NYHA FC Research Articles

TWO-THIRDS OF HEART FAILURE PATIENTS WHO MEET THE FDA-APPROVED INDICATION FOR SACUBITRIL/VALSARTAN DO NOT MEET PARADIGM-HF ENROLLMENT CRITERIA AFTER RECENT HOSPITALIZATION

The angiotensin-neprilysin inhibitor sacubitril/valsartan was approved by FDA for NYHA FC II-IV chronic heart failure (HF) patients with reduced ejection fraction (HFrEF) based on the PARADIGM-HF trial, which excluded patients with low GFR, low baseline BP, and ACE inhibitor (ACE-I) and beta blocker

Abstract 212: Integration of Multiple Cardiac Biomarkers into a Disease-Specific Score: Relationship to Clinical Status and Therapeutic Intensity

Introduction: The 2013 American College of Cardiology/American Heart Association postulated four blood biomarkers as key parameters in the risk-stratification and management of heart failure (HF). These four markers, troponin I or T, B-type natriuretic peptide or N-terminal BNP, galectin-3, and ST2, each reflect different aspects of myocardial pathophysiology in HF. We propose a novel method of integration of biomarkers which are summarized into a Modified Myocardial Injury Summary Score (MMISS) to serve as an individualized biomarker-based index of HF severity. Methods: For each patient, biomarkers were used to calculate the MMISS (Σ log10 [Biomarker(i)measured / Biomarker(i)ULN]/n, i=1). Pharmacologic regimen recorded at the time of biomarker draw was assimilated into a Therapeutic Intensity Index (TTI) based upon dosing of pertinent HF drug classes. A univariate analysis was performed to determine the relationship between MMISS and TII among patients included in this cross sectional study. Results: Of the 39 patients included in the study, 61.9% were male with a mean age of 60.5 ± 10.5. A total of 13(33.3%), 22(56.4%), and 4(10.3%) patients were classified as NYHA FC 2, 3, and 4, respectively. The etiology of HF was ischemic cardiomyopathy in 51% of patients. In creating the MMISS, 24(61.5%), 2(5.1%), and 13(33.3%) patients had two, three, and four biomarkers available, respectively. Through our analysis, we found the MMISS (range -0.76 to +1.08) to have no association with TII (R= -0.23, p=0.15). Conclusions: There is no significant correlation between the intensity of medical management and myocardial disease severity as reflected by cardiac biomarkers measured at a single time in cross-section. Our findings suggest there may be an opportunity to tailor therapy to the severity of disease as indicated by blood biomarkers. We plan to use our observation as basis for a randomized trial that leverages measured changes in MMISS to guide personalization of medical therapy.

Impaired norepinephrine regulation of monocyte inflammatory cytokine balance in heart failure.

AIMTo evaluate the effect of norepinephrine on inflammatory cytokine expression in ex vivo human monocytes and monocytic THP-1 cells.METHODSFor human monocyte studies, cells were isolated from 12 chronic heart failure (HF) (66 ± 12 years, New York Heart Association functional class III-IV, left ventricular ejection fraction 22% ± 9%) and 14 healthy subjects (66 ± 12 years). Monocytes (1 × 106/mL) were incubated with lipopolysaccharide (LPS) 100 ng/mL, LPS + norepinephrine (NE) 10-6 mol/L or neither (control) for 4 h. Tumor necrosis factor-alpha (TNFα) and interleukin-10 (IL-10) production were determined by ELISA. Relative contribution of α- and β-adrenergic receptor subtypes on immunomodulatory activity of NE was assessed in LPS-stimulated THP-1 cells incubated with NE, the α-selective agonist phenylephrine (PE), and the β-selective agonist isoproterenol (IPN). NE-pretreated THP-1 cells were also co-incubated with the β-selective antagonist propranolol (PROP), α2-selective antagonist yohimbine (YOH) or the α1-selective antagonist prazosin (PRAZ).RESULTSBasal TNFα concentrations were higher in HF vs healthy subjects (6.3 ± 3.3 pg/mL vs 2.5 ± 2.6 pg/mL, P = 0.004). Norepinephrine’s effect on TNFα production was reduced in HF (-41% ± 17% HF vs -57% ± 9% healthy, P = 0.01), and proportionately with NYHA FC. Increases in IL-10 production by NE was also attenuated in HF (16% ± 18% HF vs 38% ± 23% healthy, P = 0.012). In THP-1 cells, NE and IPN, but not PE, induced a dose-dependent suppression of TNFα. Co-incubation with NE and antagonists revealed a dose-dependent inhibition of the NE suppression of TNFα by PROP, but not by YOH or PRAZ. Dose-dependent increases in IL-10 production were seen with NE and IPN, but not with PE. This effect was also antagonized by PROP but not by YOH or PRAZ. Pretreatment of cells with IPN attenuated the effects of NE and IPN, but did not induce a response to PE.CONCLUSIONNE regulation of monocyte inflammatory cytokine production may be reduced in moderate-severe HF, and may be mediated through β-adrenergic receptors.

