NYHA Stage Research Articles

Intermittent therapy with levosimendan in patients with advanced heart failure

Abstract Introduction Therapeutic options for patients with advanced heart failure on the high-urgent (HU) heart transplant (HTx) waiting list are limited. In view of the limited data on the usefulness of classic inotropes, the calcium sensitizer levosimendan (Lev) may be a possible alternative for patients in need of a repetitive therapy with an inotropic agent as a bridge to HTx. Method In a single-center open-label study we retrospectively analyzed data from 34 HU-listed patients (from a total collective of 95 HU patients) who repetitively received Lev (12.5 mg; 0,05–0.1 μg/kg/min over 24–48h) in 2–8 weeks intervals due to cardiac instability and/or progressive second organ dysfunction. Potential side effects as well as changes of kidney, liver and heart functional parameters were evaluated (0–6 days before, 4–8 days and 14–20 days after Lev infusion). Patient collective: age 51±10 years, 6 women, 28 men; NYHA stage III-IV. 11 Patients with ischemic cardiomyopathy (32%), 19 patients with dilated cardiomyopathy (56%), 4 patients with arrhythmogenic right ventricular cardiomyopathy (12%). Results The waiting time for HTx was up to 12 months (6±5 months). There were no adverse, serious events (resuscitation, defibrillation for ventricular tachycardia (VT), intubation and ventilation, renal replacement therapy) up to 7 days after Lev infusion. Transient cardiac arrhythmias (ventricular bursts or non-sustained VTs) occurred in 11 patients (32%) with spontaneous termination and no need of urgent anti-arrhythmic therapy. The values for sodium, potassium, Hb and CRP did not change significantly after Lev. In contrast, there was a significant reduction in creatinine after 4–8 days (initially 1.43±0.4 mg/dl; after 4–8 days 1.28±0.3; p<0.0005) with an increase again after 14–20 days (1.43±0.3 mg/dl). The bilirubin value was significantly reduced after 4–8 days (initially 1.63±0.7 mg/dl; after 4–8 days 1.30±0.5; p<0.0005) with only partial (non-significant) increases again over the course (1.34±0.5 mg/dl). The BNP value was significantly reduced 4–8 days after administration of Lev (initially 1565±1136 ng/l; after 4–8 days 1103±895; p<0.0001) and increased again in the longer time course (1462±1001 ng/l; p<0.001 versus 4–8 days). 28 patients were successfully transplanted (82%). 6 patients remained without HTx (18%), of which 1 patient (3%) with clinical improvement could be discharged. 2 patients (6%) received an LVAD and 3 patients (9%) died during the waiting period. Conclusion Intermittent therapy with Lev as “a bridge to transplant” is safe and effective concerning deterioration of heart failure and prevention of progressive kidney/hepatic dysfunction. However, a prospective randomized multi-center trial is necessary to underscore the encouraging data of this observational, single center study. Funding Acknowledgement Type of funding sources: None.

Effects of Pre-Operative Risk Factors on Intensive Care Unit Length of Stay (ICU-LOS) in Major Oral and Maxillofacial Cancer Surgery.

Simple SummaryThis study aimed to investigate the effect of certain pre-operative parameters from the clinical routine directly on the post-operative intensive care unit (ICU)-length of stay (LOS) after major oral and maxillofacial cancer surgery. This study was performed to identify at-risk patients that are expected to need prolonged specialized care management post-operatively to these aforementioned operations. A homogenous cohort of 122 patients over a five year period was included in this study. At-risk patients are prone to need a significantly longer specialized care management than others. These patients are those with pre-operative severe renal dysfunction, peripheral vascular diseases and/or increasing heart failure stage categories. Confounding parameters that contribute to a prolonged specialized post-operative management in combination with other variables were identified as higher age, prolonged operative time, chronic obstructive pulmonary disease, and intra-operatively transfused blood.Objective: This study aimed to investigate the effect of certain pre-operative parameters directly on the post-operative intensive care unit (ICU)-length of stay (LOS), in order to identify at-risk patients that are expected to need prolonged intensive care management post-operatively. Material and Methods: Retrospectively, patients managed in an ICU after undergoing major oral and maxillofacial surgery were analyzed. Inclusion criteria entailed: age 18–90 years, major primary oral cancer surgery including tumor resection, neck dissection and microvascular free flap reconstruction, minimum operation time of 8 h. Exclusion criteria were: benign/borderline tumors, primary radiation, other defect reconstruction than microvascular, treatment at other centers. Separate parameters used within the clinical routine were set in correlation with ICU-LOS, by applying single testing calculations (t-tests, variance analysis, correlation coefficients, effect sizes) and a valid univariate linear regression model. The primary outcome of interest was ICU-LOS. Results: This study included a homogenous cohort of 122 patients. Mean surgery time was 11.4 (±2.2) h, mean ICU-LOS was 3.6 (±2.6) days. Patients with pre-operative renal dysfunction (p < 0.001), peripheral vascular disease-PVD (p = 0.01), increasing heart failure-NYHA stage categories (p = 0.009) and higher-grade categories of post-operative complications (p = 0.023) were identified as at-risk patients for a significantly prolonged post-operative ICU-LOS. Conclusions: At-risk patients are prone to need a significantly longer ICU-LOS than others. These patients are those with pre-operative severe renal dysfunction, PVD and/or high NYHA stage categories. Confounding parameters that contribute to a prolonged ICU-LOS in combination with other variables were identified as higher age, prolonged operative time, chronic obstructive pulmonary disease, and intra-operatively transfused blood.

