic and end-systolic volumes, LV mass, index of relative LV wall thickness, upper-lower size of the right atrium. The metrics of the best predictive model were: AUC – 0.71 0.069 with 95% CI 0.574-0.843; specificity 50%, sensitivity 90.9%; diagnostic efficiency 57.1%.Conclusion. The study made it possible to evaluate the possibilities of the results of TE in predicting the probability of VT occurrence in patients with nonischemic HF and reduced LV EF. Predictive indicators have been identified that can be used to stratify the arrhythmic risk in the exposed cohort of patients.

Cardiac 123I-mIBG Imaging in Heart Failure.

Cardiac sympathetic upregulation is one of the neurohormonal compensation mechanisms that play an important role in the pathogenesis of chronic heart failure (CHF). In the past decades, cardiac 123I-mIBG scintigraphy has been established as a feasible technique to evaluate the global and regional cardiac sympathetic innervation. Although cardiac 123I-mIBG imaging has been studied in many cardiac and neurological diseases, it has extensively been studied in ischemic and non-ischemic CHF. Therefore, this review will focus on the role of 123I-mIBG imaging in CHF. This non-invasive, widely available technique has been established to evaluate the prognosis in CHF. Standardization, especially among various combinations of gamma camera and collimator, is important for identifying appropriate thresholds for adequate risk stratification. Interestingly, in contrast to the linear relationship between 123I-mIBG-derived parameters and overall prognosis, there seems to be a “bell-shape” curve for 123I-mIBG-derived parameters in relation to ventricular arrhythmia or appropriate implantable cardioverter defibrillator (ICD) therapy in patients with ischemic CHF. In addition, there is a potential clinical role for cardiac 123I-mIBG imaging in optimizing patient selection for implantation of expensive devices such as ICD and cardiac resynchronization therapy (CRT). Based on cardiac 123I-mIBG data risk models and machine learning, models have been developed for appropriate risk assessment in CHF.

Predictive value of electrophysiological study for risk stratification of ventricular tachyarrhythmias in patients with non-ischemic cardiomyopathy and chronic systolic heart failure

A systematic review and meta-analysis of studies providing information on the use of intracardiac electrophysiological study (EPS) to stratify the risk of ventricular tachyarrhythmia (VT) in patients with non-ischemic chronic heart failure with low left ventricle ejection fraction (HFrEF). Relevant publications were searched until 20.01.2021 by two independent researchers in major search engines, electronic archives of clinical research, and open access preservatives repository. The end point considered was an episode of sudden cardiac death or sustained paroxysm of VT, or an appropriate electrotherapy of an implanted cardiac defibrillator. Ten clinical trials with 608 relevant patients (mean age: 51.5 ± 12 years; mean left ventricle EF: 26.8±8.5%, NYHA class: I - 17.7%; II - 33.7%; III - 35.9%, IV - 12.7%) were selected. The end point was registered in 92 patients (15.1%): in 47 patients (43.9%) with previously induced VT during EPS and in 45 patients (8.9%) without VT. The diagnostic odds ratio was 5.57 (2.27-13.63). The combined sensitivity and specificity of the EPS were 42% (26-61%) and 88% (83-92%) respectively. The results indicate the potential of EPS to stratify the arrhythmic risk in patients with non-ischemic HFrEF.

Effects of enriched-potassium diet on cardiorespiratory outcomes in experimental non-ischemic chronic heart failure