Incidence and prognosis implications of long term left ventricular reverse remodeling in patients with dilated cardiomyopathy

BackgroundLeft ventricular reverse remodeling (LVRR) in dilated cardiomyopathy is poorly known within the context of current therapeutic approach. Our goal is to describe the present incidence of LVRR, the factors able to predict it and the long term prognosis of these patients. Methods and resultsWe performed a retrospective analysis of a cohort or 387 consecutive outpatients. Mean follow-up was 50.4±28.4months. Sustained LVRR occurred in 57.6% of patients.The number of coronary arteries with severe stenosis (HR 0.69, 95% CI 0.55–0.86; p=0.001), New York Heart Association Functional Class (NYHA FC) (HR 0.39, 95% CI 0.27–0.54; p<0.001) as well as the severity of mitral regurgitation (MR) at the end of follow-up (HR 0.42, 95% CI 0.30–0.58; p<0.001) and the time until first event (HR 1.02, 95% CI 1.01–1.03; p<0.001) were independent predictors of left ventricular ejection fraction improvement.LVRR was tightly related to prognosis due to the fact that both improvement in cardiac function achieving normal or slightly impaired LVEF (HR 0.31, 95% CI 0.17–0.56; p<0.001) and shorter time to achieve LVRR (HR 0.99, 95% CI 0.98–0.99; p=0.017) formed part of the best model for predicting events in DCM. ConclusionMore than half of the patients showed sustained LVRR associated with a significantly better prognosis.Fewer numbers of coronary arteries with severe stenosis, milder NYHA FC and the absence of significant MR at the end of follow-up as well as longer event free period formed a simple model to prognosticate LVRR.LVRR and the time to achieve it were strongly related to long term prognosis in patients with DCM.

Effect of cardiac resynchronization therapy on ventricular tachycardias in patients with dilated cardiomyopathy and severe heart failure

The aim of the study was to elucidate the effects of cardiac resynchronization therapy (CRT) on ventricular tachycardias in patients with dilated cardiomyopathy and to analyze the prospects of radionuclide diagnostic methods for prediction of life-threatening arrhythmias in the presence of therapy. The study included 70 patients (mean age 55 12 years) aged 32 to 75 years with dilated cardiomyopathy, NYHA FC III heart failure, left ventricular (LV) ejection fraction (EF) of 30.1 3.8%, and end-diastolic volume (EDV) of 220.7 50.9 mL. Group 1 comprised 35 patients (50%) diagnosed with paroxysms of ventricular tachycardia, while Group 2 consisted of 35 patients (50%) without episodes of ventricular tachycardia. After one year of CRT, positive clinical changes were documented in all patients: LV EF increased to 42.8 4.8% (p 0.001); functional class of heart failure decreased to II; LV EDV decreased to 197.9 47.8 mL (p 0.005). The patients whose EF increased by 14% and EDV decreased by 35 mL during one-year CRT had no episodes of ventricular tachycardia. The patients, whose paroxysms of ventricular tachycardia persisted during the entire period of the study, showed EF increase by 9% and EDV decrease by 13 mL. The second stage of the study consisted in evaluating the effects of myocardial metabolism defects (MMD). No ventricular tachycardia episodes were registered in patients whose MMD became less than 15% during CRT; if the size of DMM exceeded 15%, paroxysms of ventricular tachycardia were observed. Thus, efficacious CRT in patients with dilated cardiomyopathy results in a statistically significant reduction of the number of ventricular tachycardia episodes. The improvement of fatty acid metabolism contributes to a decrease in the number of ventricular tachycardia episodes in the course of CRT.