Impairment of functional capacity assessed by cardiopulmonary echocardiography exercise test predicts adverse outcome in primary mitral valve regurgitation

Primary mitral regurgitation (MR) is the second cause of valvular surgery in Europe. Early surgery seems to improve long term prognosis, raising the need of prognostic markers. Evaluate the prognostic value of %VO 2 max, assessed by cardiopulmonary echocardiography exercise test (CPEET), in terms of free-of-cardiovascular-event survival. The patients underwent CPEET for primary MR between march 2012 and march 2019. Clinical follow-up of a composite cardiovascular event (cardiovascular death, heart failure progression ≥ 1 NYHA stage or unplanned hospitalization for heart failure, de novo atrial fibrillation, systemic embolic event, symptomatic ventricular tachycardia). 180 patients were analysed, with a median follow-up of 33 months. Free-of-events survival at 48 months was significantly associated with % VO 2max < 80% predicted (38.5% vs. 62.3%, P < 0.0001), with circulatory power < 3500 (29.8% vs. 61.7%, P < 0.0001), with half time recovery of VO 2 > 180s (42.3% vs. 58.1%, P = 0.001) and with maximal effort sPAP > 60 mmHg (42.2% vs. 67.8% P = 0.006) in univariate analysis. In multivariate analysis the impairment of %VO 2max < 80% predicted, was an independent predictor of free-of-event survival [HR = 0.96 (0.94;0.98), P < 0.0001]. An impairment of functional capacity, assessed by a cardiopulmonary-echocardiography-exercise-test with a %VO 2max < 80% of the predicted value, independently predicts cardiovascular events in primary MR. This parameter should be considered as an equivalent of symptoms and for this reason indicate an early surgical repair of the mitral valve. CPEET is a feasible and worthwhile exam, and should be considered in the evaluation of asymptomatic patients with severe MR.

The Use of a New Type of Heart Rate-controlled Training System HeartGo® for Patients with Chronic Heart Failure on the Pedelec

Background: Exercise Training is beneficial in heart failure patients, while training opportunities are limited. Pedelecs represent a novel training possibility for these patients, while safety and efficacy of pedelec training in heart failure is unknown. Therefore, we conducted a pilot study to address these issues. The study “HI-Herz.BIKE Saar” (August 2017 - September 2019) examined the health benefits and training effects of e-bikes (pedelecs) in patients from ambulatory heart groups with moderate chronic heart failure (CHI). Methods: Ten subjects with a strictly defined NYHA stage II-III heart failure and a LVEF of ?50% were selected. The presented clinical study is explicitly marked as a pilot study, as a new, so far not tested technique was used for exercise control. When selecting the heart failure patients defined in this way, a higher number of subjects could not be reached at only one study center. Participants cycled once weekly for 60-150 min and 20-50 km with a follow-up of 2 years as detailed in the Methods section. The new HeartGo® system used here for the first time allows heart rate- controlled training on a special pedelec via a smartphone app. The groups were accompanied during the training rides by a doctor and a paramedic. The training units were increased in duration, distance, and target frequency every six months. Frequency behavior, pedaling and motor load on the pedelec as well as clinical data such as ejection fraction, a biomarker (NT-pro BNP), risk factors, arterial blood pressure, and ergometric tests were measured.

Study of Cellular Aging in a Cohort of Patients with Heart Failure.

Cellular senescence and fibrosis are important phenomena in the development of heart failure (HF). These processes are closely related to telomeric length (TL). To assess cellular senescence in HF through the study of TL in peripheral blood mononuclear cells (PBMCs). Using real-time PCR, TL was measured in PBMCs from 20 patients diagnosed with HF, aged between 51 and 77years (50% males). Ten patients had HF with reduced ejection fraction (HFrEF) and ten had preserved EF (HFpEF). TL was measured in 20 healthy controls matched by age and gender. Obtained values were compared with an internal control, the 36B4 gene, which never modifies its expression, and correlated with the clinical parameters. TL mean was 1327 in patients with HF (95% CI 1309-1344) compared to 1286 (95% CI 1264-1308) in controls (p = 0.005). No differences were found when studying the correlation of telomere size with subgroups by gender, left ventricle ejection fraction (LVEF), presence of ischemic heart disease, smoking, Chronic Obstructive Pulmonary Disease (COPD), NYHA stage, degree of renal function or number of hospital admissions in the previous year. A significant and negative correlation was found between age and renal function (r = - 0.544, p < 0.05), as well as LVEF and NT-proBNP values (ρ = - 0.475, p < 0.05). TL is shorter in patients with HF when compared with age and gender balanced controls. The shortening of TL is independent of age, gender and degree of kidney function, and does not correlate with LVEF decrease or functional status.