BackgroundChronic heart failure (CHF) is a global health problem. Increased sympathetic outflow, cardiac arrhythmogenesis and irregular breathing patterns have all been associated with poor outcomes in CHF. Several studies showed that activation of the renin-angiotensin system (RAS) play a key role in CHF pathophysiology. Interestingly, potassium (K+) supplemented diets showed promising results in normalizing RAS axis and autonomic dysfunction in vascular diseases, lowering cardiovascular risk. Whether subtle increases in dietary K+ consumption may exert similar effects in CHF has not been previously tested. Accordingly, we aimed to evaluate the effects of dietary K+ supplementation on cardiorespiratory alterations in rats with CHF.MethodsAdult male Sprague–Dawley rats underwent volume overload to induce non-ischemic CHF. Animals were randomly allocated to normal chow diet (CHF group) or supplemented K+ diet (CHF+K+ group) for 6 weeks. Cardiac arrhythmogenesis, sympathetic outflow, baroreflex sensitivity, breathing disorders, chemoreflex function, respiratory–cardiovascular coupling and cardiac function were evaluated.ResultsCompared to normal chow diet, K+ supplemented diet in CHF significantly reduced arrhythmia incidence (67.8 ± 15.1 vs. 31.0 ± 3.7 events/hour, CHF vs. CHF+K+), decreased cardiac sympathetic tone (ΔHR to propranolol: − 97.4 ± 9.4 vs. − 60.8 ± 8.3 bpm, CHF vs. CHF+K+), restored baroreflex function and attenuated irregular breathing patterns. Additionally, supplementation of the diet with K+ restores normal central respiratory chemoreflex drive and abrogates pathological cardio-respiratory coupling in CHF rats being the outcome an improved cardiac function.ConclusionOur findings support that dietary K+ supplementation in non-ischemic CHF alleviate cardiorespiratory dysfunction.

Non-sustained ventricular tachycardia on remote patient monitoring in heart failure patients

Abstract Background Non-sustained ventricular tachycardia (NSVT) is commonly found in patients with structural heart disease and was historically obtained from registers of external ambulatory monitoring. The advent of remote patient monitoring (RPM) in Cardiac implantable electronic devices (CIEDs) has made it possible to detect asymptomatic NSVT in Heart Failure (HF) patients more frequently, but its impact in real world is uncertain. Purpose To determine the clinical impact of NSVT detection in RPM in ischemic and non-ischemic chronic heart failure patients with reduced ejection fraction (HFrEF) and CIEDs. Methods We retrospectively enrolled 121 consecutive patients with HFrEF, CIEDs and RPM. Patients were evaluated through routine episodic CIEDs interrogation, routine clinical evaluations and continuous monitoring data obtained from CIEDs and transmitted remotely to the care team and divided into NSVT positive (Group 1) and negative groups (Group 2). Primary endpoint was admissions to the emergency department by HF decompensation and secondary endpoint was the occurrence of arrhythmic events. A sub-analysis of non-ischemic HF was also performed. Results NSVT was detected in 78 (72,2%) patients. The mean number of episodes of NSVT was 611,68±3271,25 during the follow-up period or 2,445±16,688 in 24 hours. Mean age was 62,40±13,218 years, 71,9% were males and mean follow-up period was 56,30±39,37 months. Fifty-eight patients (47,9%) had transvenous implantable cardioverter defibrillator (ICD), 48 (39,7%) implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D), 14 (11,6%) subcutaneous ICD (S-ICD) and 1 (0,8%) CRT pacemaker (CRT-P). Medium left ventricular ejection fraction (LVEF) was 34,70±12,53%, 25 (23,14%) were in NYHA III-IV and 46 (39,0%) were ischemic (29 (37,7%) in Group 1 and 11 (37,9%) in Group 2). NSVT was associated with the occurrence of sustained ventricular tachycardia (VT) (1,88±0,186episodes of VT in group 1 and 0,03±0,186 in group 2, p=0,012), ventricular fibrillation (VF) (1,44±5,325 episodes of VT in group 1 and 0,03±0,186 in group 2, p=0,011) and admissions to the emergency department by HF decompensation at 5 years (r=0,310, p=0,011). A sub-analysis in non-ischemic HF patients also showed correlation between NSVT and VT (r=0,602, p&amp;lt;0,05) and admissions to the emergency department by HF decompensation at 5 years (r=0,382, p=0,014). Conclusions On remote patient monitoring with CIEDs, NSVT in HF patients was associated with arrhythmic events and may serve as a predictor for HF decompensations. Funding Acknowledgement Type of funding sources: None.

Mechanical Dyssynchrony for Prediction of the Cardiac Resynchronization Therapy Response in Patients with Dilated Cardiomyopathy.