FEASIBILITY AND SAFETY OF HM II TO HVAD VS. HM II TO HM II EXCHANGE STRATEGY FOR PUMP THROMBOSIS

The reported incidence of pump thrombosis (PT) with the Heartmate II (HMII) LVAD has increased, yet neither recent HMII design changes nor specific mechanical risk factors appear to fully explain this rise in PT. Our institutional approach is to consider pump exchange (PE) to the Heartware (HVAD) in HMII patients with PT. We compared our experience with HMII-HMII vs. HMII-HVAD exchanges to determine if the latter strategy is feasible, well-tolerated, and associated with similar clinical outcomes compared with the prevailing standard of HMII-HMII exchange. This was a retrospective case series of all HMII patients who underwent PE (n=9) from 2009-2013 for suspected PT (Group A: HMII-HMII, n=4; Group B: HMII-HVAD, n=5). We assessed the following post-PE outcomes: INTERMACS-defined right ventricular failure (RVF) and major bleeding; renal failure requiring dialysis; recurrent suspected PT; NYHA FC; and mortality at 90 days and at 1 year. The majority of patients underwent initial HMII implantation from 2012-2013 (n= 8; 89%). Of the group A patients, 75% were BTT at time of exchange. The median time to PE was 207 days (range 42 to 1311). Manufacturer analysis confirmed HMII PT in 8 patients, with 1 patient’s pump deemed inconclusive. Overall survival following PE was 89% at 90-days and 67% at 1 year. Survival by groups at 90 days and at 1 year was: 75% and 50% (Group A) vs. 100% and 80% (Group B). Patients in both groups were either NYHA FC 2 or 3 at 90 days. Post-PE morbidity included: RVF (Group A 50% vs. Group B 20%), renal failure (Group A 25% vs. Group B 20%), major bleeding (Group A 50% vs. Group B 40%) and recurrent suspected PT (Group A 50% vs. Group B 20%). Two patients had recurrent suspected PT following HMII to HMII (1 urgently transplanted; 1 died suddenly by 1 year). One patient with recurrent PT following HMII to HVAD exchange had a known hypercoagulable state, and also died within 1 year post-exchange (at 285 days). HMII to HVAD PE is an acceptable and surgically feasible strategy for those with HMII PT. Our experience indicates that HMII to HVAD PE is not associated with increased morbidity or mortality compared with HMII to HMII exchange. While the rates of recurrent PT may appear to favour exchange to HVAD, this warrants larger clinical study, and a firmer understanding of the pump-specific risks related to the HMII.

Prognostic value of neutrophil-to-lymphocyte ratio in pulmonary arterial hypertension.

To evaluate the prognostic value of baseline neutrophil-to-lymphocyte ratio (NLR) in the prediction of long-term mortality in patients with pulmonary arterial hypertension (PAH). This prospective study recorded NLR during initial diagnostic right-sided cardiac catheterization in adult patients with PAH. Demographic, clinical, laboratory and haemodynamic variables were compared by NLR tertile. Univariate and multivariate Cox regression analyses were used to determine whether NLR was independently associated with mortality. Adults with PAH (n = 101) were followed-up for mean ± SD 36.8 ± 23.6 months. The number of deaths, New York Heart Association functional capacity (NYHA FC), levels of brain natriuretic peptide (BNP) or C-reactive protein (CRP) and presence of pericardial effusion increased as the NLR tertile increased, but haemoglobin and tricuspid plane annular systolic excursion (TAPSE) decreased. On univariate analysis, high NLR values were associated with mortality, but on multivariate analysis, NLR did not remain an independent predictor of mortality. Baseline NYHA FC, TAPSE, BNP level and pericardial effusion were independent predictors of mortality. NLR was correlated with important prognostic markers in PAH such as NYHA FC, BNP and TAPSE. This simple marker may be useful in the assessment of disease severity in patients with PAH.

CLINICAL ASPECTS OF MYOCARDIAL ELECTRICAL INSTABILITY IN CHRONIC IHD

The aim of the study was to assess associations between myocardial electrical instability estimates (heart rhythm turbulence, T- wave microvolt alternation, QT dispersion) and structural and functional changes in heart in the settings of IHD with ventricular premature beats. Eighty two subjects with exertional angina (NYHA FC II-III) and Lown Grade 3-5 class ventricular arrhythmia were examined. Controls included 28 pts. with chronic IHD with no arrhythmias. Heart rhythm turbulence, T- wave alternation and QT dispersion were defined based on 12-lead ECG data with record duration of 5 minutes using Intecard-7 apparatus. All patients underwent common clinical examination, 60-lead electrocardiogram (ECTG-60), ECG daily monitoring test (SMECG) (Cardian, Belarus), bicycle ergometric test, short ECG recording vagal sympathetic balance was estimated (using Briz Program Package and SMECG). IHF subjects who had Lown Grade III-V class ventricular arrhythmia had a higher frequency of heart rhythm turbulence disturbance, higher T microvolt alternation estimates and QT dispersion. Close relationship between myocardial electrical instability parameters (heart rhythm turbulence, T microvolt alternation and QT dispersion) and myocardial ischemic signs, LVEF, and heart rhythm variability in chronic IHD have been identified.