Atrial fibrillation is not associated with altered left atrial microRNA expression profile in ischemic end-stage human heart failure

Abstract Introduction In patients with chronic heart failure (CHF) left ventricular dysfunction results in elevated left atrial (LA) pressure, triggering pathological atrial remodelling and atrial fibrillation (AF). Nevertheless, it has been reported that some patients with CHF remain in sinus rhythm (SR) despite of the pathological structural alterations (e.g. dilation and fibrosis) of the LA. Of particular interest, data is scarce regarding the molecular explanation for the observed variability in AF development among CHF patients. Recent studies have indicated that alterations in microRNA (miRNA) expression might contribute to the pathogenesis of AF. However, the majority of previous studies focusing on miRNA expression compared healthy LA with SR to pathologically remodelled, dilated LA with AF. Consequently, whether dysregulation of miRNA expression directly contribute to AF and not only to pathological LA remodelling has not been tested before. Purpose The present study aimed to investigate miRNA expression in comparably remodelled LA from end-stage CHF patients with permanent AF (CHF-AF) or SR (CHF-SR). Methods LA samples were collected from male, non-diabetic, ischemic end-stage CHF patients undergoing heart transplantation (n=24). Patients were carefully selected to avoid any differences in age (55±2 vs. 54±2 years, CHF-AF vs. CHF-SR, n.s.), ejection fraction ([EF]: 22.5±1.8 vs. 23.3±2.5%, CHF-AF vs. CHF-SR, n.s.) LA diameters (longitudinal LA diameter: 56±4 vs. 48±5mm.; CHF-AF vs. CHF-SR, n.s.; horizontal LA diameter: 61±2 vs. 54±3, CHF-AF vs. CHF-SR, n.s.) and NYHA stage. As a molecular marker of atrial load, the mRNA expression of atrial natriuretic peptide (ANP) was measured with qRT-PCR. The extent of left atrial fibrosis was assessed on picrosirius red stained histological sections. Global LA miRNA expression profiling (including the measurement of 800 human miRNA) was carried out using a commercially available kit. Results LA mRNA expression of ANP was comparable between the AF-CHF and the SR-CHF groups, suggesting that atrial load occurred to the same level in the two experimental groups. Furthermore, no differences could be observed in the extent of atrial collagen content between the AF-CHF and the SR-CHF groups (collagen area: 20.3±1.3% vs. 23.9±3.1%, n.s.), providing evidence that fibrotic remodelling had occurred to a similar magnitude. The high-throughput miRNA measurement revealed no differences in atrial miRNA expression between the two study groups. Conclusion The present study provides evidence for the first time that AF is not associated with different LA miRNA expression in end-stage CHF patients with comparable level of LA dilatation, ANP expression (atrial load) and interstitial fibrosis. Based on these findings, the potential of miRNA-based therapeutic interventions might be limited in AF patients with ischemic end-stage CHF. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): NVKP_16-1-2016-0017

Neutrophil neprilysin expression correlates with inflammatory activation in chronic HFrEF patients

Abstract Background Inhibition of neprilysin by the angiotensin receptor-neprilysin inhibitor has shown remarkable success in the treatment of heart failure with reduced ejection fraction (HFrEF). However, the exact mechanism of action is still a matter of debate. Neprilysin (NEP) is a ubiquitous transmembrane endopeptidase markedly expressed on the cell surface of neutrophils, in this context also known as CD10. Originally, CD10 has been identified as a cell surface marker to discriminate mature from immature neutrophils. Other inflammatory neutrophil surface markers such as CD11b, CD64 and CD66b are commonly used to determine the activation status of neutrophils. In our previous explorative study, NEP expression on neutrophils correlated inversely with HF severity and mortality. This study aimed to explore the relationship between NEP expression and typical neutrophil activation markers and to confirm its relation to HF severity reflected by NT-proBNP and NYHA class in a bigger cohort of HFrEF patients. Methods We prospectively enrolled 208 consecutive patients with stable HFrEF. Mean fluorescence intensity (MFI) of CD10 expression on peripheral blood neutrophils was determined by flow cytometry of whole blood samples. In addition, for a subset of 117 patients the expression of CD11b, CD64 and CD66b was measured. EDTA anticoagulated blood (100 μl) was stained using a combination of six antibodies with fluorescence minus one sample as control [CD10 (#332777), CD45 (#560178), CD16 (#335035), CD11b (#555388), CD64 (#561191), CD66b (#562254); BD Biosciences, San Jose, CA, USA]. Results Median age was 64 years (IQR 54–72), 57 (27%) patients were female. Median NT-proBNP values were 1819 pg/ml (IQR 740–4264). Approximately half of the study population with 115 (55.3%) patients had a non-ischemic etiology of HF. Median MFI of NEP (CD10) on neutrophils was 5542 (IQR 4168–6903). Neutrophil NEP expression decreased with HF severity reflected by NYHA stage (p=0.006) and tertiles of NT-proBNP (p=0.003). Interestingly, non-ischemic HFrEF was characterized by higher neutrophil NEP expression compared to ischemic HFrEF [5703 (IQR 4548–7235) vs 4994 (IQR 3844–6718), p=0.018]. Neutrophil NEP expression correlated highly significant with CD11b expression (r=0.61, p&amp;lt;0.001) but not with CD64 and CD66b [p=ns] (Figure 1). Conclusion These data support the evidence for an inverse correlation of neutrophil NEP expression with HF severity in stable HFrEF patients and for NEP upregulation on neutrophils in patients with non-ischemic cardiomyopathy. There was a strong relationship between neutrophil NEP regulation and the activation marker CD11b, proposing a link between the neutrophil NEP compartment and systemic inflammatory response. Figure 1 Funding Acknowledgement Type of funding source: None