Aim To evaluate the predictive value of indexes of left ventricular mechanical dyssynchrony (MD) as determined by data of electrocardiogram (ECG)-gated myocardial perfusion scintigraphy (ECG-MPS) for prediction of the efficacy of resynchronization therapy (RT) in patients with chronic heart failure (CHF).Material and methods This prospective study included 32 patients with nonischemic CHF and standard indications for RT. All patients underwent complete clinical an instrumental examination, including 24-h ECG monitoring and echocardiography (EchoCG). In order to evaluate the left ventricular (LV) myocardial perfusion, contractile function, and MD, myocardial perfusion scintigraphy was performed for all patients at rest prior to RT. In addition to the perfusion defect size at rest and hemodynamic parameters, LV MD was determined. The following indexes were used for analysis of dyssynchronization: phase standard deviation (PSD), phase histogram bandwidth (HBW), and phase histogram asymmetry and steepness. The treatment efficacy was evaluated by the clinical status of patients (clinical condition evaluation scale for CHF patient) and EchoCG at 6 months following RT. The criteria for a positive response to RT were an increase in LV ejection fraction (EF) by 5% and/or a decrease in the LV end-diastolic volume by 15% compared to preoperative values.Results According to ECG-MPS findings, all patients had scintigraphic signs of severe CHF with dilated LV cavity (end-diastolic volume, EDV 246 [217; 269] ml) and also of pronounced mechanical and electrical dyssynchrony. The values of mechanical dyssynchrony were PSD 53 [41; 61], HBW 176 [136; 202], asymmetry 1.62 [1.21; 1.89], and steepness 2.81 [1.21; 3.49]. The QRS duration was 165 [155; 175] msec. Furthermore, the LV perfusion was moderately impaired (perfusion defect size 4 [3; 10] %). Mean follow-up duration after implantation of the resynchronizing device was 6±1.7 mos. According to the selected criteria, 20 (63 %) patients were considered as responders and 12 (37 %) patients as non-responders. Before implantation of the cardiac synchronizing device, responders and non-responders differed only in LV MD (PSD 44 [35; 54] vs. 63 [58; 72]; p=0.0001); HBW 158 [118; 179] vs. 205 [199; 249]; p=0.0001; asymmetry 1.77 [1.62; 2.02] vs. 1.21 [0.93; 1.31]; p=0.0001; steepness 3.03 [2.60; 3.58] vs. 1.21 [0.19; 1.46]; p=0.0001), respectively. A one-factor logistic regression analysis showed that MD values were statistically significant predictors of a positive response to RT. A multi-factor logistic analysis of phase histogram steepness (odds ratio, OR 1.196; 95 % confidence interval, CI 1.04-1.37) and PSD (OR 0.67; 95 % CI 0.47-0.97) were identified as independent predictors for the response to RT. According to results of the ROC analysis, a PSD &lt;55 and a phase histogram steepness &gt;1.54 may predict the effectiveness of RT (AUC= 0.92; р=0.0001).Conclusion LV MD parameters determined with ECG-MPS allow predicting the effectiveness of RT in patients with nonischemic CHF. In this patient group, high values of standard deviation and low values of phase histogram steepness were independent predictors for the absence of response to RT after 6 mos. of follow-up.

B-PO03-183 SURVIVAL FOLLOWING THORACOSCOPIC SYMPATHECTOMY FOR REFRACTORY VENTRICULAR TACHYCARDIA

Several studies have reported ventricular tachycardia (VT) outcomes after thoracoscopic sympathectomy (TS) for refractory VT. However, less is known about overall survival following TS. To assess survival following TS for refractory VT. We retrospectively evaluated all patients with a previously implanted ICD that underwent at least one TS for the treatment of refractory VT at Emory Healthcare between February 2015 and April 2020. Baseline characteristics and clinical outcomes were evaluated by chart review. The primary endpoint was overall survival and the secondary endpoint was survival free of recurrent ICD shocks. We identified 41 patients with a mean age of 60.7 ± 13.5 years, of which 33 (80.5%) were male. Thirty-six patients (87%) had bilateral sympathectomy. Twelve (29.3%) patients had ischemic heart failure (CHF) and 21 (51.2%) with non-ischemic CHF. They had failed on average 2.15 ± 1.01 antiarrhythmics. Thirty-two (78%) patients underwent unsuccessful VT ablation with an average of 1.52 ± 0.89 attempts. Mean duration of follow-up was 39.3 ± 4.3 months. Overall survival at 36 months post-TS was 75.6% (Figure). Recurrent ICD shocks occurred in 46.3% at 12 months after TS. Mean shock-free survival was 11.4 ± 2.18 months. Survival at 3 years following thoracic sympathectomy for refractory VT was 75.6%, with 46.3% recurrent ICD shocks at 12 months. These data suggest that TS is a safe adjunct to refractory VT management in this challenging group of patients.