MULTIPLEX ANALYSIS OF BIOMARKERS OF NEOANGIOGENESIS AND INFLAMMATION IN HEART TRANSPLANT RECIPIENTS

Aim of study: multiplex analysis of the levels of biomarkers of neoangiogenesis and inflammation in cardiac transplant recipients. Materials and methods. 59 pts. with heart failure III–IV according to NYHA FC, waiting for a heart transplant, aged 22 to 73 years, 48 males and 11 females. 41 recipient (30 men and 11 women) had dilated cardiomyopathy, 18 – coronary heart disease (CHD). The concentration of VEGF-A, VEGF-D, PlGF, PDGF-BB, FGF, sCD40L, MCP-1 was measured using xMAP technology, the sets of reagents Simplex ProcartaPlexTM (Affymetrix, USA). Results. There are four levels of seven biomarkers of neoangiogenesis and inflammation method for multiplex analysis in patients with heart failure. A year after transplantation, the mean levels of biomarkers VEGF-A (p = 0.001), PDGF-BB (p = 0.018), MCP-1 (p = 0.003) was significantly decreased, and the others had a tendency to decrease relative to the level before transplantation. It was shown individual differences of levels of VEGF-A, VEGF-D and PlGF before and after transplantation. There were found different dynamics of the concentrations of biomarkers and growth factors before and after heart transplantation in patients with cardiovascular complications and without them. Conclusion. Multiplex analysis allows to measure the concentration range of analyte biomarkers of neoangiogenesis, inflammation in one sample of blood serum of patients with severe heart failure and after transplantation. There are marked individual differences in the concentration of biomarkers in different clinical situations that may have clinical significance in the conduct and supervision of recipients after transplantation.

Is early diagnosis of pulmonary arterial hypertension possible in inflammatory rheumatic diseases? Experience from a single center in Turkey.

Pulmonary arterial hypertension (PAH) is a devastating complication of inflammatory rheumatic diseases. The aim of this study was to determine the role of screening for the early diagnosis of pulmonary hypertension (PH) in inflammatory rheumatic diseases. Data of patients with inflammatory rheumatic diseases and PH who had no obvious cause of PH and who were evaluated by Working Group for Pulmonary Hypertension in Hacettepe University were investigated retrospectively. All patients with inflammatory disease were evaluated by right heart catheterization (RHC) to check if they had systolic pulmonary arterial pressure (sPAP) ≥40 mmHg and/or symptoms related to PH unless explained by other causes. RHC was performed in 47 patients with inflammatory rheumatic diseases and PH out of 50 patients who were to be evaluated by RHC based on clinical and Doppler echocardiographic findings. There was a positive correlation between sPAP estimated by Doppler echocardiography and sPAP determined by RHC in patients with inflammatory rheumatic diseases (r=0.66; p<0.001). The mean pulmonary arterial pressure (mPAP) was found to be <25 mmHg in 27.7% of the patients. New York Heart Association functional capacity (NYHA FC) was class III or IV in 79.0% of the patients with PAH. PAH was more frequent in patients with NYHA FC III-IV compared with patients with NYHA FC I-II [58.7% (15) patients vs. 19.0% (4) patients; p=0.009]. In this study, approximately 80% of the patients with inflammatory disease-associated PAH were diagnosed late in NYHA FC III or IV. There are still unresolved issues in the diagnosis and treatment of PH in inflammatory diseases. Collaboration and multidisciplinary approach are the key points to overcome the challenges in this field.

Saudi experience in the management of pulmonary arterial hypertension; the outcome of PAH therapy with the exclusion of chronic parenteral prostacyclin.