Patients with heart failure and a LVEF less than 40% present an overall lower health related quality of life than those with LVEF between 40% and 60%: a multinational real-world survey in EU

Abstract Background and purpose Heart Failure (HF) is associated with symptoms such as dyspnoea and fatigue which can impact patients' health related quality of life (HRQoL). This study aimed to characterize and assess the HRQoL of patients with HF and left-ventricular ejection fraction (LVEF) &amp;lt;40% versus those with ≥40%-60%. Methods A cross-sectional study of patients with HF was conducted in France, Germany, Italy, Spain and United Kingdom. Patient record forms (PRFs) were completed by 257 cardiologists and 158 general practitioners (GPs) for consecutively consulting patients. The same patients were invited to provide patient-reported outcomes including self-completion questionnaires, Minnesota Living with Heart Failure Questionnaire (MLHFQ) and EQ-5D-5L VAS. Results 204 HF patients with LVEF &amp;lt;40% (mean age 67.7 years) and 600 patients with LVEF ≥40–60% (mean age 68.9 years) were included. Proportion of males was significantly higher in the lower LVEF group (73.5% vs. 61.2%, p=0.0017). Overall, the patients with lower LVEF more frequently presented with comorbidities than those with LVEF ≥40–60% (p&amp;lt;0.05, Figure 1). NYHA stage III/IV (35.8%/7.4% vs. 15.3%/0.8%) as well as self-reported HF symptoms were more frequently reported in the lower LVEF group (p&amp;lt;0.05, Figure 1). Similarly, patients with LVEF &amp;lt;40% reported statistically significantly worse HRQoL compared to those with LVEF ≥40–60% (Table 1). Conclusions The HRQoL of all HF patients with LVEF ≤60% appears impacted, while those with LVEF &amp;lt;40% had significantly worse HRQoL than those with LVEF ≥40–60%. These differences in HRQoL may not only be related to the LVEF but also to the overall characteristics of these patients. Addressing the HRQoL burden for patients should be a key aspect of HF management strategies for all HF patients. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Novartis Pharma AG

Symptom-based clusters in patients with advanced chronic organ failure identify different trajectories of symptom variations.

Healthcare needs are complex and heterogeneous in advanced chronic organ failure. However, based on symptom clusters, groups of patients with similar quality of life, care dependency and life-sustaining treatment preferences can be identified. To evaluate the stability of symptom-based clusters over time, and whether and to what extent the clusters are able to predict patients' 2-year survival and hospitalization rates. This is a secondary analysis of a longitudinal observational study including 95 outpatients with chronic obstructive pulmonary disease (COPD) GOLD stage III-IV, 80 outpatients with chronic heart failure (CHF) NYHA stage III-IV and 80 outpatients with chronic renal failure (CRF) requiring dialysis. Patients were clustered into three groups applying K-means algorithm on baseline symptoms' severity and were then longitudinally evaluated. 2-year survival and hospital admissions during 1 year were estimated using Kaplan-Meier curves and Cox models. 1-year tendencies in symptom variation, using mixed linear models, and clusters comparison over time were performed. The three clusters were unable to predict patients' survival and hospital admissions. Noteworthy, they show different trajectories of symptom variation, with Cluster 1 patients experiencing a worsening of symptoms, associated with an increased care dependency, and Cluster 2 and Cluster 3 patients being stable or having a relief in some symptoms. Although Cluster 1 is becoming more similar to Cluster 2, the three clusters preserve the overall characteristics and differences. Symptom-based clusters might help to identify patients with different trajectories of symptom variations. Symptom clusters do not predict survival and hospital admissions and are stable over time.

A Novel Risk Stratification System for Predicting In-Hospital Mortality Following Coronary Artery Bypass Grafting Surgery with Impaired Left Ventricular Ejection Fraction.

Coronary artery disease (CAD) is the most common cause of heart failure (HF), and impaired ejection fraction (EF<50%) is a crucial precursor to HF. Coronary artery bypass grafting (CABG) is an effective surgical solution to CAD-related HF. In light of the high risk of cardiac surgery, appropriate scores for groups of patients are of great importance. We aimed to establish a novel score to predict in-hospital mortality for impaired EF patients undergoing CABG. Clinical information of 1,976 consecutive CABG patients with EF<50% was collected from January 2012 to December 2017. A novel system was developed using the logistic regression model to predict in-hospital mortality among patients with EF<50% who were to undergo CABG. The scoring system was named PGLANCE, which is short for seven identified risk factors, including previous cardiac surgery, gender, load of surgery, aortic surgery, NYHA stage, creatinine, and EF. AUC statistic was used to test discrimination of the model, and the calibration of this model was assessed by the Hosmer-lemeshow (HL) statistic. We also evaluated the applicability of PGLANCE to predict in-hospital mortality by comparing the 95% CI of expected mortality to the observed one. Results were compared with the European Risk System in Cardiac Operations (EuroSCORE), EuroSCORE II, and Sino System for Coronary Operative Risk Evaluation (SinoSCORE). By comparing with EuroSCORE, EuroSCORE II and SinoSCORE, PGLANCE was well calibrated (HL P = 0.311) and demonstrated powerful discrimination (AUC=0.846) in prediction of in-hospital mortality among impaired EF CABG patients. Furthermore, the 95% CI of mortality estimated by PGLANCE was closest to the observed value. PGLANCE is better with predicting in-hospital mortality than EuroSCORE, EuroSCORE II, and SinoSCORE for Chinese impaired EF CABG patients.