Clinical Predictors of Occurrence of Ventricular Tachyarrhythmias in Patients with Reduced Left Ventricle Ejection Fraction. Results of Single-Center Prospective Study.

Aim To evaluate the diagnostic significance of clinical and demographic parameters for predicting a 2-year probability of ventricular tachyarrhythmias (VT) in patients with chronic heart failure and reduced left ventricular ejection fraction (CHFrLVEF).Material and methods This single-center, prospective cohort study included 175 patients with CHFrLVEF who were implanted with a cardioverter defibrillator (CD). The endpoint was a CD-detected episode of VT. Patients were followed up for 2 years with visits at 3, 12, and 24 months after CD implantation.Results The primary endpoint was observed in 43 (24.4 %) patients at an average of 20.9 months (95 % confidence interval (CI), 20-21.9). The 2-year risk of fatal ventricular arrhythmias increased with detection of unstable VT (one-factor analysis, odds ratio (OR), 4.2; 95 % CI, 1.1-16.5; р=0.041; multifactor analysis, OR, 6.3; 95 % CI, 1.5-26.3; р=0.012) and with ischemic CHFrLVEF origin (one-factor analysis, OR, 2.2; 95 % CI, 1.1-4.5; p=0.021; multifactor analysis, OR, 2.5; 95 % CI, 1.2-5.1; р=0.018). In the presence of any type of atrial fibrillation (AF) in patients with non-ischemic CHFrLVEF, the probability of VT increased threefold (one-factor analysis, OR, 2.97; 95 % CI, 1.02-8.8; р=0.047; multifactor analysis, OR, 3.5; 95 % CI, 1.1-10.9; р=0.032).Conclusion The presence of ischemic heart disease and unstable VT paroxysms can be included in the number of important clinical predictors of VT in patients with CHFrLVEF. In patients with non-ischemic CHF, the presence of AF is associated with a high risk of VT.

Role of fibrinogen–erythrocyte and erythrocyte–erythrocyte adhesion on cardiovascular pathologies

Cardiovascular pathologies are the major cause of death worldwide. Erythrocyte aggregation is an indicator of cardiovascular risk, which is influenced by high plasma fibrinogen levels. Our main goals were to understand how fibrinogen–erythrocyte binding influences erythrocyte aggregation and how it constitutes a cardiovascular risk factor in essential arterial hypertension (EAH) and chronic heart failure (CHF). Differences on cell stiffness, protein-cell interaction and cell–cell adhesion forces were evaluated by AFM-based force spectroscopy with cells from 31 EAH patients, 30 CHF patients and 15 healthy blood donors. The main procedures used were previously described by us [1–3]. Results were correlated with patients’ clinical profiles. From cell–cell adhesion studies, we concluded that, upon increasing fibrinogen concentration (from 0 to 1 mg/mL), there was an increase in the work and force necessary for erythrocyte–erythrocyte detachment on EAH patients and healthy donors. Nevertheless, higher values from both parameters were obtained for EAH patients, when comparing to healthy donors, at each fibrinogen concentration [4]. Fibrinogen-erythrocyte (un)binding forces were higher in EAH and in CHF patients, when compared with the control group, despite a lower binding frequency [5,6]. Ischaemic CHF patients showed increased binding forces compared to non-ischaemic patients. A 12-month clinical follow-up shows that CHF patients with higher fibrinogen–erythrocyte binding forces, probed by AFM at the beginning of the assessment, had a significantly higher probability of being hospitalised due to cardiovascular complications, pointing out the value of AFM for clinical prognosis [5]. Erythrocyte stiffness studies revealed differences between patients and healthy donors, in terms of erythrocyte elasticity (Young’s modulus) and AFM tip penetration depth into the cells [5,6]. Erythrocytes from non-ischaemic CHF patients presented a higher average stiffness than those from the other groups (ischaemic CHF and control). Nevertheless, a significantly higher cell penetration depth at the same applied force was observed for ischaemic CHF patients [5]. In conclusion, fibrinogen promotes erythrocyte adhesion, leading to its aggregation, probably by transient simultaneous binding of the protein to two cells, bridging them. Our results may be relevant for potential future drug interventions to reduce aggregation and enhance microcirculatory flow conditions in cardiovascular patients.