AIMS:The purpose of this study is to present our center's experience in managing patients with pulmonary arterial hypertension (PAH). The main objective is to describe patients' management profile and treatment outcome.METHODS:This study presents the results from a single pulmonary hypertension (PH) specialized center in Saudi Arabia. Both incidence and prevalence cases are included. We have previously reported the clinical and physiological characteristics at the time of diagnosis for this cohort of patients. In this study, we describe the clinical management and the outcome of therapy in the same cohort, who were prospectively followed for a mean of 22 months.RESULTS:A total of 107 patients were identified as having PAH. At the time of enrollment, 56.1% of patients were in modified New York Heart Association functional class (NYHA FC) III and 16.8% were in IV. Phosphdiesterase-5 inhibitor was the most commonly used target therapy (82.2%) followed by endothelin receptors antagonist (74.4%). Only five patients (4.7%) were candidate to use calcium channel blockers. Seventy-nine patients (73.8 %) received a combination nonparenteral target therapy. Thirty-one patients (28.9%) died during the follow-up period. Modified NYHA FC III and IV patients, portopulmonary hypertension, heritable PAH, and PAH associated with connective tissue diseases had the highest mortality rate (P < 0.001).CONCLUSION:Our patients are detected at advanced stage of the disease, and thus the mortality is still unacceptably high. Advanced functional class at presentation and certain disease subgroups are associated with increased mortality.

Coronary Stress Test as a Predictor of Quality of Life in Chronic Heart Failure Patients

Abstract Introduction. Exercise tolerance is one of the life quality parmeters in chronic heart failure patients. The aim of our study was to assess the quality of life of patients with chronic heart failure by estimating their exercise tolerance. Methods. We examined 113 patients with stable chronic heart failure in the period of 18 months. They were divided in two groups, a control group (on conventional therapy of angiotensin-converting enzyme inhibitors and diuretics) and a therapy group (conventional therapy plus beta-blockers). The therapy group was divided into 3 subgroups according to the beta-blocker taken (a Metoprolol Bisoprolol and Carvedilol subgroup). Exercise tolerance was detected by coronary trade-mill stress testing every 6 months (only in patients of NYHA FC II and III), symptoms limited or modified after 6-minutes Bruce test. Results. Our results showed that there was a statistically significant difference between the control group and all the therapy subgroups in NYHA FC, NYHA score and exercise tolerance at the end of the study, but there was no difference among the subgroups. Conclusion. Beta-blockers improve the exercise tolerance as a variable defining quality of life.

Echocardiographic Predictors of Worse Outcome After Cardiac Resynchronization Therapy.

BackgroundCardiac resynchronization therapy (CRT) is the recommended treatment by leading global guidelines. However, 30%-40% of selected patients are non-responders.ObjectiveTo develop an echocardiographic model to predict cardiac death or transplantation (Tx) 1 year after CRT.MethodObservational, prospective study, with the inclusion of 116 patients, aged 64.89 ± 11.18 years, 69.8% male, 68,1% in NYHA FC III and 31,9% in FC IV, 71.55% with left bundle-branch block, and median ejection fraction (EF) of 29%. Evaluations were made in the pre-implantation period and 6-12 months after that, and correlated with cardiac mortality/Tx at the end of follow-up. Cox and logistic regression analyses were performed with ROC and Kaplan-Meier curves. The model was internally validated by bootstrapping.ResultsThere were 29 (25%) deaths/Tx during follow-up of 34.09 ± 17.9 months. Cardiac mortality/Tx was 16.3%. In the multivariate Cox model, EF < 30%, grade III/IV diastolic dysfunction and grade III mitral regurgitation at 6-12 months were independently related to increased cardiac mortality or Tx, with hazard ratios of 3.1, 4.63 and 7.11, respectively. The area under the ROC curve was 0.78.ConclusionEF lower than 30%, severe diastolic dysfunction and severe mitral regurgitation indicate poor prognosis 1 year after CRT. The combination of two of those variables indicate the need for other treatment options.