P980Evaluation of the outcomes of radiofrequency catheter ablation in patients with ischemic ventricular tachycardia

Abstract Background Ablation of ventricular tachycardia (VT) is an effective and safe treatment option in symptomatic patients under antiarrhythmic drugs or patients with frequent ICD therapies. Purpose We aimed to evaluate outcomes of VT catheter ablation in patients with ischemic VT. Methods All of the patients who underwent VT catheter ablation between June 2014 and November 2018 were included. Results 128 patients (120 male, 8 female) were included and mean age was 65 ± 10 years. Mean ejection fraction was 28.6 ± 8.2 %. Baseline characteristics were listed in Table-1. Mean follow-up was 22.3 ± 6.4 months. 52 (46.6 %) patients were admitted with electrical storm. Acute success rate was 96.6%. Complications including transient ischemic attack, deep venous thrombosis, pericardial effusion and inguinal hematoma were developed in 6 patients. Recurrence of VT was occured in 44 (34.4 %) patients and the presence of PCI history and admission with electrical storm were predictors of recurrence. All cause mortality was occured in 39 patients and predictors of all cause mortality was detected as follows; diabetes, NYHA stage &amp;gt;2, lower levels of EF and higher BNP levels. Cardiovascular mortality was developed in 28 patients and predictors were defined as, lower levels of EF, higher BNP levels and number of shock after index ablation. VT recurrence was not found to be related with both cardiovascular and all cause mortality. Conclusion VT ablation is a safe and effective option in patients with ischemic VT who are symptomatic despite optimal medical treatment. Admission with electrical storm and history of PCI were predictors of VT recurrence after ablation. Higher levels of BNP, lower EF values are related with both all cause and cardiovascular mortality. Table-1 Gender, male, (%) 120(93,8) Age(year) 65,5 ± 9,7 HT 93(72,7) DM 35(27,3) AF 41(32,0) NYHA class(pre-ablation) IIIIII IV 71(55,5)27(21,1)25(19,5) 5(3,9) Previous PCI 83(64,8) Previous Cardiac surgery CABG AVR MVR 72(56,3) 70(54,7 1(0,8) 4(3,1) LV EF (%)≤3031-40 ≥41 28,6 ± 8,290(70,3)28(21,9) 10(7,8) Electrical storm 52(40,6) LV EDD (mm) 63,8 ± 8,5 Baseline characteristics

Cardiac impact of arteriovenous fistulas: what tools to assess?

The relationship between arteriovenous access flow (Qa) and cardiovascular changes is complex. Several studies have shown cardiac remodeling and symptoms of heart failure for high-flow arteriovenous fistulas (AVF). To evaluate the early cardiovascular impact of AVF. Forty-seven patients with an AVF, hospitalized for the evaluation of high-flow AVF or a pre-kidney transplant assessment were included. We collected clinical and biological data. We also collected data of the assessment by transthoracic echocardiography, functional evaluation by 6-min-walk test and peak oxygen consumption, and measurement of coronary flow reserve by dynamic myocardial perfusion imaging. The measurement of Qa was performed by color Doppler ultrasound and then indexed to the body surface area (Qai) and to the cardiac output (CO) (Qa/CO). Patients were poorly symptomatic (18 and 1 patients NYHA stage 2 and 3, respectively). There was no correlation between Qa, Qai, or Qa/CO and functional status, assessed by peak oxygen consumption (P = 0.891; P = 0.803; P = 0.939, respectively). Symptomatic patients did not have higher Qa, Qai or Qa/CO than asymptomatic (2260 vs 2197mL/min, P = 0.402; 1257 vs 1256mL/min/m2, P = 0.835; and 34% vs 37%, P = 0.701, respectively). There was no correlation between Qa, Qai or Qa/CO and left ventricular end-diastolic volume or left ventricular ejection fraction. There was no correlation between coronary flow reserve and these 3 parameters of vascular access flow. However, the global longitudinal strain (GLS) was correlated with Qa and Qa/CO (R = 0.331, P = 0.023 and R = 0.380, P = 0.008, respectively). Increase of Qa or Qa/CO was associated with an alteration of the GLS. A cut-off value of 2250mL/min for Qa allowed 83% sensitivity and 63% specificity for detecting an alteration of the GLS > - 18%. A cut-off value of 33% for Qa/CO allowed 92% sensitivity and 65% specificity. Impact of AVF on cardiac parameters is weak. However, GLS is the first parameter to be impacted by the flow of the fistula. Systematic transthoracic echocardiography evaluation with measurement of GLS should be proposed for all patients with Qa > 2250mL/min or Qa/CO > 33%, to detect those at higher risk of cardiac impact of the AVF.

CBIN1 Score (CS) Identifies Ambulatory HFrEF Patients and Predicts Cardiovascular Events.