Biventricular pacemaker and defibrillator implantation in patients with chronic heart failure in China.

AimsThis study aims to investigate the current status of biventricular pacemaker and defibrillator implantation in chronic heart failure (CHF) patients with indications for primary prevention of sudden cardiac death (SCD) in China and the effects of cardiac resynchronization therapy (CRT)‐pacemaker (P) and CRT‐defibrillator (D) implantation on the clinical prognosis of CHF among patients undergoing CRT.Methods and resultsOverall, 798 consecutive patients who had devices implanted (implantable cardioverter defibrillator: 199, CRT‐D: 362, and CRT‐P: 237) from May 2012 to July 2013 in POSCD‐China, a multicentric prospective cohort study, were enrolled. The primary endpoint was all‐cause death, and the secondary endpoint was SCD. In total, 71.3% of patients had non‐ischaemic CHF. The mean follow‐up time was 27.7 ± 12.0 months, and death occurred in 158 cases, with 35 cases of SCD. CHF was the main cause of death (68.4%), followed by sudden death (22.2%). In the CRT‐P group, the SCD rate was 8.0%, which was much higher than that in the CRT‐D (3.3%) and implantable cardioverter defibrillator (2.0%) groups. No significant differences were identified in the all‐cause death rate between the CRT‐D and CRT‐P groups (CRT‐D vs. CRT‐P, 20.4% vs. 19.4%, P = 0.840).ConclusionsIn China, among CHF patients with indications for primary prevention of SCD who received device implantation, non‐ischaemic CHF was the main aetiology, and the most important cause of death was heart failure. No differences in all‐cause death were observed between the CRT‐D and CRT‐P groups, but the CRT‐D group had a lower SCD rate than the CRT‐P group.

P2614Comparison of global longitudinal strain and ejection fraction in correlation to NT-proBNP in ischemic and non-ischemic heart failure

Abstract Background In chronic heart failure (CHF) NT-proBNP and left ventricular ejection fraction (LVEF) by echocardiography are standard diagnostic as well as follow-up markers and are known to correlate with prognosis. Speckle-tracking echocardiography is a more recent technique to quantify myocardial deformation as a measurement of left ventricular function with potential benefits over LVEF. Purpose The purpose of this investigation was to analyse the cross-sectional relationship between 2D speckle tracking-derived global longitudinal strain (GLS) and NT-proBNP plasma levels in a prospective cohort of ischemic and non-ischemic CHF patients. Methods We enrolled 205 patients with chronic heart failure. Major inclusion criteria were age over 18 years, stable disease with absence of unplanned hospitalization or change in medication or device therapy in the previous month or major surgery in the previous 3 months. CHF treatment had to be according to the recommendations of the ESC CHF guidelines 2016 and LVEF had to be below 50%. Patient history, physical examination and an extensive echocardiography exam were performed. Lab results included NT-proBNP. Manual longitudinal strain was calculated using EchoPAC (General Electric Medical Systems, Horten, Norway) by a single and blinded examiner. LVEF was measured using Simpson's biplane method. Results 205 patients included in the study. The baseline characteristics included mean age 65.0 years and 75% male. Mean GLS was −9.6% (SD ±4.5%) and median NT-proBNP 1269.5 (IQR 379.5–2759.5) ng/ml. The CHF aetiology was 70.0% ischemic vs 30.0% non-ischemic. There was a significant negative correlation between GLS and NT-proBNP (Pearson r=0.239, p=0.029), this was not significant for LVEF and NT-proBNP (Pearson r=0.149, p=0.228).In a multivariate regression analysis adjusted for age, sex, NYHA classification and HF aetiology, GLS remained significantly correlated with NT-proBNP (adjusted beta-coefficient= 0.289, p=0.011). Furthermore, in contrast to LVEF, GLS showed a significant correlation to NT-proBNP in patients with ischemic (Pearson r=0.266, p=0.049) as well as non-ischemic aetiology of heart failure (Pearson r=0.434, p=0.034). Conclusion Global longitudinal strain, not LVEF, was significantly correlated with NT-proBNP in patients with CHF, independently of age, sex, symptoms or heart failure aetiology. This shows that speckle-tracking might be superior to LVEF for the assessment of left ventricular function in CHF.