Abstract 12899: A New Prognostic Marker for Functional Deterioration in Heart Failure: Coronary Vascular Resistance

Introduction: Heart failure (HF) is a challenging clinical syndrome with complex pathophysiology. Previous studies demonstrated that coronary flow reserve assessed by PET technique was impaired in HF. Transthoracic echocardiography (TTE) can provide reliable data for myocardial blood flow (MBF) which can be measured from coronary sinus (CS). In relation with MBF, coronary vascular resistance (CVR) can be evaluated. In this study, we aimed to evaluate the association of MBF and CVR with clinical data in HF. Methods: The MBF was measured in 100 patients (80 patients with HF (LVEF&lt;30%) and 20 healthy control subjects. MBF was measured from anterograde CS flow TVI at PLAX RV inflow view and CS diameter at A2C view (2Πr2*TVI*heart rate) and indexed to left ventricular mass index. Patient group was categorized based on NYHA functional classes (NYHA FCs). Results: There was an incremental trend for MBF with advancing NYHA FCs (β=0.253, p=0.015). MBF was similar among HF patients due to NYHA FCs. However, MBF was higher in NYHA FC 4 group compared to healthy subjects (p=0.029). Also, CVR was lower in HF patients than the control group (11.15±6.54 vs.24.84±7.29, p&lt;0.001). In the subgroup analysis, CVR was not statistically different between non-ischemic and ischemic etiology of HF (6.91±1.38 vs. 6.31±0.89, p=0.249). Additionally, CVR was significantly lower in NYHA FC 4 compared to other study groups. CVR was positively correlated with peak VO2 (β=0.596, p&lt;0.001), and Seattle Heart Failure Model derived life expectancy (β=0.476, p&lt;0.001) and negatively correlated with serum BNP level (β=-0.450, p=0.001), troponin I (β=-0.366, p=0.001) and serum uric acid level (β=-0.503, p&lt;0.001). In multivariate analysis, CVR is an independent predictor of mortality (HR:0.763 95%CI:0.624-0.933 P=0.008). In ROC analysis, a cut of value 6.73 for CVR has a 74% sensitivity and 66.7 % specifity for prediction of mortality in HF(AUC 0.825 P&lt;0.001). Conclusion: Our results showed that CVR was reduced with advancing FC in HF patients, despite MBF was similar among different FCs. In addition, CVR was significantly correlated with various prognostic markers in HF patients. Therefore, evaluation of MBF hemodynamics, particularly CVR, with TTE may utilize prognostic assessment of HF patients.

Safety and feasibility of coronary stenting in unprotected left main coronary artery disease in the real world clinical practice--a single center experience.

BackgroundThis study evaluated the feasibility, safety, and prognostic outcome in patients with significant unprotected left main coronary artery (ULMCA) disease undergoing stenting.Method and ResultsBetween January 2010 and December 2012, totally 309 patients, including those with stable angina [13.9% (43/309)], unstable angina [59.2% (183/309)], acute non-ST-segment elevation myocardial infarction (NSTEMI) [24.3% (75/309)], and post-STEMI angina (i.e., onset of STEMI<7 days) [2.6% (8/309)] with significant ULMCA disease (>50%) undergoing stenting using transradial arterial approach, were consecutively enrolled. The patients’ mean age was 68.9±10.8 yrs. Incidences of advance congestive heart failure (CHF) (defined as ≥ NYHA Fc 3) and multi-vessel disease were 16.5% (51/309) and 80.6% (249/309), respectively. Mechanical supports, including IABP for critical patients (defined as LVEF <35%, advanced CHF, or hemodynamically unstable) and extra-corporeal membrane oxygenator (ECMO) for hemodynamically collapsed patients, were utilized in 17.2% (53/309) and 2.6% (8/409) patients, respectively. Stent implantation was successfully performed in all patients. Thirty-day mortality rate was 4.5% (14/309) [cardiac death: 2.9% (9/309) vs. non-cardiac death: 1.6% (5/309)] without significant difference among four groups [2.3% (1) vs. 2.7% (5) vs. 9.3% (7) vs. 12.5% (1), p = 0.071]. Multivariate analysis identified acute kidney injury (AKI) as the strongest independent predictor of 30-day mortality (p<0.0001), while body mass index (BMI) and white blood cell (WBC) count were independently predictive of 30-day mortality (p = 0.003 and 0.012, respectively).ConclusionCatheter-based LM stenting demonstrated high rates of procedural success and excellent 30-day clinical outcomes. AKI, BMI, and WBC count were significantly and independently predictive of 30-day mortality.

Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension--A single-center experience in Taiwan.