BackgroundCardiac Bridging Integrator 1 (cBIN1) is a membrane deformation protein that generates calcium microdomains at cardiomyocyte t-tubules, whose transcription is reduced in heart failure, and is released into blood. cBIN1 score (CS), an inverse index of plasma cBIN1, measures cellular myocardial remodeling. In patients with heart failure with preserved ejection fraction (HFpEF), CS diagnoses ambulatory heart failure and prognosticates hospitalization. The performance of CS has not been tested in patients with heart failure with reduced ejection fraction (HFrEF).Methods and ResultsCS was determined from plasma of patients recruited in a prospective study. Two comparative cohorts consisted of 158 ambulatory HFrEF patients (left ventricular ejection fraction (LVEF) ≤ 40%, 57 ± 10 years, 80% men) and 115 age and sex matched volunteers with no known history of HF. N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations were also analyzed for comparison. CS follows a normal distribution with a median of 0 in the controls, which increases to a median of 1.9 (p < 0.0001) in HFrEF patients. CS correlates with clinically assessed New York Heart Association Class (p = 0.007). During 1-year follow-up, a high CS (≥ 1.9) in patients predicts increased cardiovascular events (43% vs. 26%, p = 0.01, hazard ratio 1.9). Compared to a model with demographics, clinical risk factors, and NT-proBNP, adding CS to the model improved the overall continuous net reclassification improvement (NRI 0.64; 95% CI 0.18-1.10; p = 0.006). Although performance for diagnosis and prognosis was similar to CS, NT-proBNP did not prognosticate between patients whose NT-proBNP values were > 400 pg/ml.ConclusionCS, which is mechanistically distinct from NT-proBNP, successfully differentiates myocardial health between patients with HFrEF and matched controls. A high CS reflects advanced NYHA stage, pathologic cardiac muscle remodeling, and predicts 1-year risk of cardiovascular events in ambulatory HFrEF patients. CS is a marker of myocardial remodeling in HFrEF patients, independent of volume status.

Можливості кардіопротекторної терапії в лікуванні та профілактиці серцевої недостатності в післяінфарктному періоді

Recently, numerous and quite convincing data has been accumulated on the effectiveness and safety of lipid-lowering drugs, beta-blockers, antiplatelet and antihypertensive drugs in patients with chronic heart failure (CHF), depending on the origin of the latter. The practitioner is suggested to use several drugs of different classes at the same time in order to reduce cardiovascular mortality, as well as the risk of recurrent myocardial infarction and ischemic stroke. In CHF, metabolism in cardiomyocytes varies depending on the stage of the disease. The changes that occur in the postinfarction period are compensatory in nature, which contributes to the partial improvement of impaired metabolism, while others, on the contrary, further inhibit the processes of energy production in the myocardium. In our research paper we will discuss some capabilities of metabolic therapy of CHF and prospects in the treatment and prevention using hawthorn extract; analyze the features of interaction of some well-known cardioprotective drugs with long-term antiplatelet therapy in the postinfarction period. Initiation of therapy with a new drug in addition to clopidogrel, such as trimetazidine, may adversely affect antiplatelet activity of clopidogrel (TRACER study, 2019). As a compromise, some herbal cardioprotective drugs may be used. Hawthorn preparations containing vaso- and cardioactive substances have significant potential in the treatment of cardiovascular diseases. Diversified mechanism of action of hawthorn has a significant impact on various parts of the cardiovascular system. Clinical trials of more than 4,000 patients confirm that standardized hawthorn extracts are effective as adjunctive therapy in the treatment of NYHA stage I–III CHF. The main two-year results of the WISO cohort study showed that the three pivotal symptoms of heart failure — fatigue (p = 0.036), stress dyspnea (p = 0.020) and palpitations (p = 0.048) — were significantly less marked after treatment in the hawthorn group versus comparative group. Cochrane analysis (2009) of studies investigating hawthorn extract included 14 studies where hawthorn was used primarily as an adjunct to conventional treatment. Exercise tolerance increased significantly during the treatment with hawthorn extract. Thus, the weighted difference between the average double multiplication rates during cardiac stress test (CST) was 122.76 W/min, whereas end-diastolic pressure in the right ventricle and myocardial oxygen consumption decreased with hawthorn treatment (a weighted mean difference was 19.22 mmHg per 1 min). The reported side effects were infrequent, mild and transient. A special hawthorn extract is indicated for the treatment of patients with NYHA stage II heart failure as an alternative and supplement to the standard evidence-based drug therapy. The beneficial effect on clinical symptoms allowed patients in the Crataegus group to reduce the use of angiotensin-converting enzyme (ACE) inhibitors from 54 to 36% (p = 0.004), cardiac glycosides from 37 to 18% (p = 0.001), diuretics from 61 to 49% (p = 0.061), beta-blockers from 33 to 22% (p = 0.052). At the same time, SPICE and HERB CHF studies show greater efficacy of Crataegus preparations in the treatment of mild to moderate heart failure (NYHA stage I–II). Higher doses (1800 mg) may be required for critically ill patients in order to achieve sustained improvement. Analysis of the data available to date is promising but suggests the need for a more focused approach to dosing based on the disease severity.