Medical Therapy Optimization of Advanced Heart Failure in a Cancer Patient: When to Quit?

Introduction In CHF patients, medical therapy optimization (MTO) remains the mainstay of management. However, attaining MTO can be challenging in patients with advanced CHF due to their symptomatic and hemodynamic intolerance. We present a case of a patient with advanced CHF and rectal cancer in whom slowly cautious MTO succeeded in improving cardiac function and candidacy for cancer chemotherapy and surgery. Case A 57-year-old male with a medical history of advanced nonischemic CHF (EF 10-15%), a-fib, and rectal well-differentiated adenocarcinoma stage IIA (diagnosed 1 month ago) with GI bleeding and defecation pain presented with dyspnea on minimal exertion and orthopnea. He also had dizziness with standing due to symptomatic hypotension. SBP was between 100-115 mmHg. MRI pelvis showed T3 rectal mass with no enlargement of lymph nodes. Further imaging showed no distant metastases. Due to his advanced CHF, the patient was considered at high risk for surgery or chemotherapy. Rectal palliative radiation therapy was performed. He agreed on hospice palliative care for symptomatic relief. From Cardiology stand of point, the decision was made to continue MTO aiming for myocardial recovery. Radical adjustment of regimen and initiation of medications at miniscule doses eventually led to myocardial recovery with EF of 51% (figure 1). Patient's SOB and dizziness improved. Cancer progressed to stage IIIb. Due to his improvement, the patient became at lower cardiac risk for other cancer therapy options. As a result, Oncology plan changed to proceed with FOLFOX (5-FU/ Leucovorin/ Oxaliplatin) chemotherapy and surgery. Discussion In our patient, advanced therapy with left ventricular assist device was not possible given his risk of worsening GI bleeding on anticoagulation. Heart transplantation was not an option given the risk of cancer progression on immunosuppressive therapy. In the context of the patient's condition and comorbidities, the best option left was to proceed with cautious MTO with clinical and hemodynamic monitoring. MTO resulted in clinical and cardiac function improvement. This gave the patient the window to become a candidate for other cancer therapy options that were not available for him before. Conclusion Medical therapy optimization in all patients with CHF should always be sought. Despite being challenging under certain circumstances, as seen in our patient, slow and cautious MTO can eventually result in significant improvement in clinical status, cardiac function, and candidacy for other therapy options for other comorbidities.

Functional capillary impairment in patients with ventricular assist devices

The implantation of continuous – flow ventricular assist devices (VAD) is suggested to evoke angiodysplasia contributing to adverse events such as gastrointestinal bleeding. We evaluated in vivo capillary density and glycocalyx dimensions to investigate possible systemic microvascular changes in patients with chronic heart failure and VAD support vs. standard medical treatment. Forty-two patients with VAD support were compared to forty-one patients with ischemic and non-ischemic chronic heart failure (CHF) on standard pharmacotherapy and to a group of forty-two healthy subjects in a prospective cross-sectional study. Sublingual microcirculation was visualized using Sidestream Darkfield videomicroscopy and functional and perfused total capillary densities were quantified. Patients with VAD implantation were followed for one year and bleeding events were recorded. Median time after VAD implantation was 18 months. Patients were treated with centrifugal-flow devices (n = 31) or axial-flow devices (n = 11). Median functional capillary density was significantly lower in patients with VAD therapy as compared to CHF patients (196 vs. 255/mm2, p = 0.042, adjusted p-value). Functional and total capillary densities were 44% and 53% lower (both p < 0.001) in patients with VAD therapy when compared to healthy subjects. Cox regression analysis revealed loss of capillary density as a significant predictor of bleeding events during one -year follow-up of VAD patients (HR: 0.987, CI (95%): 0.977–0.998, p = 0.021 for functional and 0.992, CI (95%): 0.985–0.999, p = 0.03 for total capillary density). In conclusion, patients with VAD support exhibit capillary density rarefaction, which was associated with bleeding events. If confirmed independently, capillary impairment may be evaluated as novel marker of bleeding risk.