Pulmonary endarterectomy (PEA) is a potentially curative surgical procedure for patients with chronic thromboembolic pulmonary hypertension. The aim of this study is to review our institutional experience with this operation. We conducted a retrospective review of PEA performed at our institution between January 2005 and December 2013. The measured outcomes were inhospital complications, improvement in cardiac function and exercise capacity, and actuarial survival after PEA. Ten consecutive patients (7 women, 3 men) underwent PEA with a mean age of 59.9±12.9 years. The preoperative New York Heart Association functional class (NYHA FC) for these patients was either Class III (n=6) or Class IV (n=4). The period from symptom onset to diagnosis was 34.3±37.9 months, and that from diagnosis to operation was 31.4±46.8 months. After PEA, the duration of intensive care unit stay and hospital stay prior to discharge were 9.7±5.7 days and 18.7±7.4 days, respectively. Postoperative complications included reperfusion lung edema (n=3) and pneumonia (n=1), and all recovered with medical therapy. After a mean follow-up of 48.4±35.1 months, all patients showed marked improvements in their clinical status and were still alive without evidence of disease recurrence. With proper patient selection, the cooperation of a multidisciplinary team, and meticulous postoperative management, PEA can be conducted safely with relatively low risk at a center with limited experience with the procedure.

RESULTS OF INTRAMYOCARDIAL ADMINISTRATION OF A MONONUCLEAR FRACTION OF AUTOLOGOUS BONE MARROW CELLS IN CHD PATIENTS WITH CONCOMITANT CARDIAINSUFFICIENCY

Aim . Evaluation of long-term results of drug therapy and intramyocardial administration of a mononuclear fraction of bone marrow cells in CHD patients with chronic cardiac insuf fi ciency. Materials and methods . 109 patients were randomized into two groups by using an envelope method. Intramyocardial administration of a mononuclear fraction of autologous bone marrow cells and cardiac insuf fi ciency therapy were performed for the 1st group (n = 55), while the 2nd group (n = 54) received drug therapy only. All patients underwent clinical examination at admission and at 6 and 12 months after the onset of the study. Results. In the 1st group the angina functional class was reliably lowered (from 3.3 ± 0.2 at the onset of the study down to 2.5 ± 0.1 after 12 months). The distance covered during a 6-minute walk test increased from the initial 185 ± 39 meters up to 359 ± 69 me- ters by the end of the 12th month. The angina class decreased from 3.1 ± 0.4 at the onset of the study down to 1.6 ± 0.4 by the end of the 12th month. Minnesota Life Quality Index reduced from 65.3 ± 21 points down to 22.4 ± 6 points in the fi rst group, while in the control one it decreased down to 59.9 ± 16 points. On the contrary, cardiac insuf fi ciency in patients of the second group tended to continually progress: from NYHA FC 3.5 ± 0.1 at the beginning of the study up to 3.9 ± 0.1 in the course of 12-month observation. The angina class remained the same (3.5 ± 0.5 at the beginning and 3.5 ± 0.4 after 12 months respectively). Conclusion. Intramyocardial implantation of a mononuclear fraction of autologous bone marrow cells is a safe method that contributes to the improvement of the left ventricular function, clinical data and prognosis.

The Correlation between Peripartum Cardiomyopathy and Autoantibodies against Cardiovascular Receptors

BackgroundPeripartum cardiomyopathy (PPCM) is characterized by left ventricular systolic dysfunction and heart failure. However, its pathogenesis is not clear. Our preliminary study revealed that autoantibodies against β1-adrenergic receptors (β1R-AABs) and M2-muscarinic receptors (M2R-AABs) participated in heart failure regardless of primary heart disease. Whether β1R-AABs and M2R-AABs participate in the pathogenesis of PPCM is still unknown.MethodsTotally 37 diagnosed PPCM patients and 36 normal pregnant women were enrolled in this study. Clinical assessment and 2-dimensional echocardiographic studies as well as the measurement of β1R-AABs or M2R-AABs by enzyme linked immunosorbent assay (ELISA) were performed.ResultsThe positive rates for β1R-AABs and M2R-AABs were 59.5% (22/37) and 45.9% (17/37) in PPCM patients, and 19.4% (7/36) (P<0.001) and 16.67% (6/36) (P<0.001) in normal pregnant women, respectively. Both β1R-AABs and M2R-AABs had a positive correlation with serum expression level of NT-proBNP, left ventricular dimension and NYHA FC (rs: 0.496–0.892, P<0.01). In addition, a negative correlation between the activity of β1R-AABs and M2R-AABs and LVEF, LVFS was observed (rs: −0.488–0.568, P<0.01). Moreover, autoantibodies against cardiovascular receptors increased the risk of the onset of PPCM (OR = 18.786, 95% confidence interval 1.926–183.262, P = 0.012).ConclusionsThe β1R-AABs and M2R-AABs reveal a significant elevation and are correlated with the increased left ventricular dimension and worse cardiac contraction function. The autoantibodies of cardiovascular receptors are independent risk factors for the onset of PPCM.