Resting Heart Rate and Associated Factors in Patients with Chronic Heart Failure in Cameroon: A Cross-sectional Study in Sub-saharan Africa

Introduction: Controlled heart rate has been associated with better prognosis in patients with chronic heart failure (CHF). Radial pulse palpation is a simple and useful method to evaluate heart rate control especially in limited resources setting such as sub-Saharan Africa. However, data on heart rate control in patients with heart failure are scarce in our context. Therefore, we sought to investigate heart rate control in patients followed for chronic heart failure in Cameroon. Methodology: We conducted a cross-sectional study from January to September 2017 in three specialized cardiology centers of Cameroon. We included patients with chronic heart failure, normal sinus rhythm without recent cardiac events. Resting heart rate was measured by pulse palpation after 05 minutes of rest, three (03) times over 60 seconds. An uncontrolled heart rate was defined as HR ≥70bpm. Results: Overall, 213 patients with a mean age of 63±15 years were included. About 64.8% of patients have a heart rate above recommended targets (≥70 bpm). There was no significant association between age, gender, NYHA stage, cardiovascular risk factors or current therapies and heart rate control. Conclusion: Uncontrolled heart rate is frequent in patients with chronic heart failure in our context with more than half presenting a resting heart rate above currently recommended values.

Percutaneous mitral dilatation in pregnant women: Short-term results

Rheumatic mitral stenosis (MS) is one of the most common valvulopathies in north Africa. Among her circumstances of discovery,pregnancy. Percutaneous mitral dilatation (PMD) is currently the treatment of choice for tight MS. To describe the short-term results of PMD performed for pregnant women with tight MS. This is a retrospective study of 8 pregnant women with a tight MS hospitalized in our Cardiology Department between 2012 and 2018 for PMD. For each patient, clinical, echocardiographic(TTE), and hemodynamic data were analyzed before and after PMD. There were 8 patients with an average age of 28.5 years (from 25 to 37). Two patients were known to have a MS and had previous PMD. All patients consulted for NYHA stage III dyspnea. At the ECG: 6 were in sinus rhythm. TTE pre-dilatation showed: an average mitral surface area at 1.1 cm 2 ,the average transmitral gradient was on average 12.05 mmHg. There was a bi-commissure fusion of the mitral valve in 6 patients. Mitral insufficiency (MI) was: minimal in 2 cases and moderate in 1 case, 5 patients had pulmonary arterial hypertension with mean SPAP at 43.2 mmHg. The right cavities were dilated in two women. The result of PMD was satisfactory in all patients. MI worsened one grade in one patient, and two grades in another, while a MI was newly created in one case. A transition to atrial fibrillation was noted in 1 patient who was well tolerated. TTE control immediately after PMD in the catheterization room showed: an average mitral area of 1.9 cm 2 (1.4 to 2.4 cm 2 ) so an improvement of more than 50% in the initial mitral area. The average transmitral gradient became 4.67 mmHg. Both commissures were completely opened in 7 patients. Dyspnea became class I in one patient while the others became asymptomatic. All patients delivered at term. The newborns were all in good health. PMD is still the treatment of choice in pregnant women with symptomatic MS if the anatomy of the valve allows it.

Plastie mitrale percutanée dans l’IM organique dégénérative par mitraclip ou neochord: étude observationnelle monocentrique

High risk patients with degenerative mitral regurgitation who are contraindicated for surgery may now benefit from minimally invasive techniques. We aimed to evaluate the efficiency and safety of 2 recent techniques: Mitraclip, an edge-to-edge suture by endovascular access, and Neochord, a transpical implantation of artificial chordae tendinae. Patients with severe mitral degenerative regurgitation were included at the University Hospital of Montpellier, with clinical and echocardiographic follow-up performed at baseline and at 6 months. The primary endpoint of the study evaluated success of the procedure (defined as residual MR grade ≤ 2) and evolution of the NYHA functional class. Secondary endpoints included several echocardiographic parameters. Between January 2016 and October 2018, 26 patients were evaluated, 22 of them in the Mitraclip group and 4 in the NeoChord group. In the Mitraclip group, the procedure was successful in 15/22 patients (69%), with one death and one implantation failure observed. An improvement of NYHA functional class occurred in all patients with successful procedure. We observed a decrease of the left ventricular end-diastolic volume from 110 to 103 mL ( P = 0.005), and of the left ventricular end-diastolic diameter from 55 to 50 mm ( P = 0.001). The peak pressure gradient between the right ventricle and right atrium decreased from 59 to 40 mmHg ( P = 0.002). Conversely, there was no improvement of primary endpoint in the NeoChord group, with even a worsening of the NYHA stage and the MR severity for 3/4 patients. In the Mitraclip group, MR severity was significantly reduced in 69% of patients, leading to functional improvement when successful. The NeoChord technique seems quite disappointing, but is still to be evaluated in the long term on a larger scale. The Mitraclip is an alternative for high-risk patients contraindicated for surgery, with an acceptable success rate in this study.