Association of levels of interleukin 17 and T-helper 17 count with symptom severity and etiology of chronic heart failure: a case-control study

AimTo assess the association between the levels of interleukin 17 (IL-17) and T-helper 17 count and symptom severity and etiology of chronic heart failure.MethodsThis single-center prospective case-control study, conducted from December 1, 2015 to January 1, 2017 in Tehran Heart Center, evaluated gene expression of IL-17, relative count of (CD4+IL17+) Th17 cells and CD4+ helper T-cells in peripheral blood mononuclear cells of 42 patients with CHF and 42 matched controls. A multiple regression model assessed the predictors of peripheral IL-17 expression and Th17 count in patients with CHF.ResultsIL-17 expression was increased in patients with CHF, both at baseline and after stimulation. IL-17 and Th17 counts were higher in patients with advanced New York Heart Association (NYHA) functional class (class IV) than in controls and patients with class I. Th17 cell population expanded in patients with CHF, more prominently in patients with class IV than in controls and patients with class I, regardless of the ischemic or non-ischemic CHF origin. Multiple regression model showed that NYHA was the only meaningful predictor of IL-17 levels and Th17 count.ConclusionWe demonstrated the lymphocytic origin of IL-17 production in advanced CHF and the ability of disease severity to predict IL-17 levels.Oxford Centre for Evidence-based Medicine level of evidence: 3.

CARDIAC SYMPATHETIC ACTIVITY, MYOCARDIAL PERFUSION AND HEART CONTRACTILITY IN PATIENTS WITH ISCHAEMIC AND NON-ISCHAEMIC HEART FAILURE

Purpose:to assess the cardiac sympathetic activity, perfusion and contractility in ischemic and nonischemic chronic heart failure patients by using a radionuclide methods.Material and Methods.The study included 33 heart failure patients with NYHA class III and ischemic (n=13.39%) and non-ischemic (n=20.61%) heart failure. All patients underwent123I-MIBG imaging, myocardial perfusion imaging with 99mTc-MIBI and gated blood-pool single-photon emission computed tomography. Based on123I-MIBG study heart to mediastinum ratio as well as123I-MIBG washout rate were calculated. According to the myocardial perfusion imaging, Summed Rest Score was evaluated. Systolic and diastolic functions and ejection fraction as well as mechanical intraventricular dyssynchrony of both ventricles were analyzed by gated blood-pool single-photon emission computed tomography.Results.There was no statistically significant difference of hemodynamic parameters between the groups. In the first group, which include patients with ischemic heart failure, there were found the following correlations: washout rate and left ventricular end-diastolic volume (0.75; p&lt;0.05), washout rate and left ventricular end-systolic volume (0.68; p&lt;0.05), heart to mediastinum ratio and right ventricular ejection fraction (–0.57; p&lt;0.05). In the group of patients with non-ischemic heart failure there were the following correlation: heart to mediastinum ratio and left ventricular end-systolic volume (–0.77; p&lt;0.05), heart to mediastinum ratio and left ventricular ejection fraction (0.77, p&lt;0.05), heart to mediastinum ratio and right ventricular ejection fraction (0.62, p&lt;0.05), washout rate and left ventricular interventricular dyssynchrony (0.6; p&lt;0.05).Conclusion.It was found out that heart failure patients were characterized by a correlation between sympathetic activity and volumes, hemodynamics and contractility of heart ventricles. The relationship between the cardiac sympathetic activity and myocardial perfusion as well as contractility depend on the etiology of chronic heart failure.