Abstract 18401: The Immunoregulatory Cytokine FGL2 is Associated With Functional Impairment in Patients With Heart Failure

Introduction: Chronic heart failure is a condition that is characterized by immune activation and release of pro-inflammatory cytokines, which are associated with worsening functional class. Fibrinogen-like protein 2 (FGL2) is a novel immunoregulatory protein that is involved in innate and adaptive immune responses. A connection between plasma FGL2 levels and heart failure has not been previously reported. Objective: To determine if there is an association between plasma FGL2 levels and functional impairment in heart failure. Methods: Seventy-four heart failure patients with NYHA FC I-IV, standard medical treatment, mean age 55 ± 11 years, mean ejection fraction of 29% ± 10%, and 23% females were included. Functional impairment was assessed by determination of peak VO2. Plasma levels of FGL2 and CRP were determined using ELISA in HF patients and healthy controls. We compared peak VO2 according to tertiles of FGL2 using ANOVA (tertile 1&lt;39.7, tertile 2=39.7 to 63.2, and tertile 3&gt;63.2 ng/ml). Correlations were assessed using Pearson’s correlation. We performed a multiple linear regression analysis to investigate the association between peak VO2 and FGL2 adjusting for variables of clinical significance and/or statistical significance. Results are provided as mean ± SD. Results: The plasma levels of FGL2 were significantly higher in HF patients compared with controls (58.6 ± 41.2 versus 32.4 ± 14.7 ng/ml, respectively, p&lt;0.001). 28% of the patients had an ischemic cardiomyopathy, 34% had hypertension, and 18% had diabetes. In HF patients, the mean peak VO2 was 16.9 ± 5.0, 14.2 ± 4.9, and 12.7 ± 3.8 ml/kg/min in the 1 st , 2 nd and 3 rd tertile of FGL2, respectively (p= 0.012). FGL2 was negatively correlated with peak VO2 (r= -0.271, p=0.026) and positively correlated with CRP (r= 0.314, p=0.011). In the adjusted regression model, FGL2 was independently associated with peak VO2 (adjusted beta estimated=-0.031, test statistic=5.77, p=0.016). Conclusion: In heart failure patients, higher levels of plasma FGL2 were associated with a greater degree of functional impairment as measured by peak VO2. These results suggest that immune activation as measured by FGL2 is associated with the severity of heart failure.

The mid-term surgical results of Fontan conversion with antiarrhythmia surgery

We investigated the mid-term surgical results of Fontan conversion with antiarrhythmias surgery and permanent pacemaker implantation, which were complications of a previous Fontan operation. From January 1996 to November 2011, we performed Fontan conversion in 31 of 260 Fontan cases (M:F = 17:14, mean age = 19.0 years). The Fontan conversion from atriopulmonary connection (APC) to extracardiac conduit (ECC) was performed in 20 patients, APC to lateral tunnel in 5 and lateral tunnel to ECC in 6. The clinical outcomes and improvements of arrhythmias were analysed. The types of arrhythmias included atrial flutter in 21 patients, atrial fibrillation with flutter in 4 patients and junctional tachycardia in 3 patients. Twenty-six patients (83.9%) required antiarrhythmia surgery (isthmus cryoablation = 9, right-sided maze = 13, bilateral maze = 4). In addition, 23 patients (74.2%) received a permanent pacemaker. The New York Heart Association functional class (NYHA Fc) was statistically improved after the surgery during the 6.5-year median follow-up duration (preoperative NYHA Fc = 1.77, postoperative NYHA Fc = 1.13, n = 15, P = 0.001). There were 4 late mortalities. Actuarial 5-year survival was 90.0 ± 5.5%. And freedom from arrhythmia was 91.8 ± 5.5%, at 5 years. Normal sinus rhythm was maintained in 12 patients (38.7%), pacing-dependent rhythm in 10 patients (32.3%) and intermittent pacing-dependent rhythm in 4 patients (12.9%). Fontan conversion with antiarrhythmia surgery and permanent pacemaker implantation is safe and improves the clinical outcome and arrhythmias.