P6287Analysis of novel cardiac markers sST2 and IL-33 in chronic heart failure with reduced ejection fraction

Abstract Background Soluble (s) ST-2 has been recently evaluated as a monitoring parameter in heart failure (HF). Besides being a marker for cardiac strain and hemodynamic stress, studies also found an influence of ST2 on the immune system, above all mediated through its Janus-Face ligand IL-33, an alarmin released under stress conditions or by cellular death. In contrast to sST2, the role of IL-33 in HF is yet unknown. Objective In this project, we aimed for an analysis of the ST2/IL33 pathway in patients with heart failure with reduced ejection fraction (HFrEF). Methods In total, 200 patients were included in the study: 59 with ischemic (ICM), 65 with dilated (DCM) cardiomyopathy (mean LVEF 38%), as well as 76 control patients without coronary artery disease or signs of heart failure. Serum samples were analyzed by use of ELISA after informed consent. Results sST2 showed a significant elevation in all HF patients (p&lt;0.0001) compared to the control group. No significant differences in levels of sST2 were observed between ICM and DCM patients. In contrast to sST2, no differences between HF patients and control group were observed for IL-33. Furthermore, sST2 showed a significant correlation with CRP (p&lt;0.001, r=0.28), NT-pro-BNP (p&lt;0.0001, r=0.40) and an inverse correlation with ejection fraction (p&lt;0.0001, r=−0.40). Additionally, sST2 showed a significant elevation in patients in NYHA stages I-II (p=0.030) and NYHA stages III-IV (p&lt;0.01). Again, no significant correlations were observed between IL-33 and parameters mentioned above. Analysis of sST2 in heart failure Conclusions We observed a significant increase and correlation with disease severity of sST2 in chronic HFrEF patients of both ischemic and non-ischemic origin, but contrary to our expectations, no significant changes in serum levels of IL-33. Thus, a mechanism independent of ST2/IL33 axis could be responsible of sST2 secretion in HF. Further studies including acute decompensated patients could provide a better understanding of the IL-33 role in HF.

The effect of nutritional support on nutritional status and quality of life as well as on inflammatory markers and cardiac functions in patients with cardiac cachexia due to chronic heart failure

Objective: Cardiac cachexia (CC) is defined as a loss of at least 6% of total body weight in 6 months due to chronic heart failure (CHF). The prevalence of CC in patients with NYHA class II-IV is estimated to be approximately 12%-15%. There are only a few studies that demonstrate the effects of malnutrition treatment on nutrition, physical activity, quality of life (QoL), and clinical course of the disease. This study aimed to evaluate the effect of nutrition treatment on anthropometric measurements, fat free mass (FFM), muscle strength, physical performance, and QoL together with cardiac functions and immunity in patients with CC. Method: This was a prospective clinical intervention study. Patients with NYHA stage II-IV CHF (n=725) followed-up in Internal Medicine and Cardiology Departments were screened for CC. Eighteen patients with CC were enrolled in the study. The control group included 18 healthy adults. Nutritional status assessment, anthropometric measurements, gait speed, muscle strength, bioelectrical impedance analysis (BIA Tanita, Japan), biochemical analyses, and cytokine measurements were performed. Cardiac functions were assessed by echocardiography. Nutrition support treatment was given to patients with CC, and they were followed-up for next 3 months. QoL was measured with “Ferrans and Powers” Quality of Life Index (cardiac version). Similar studies were repeated after follow-up. Results: After excluding all other reasons for cachexia, the prevalence of CC was 2.5% in our patients with CHF. The patients with CC had higher serum C-Reactive Protein (CRP) and IL-6 levels than the healthy controls. After nutrition support treatment, the QoL scores and visceral fat level significantly increased in patients with CC. Although mid-upper arm circumference (MUAC), handgrip strength, FFM, fat mass, and serum albumin levels increased, they were not statistically significant. Conclusion: When compared to previous studies, our CC prevalence rate was lower. Nutrition support therapy can reverse weight loss in patients with CC, which can also improve QoL. An important limitation to the study is the low number of patients that is related with the exclusion criteria regarding every type of inflammatory disease, acute medical problems, and cancer. Therefore, further studies with more patients are needed.

Fatigue in heart failure outpatients: levels, associated factors, and the impact on quality of life.

IntroductionHeart failure (HF) patients experience various psychosocial issues and physical symptoms such as fatigue, which adversely affect their quality of life (QoL). The aim of the study was to assess levels of fatigue in HF outpatients and the associated factors, as well as to explore the correlation between fatigue and QoL.Material and methodsOne hundred and thirty patients were enrolled in the study. Data collection was performed by the completion of “Minnesota Living With Heart Failure” questionnaire (MLHFQ) and the Greek version of the Modified Fatigue Impact Scale (MFIS-Greek). Data also included self-reported patients’ characteristics.ResultsOf the 130 HF outpatients, 50% scored above 69 (median) in total fatigue and above 41 and 29 (median) in physical and mental fatigue, respectively. Furthermore, 50% scored above 66 (median) in total QoL and above 32.5 and 13 (median) in the physical and mental state, respectively. These values indicate moderate to high impact of HF on fatigue and on patients’ QoL. Total fatigue was statistically significantly associated with NYHA stage (p = 0.001), confidence to acknowledge health deteriorations (p = 0.004), decrease in appetite (p = 0.001), dyspnoea at night (p = 0.001), oedema in lower limbs (p = 0.023), relation with health professionals (p = 0.031), and whether patients had limited daily activities (p = 0.002), social contacts (p = 0.014), and if they had financial worries (p = 0.003). Finally, as the score of fatigue increased, so the QoL score also increased.ConclusionsA broader understanding of this distressing symptom in HF may contribute to the development of suitable interventions with the ultimate goal of improving QoL.