Persistent Heart Research Articles

2418Th17 signature, autoimmunity and differentially expressed genes in cardiomyopathy and heart failure

Abstract Background Cardiomyopathy may occur due to viral infections or drug induced heart damage. Cardiac myosin released from damaged heart has been shown to be a damage associated molecular pattern which binds to TLR2 or TLR8 and can act as an adjuvant to induce a strong autoimmune response against the heart. The result is autoimmunity against the heart which can lead to apoptosis, fibrosis and heart failure. Purpose Immune biomarkers of the early stages of heart failure are needed to identify individuals who develop progressive heart failure, do not recover their ejection fraction and may be candidates for immunotherapies. Methods Forty-one patients with myocarditis and heart failure <6 months after onset were followed for 12 months and compared to age matched controls. Peripheral blood mononuclear cells were analyzed by FACS analysis and serum analyzed by ELISA for autoantibodies and cytokines. Statistical analysis was determined by Mann Whitney test. Peripheral blood of 10 patients with dilated cardiomyopathy (DCM) vs 19 healthy controls were analyzed for gene expression by RNA sequencing and pathway analysis using Reactome. Results Autoantibodies against human cardiac myosin and the beta-adrenergic receptor were significantly elevated in our cohort and functionally acted on cardiomyocytes to activate protein kinase A. Concomitantly, a Th17+ immunophenotype was significantly elevated in blood as well as in cardiac biopsies. CD4+IL17+ T cells (p=0.0008) and Th17-promoting cytokines TGF beta (p<0.0001), IL-6 (p<0.0001), IL-23 (p=0.0001), GMCSF (p=0.0336) and GMCSF-secreting CD4+ T cells (p=0.0006) were significantly elevated in blood. A Th17 immunophenotype was significantly associated with heart failure primarily in males (p=0.029). Persistent heart failure (NYHA class III and IV) and non-recovery of left ventricular function were associated with significantly higher percentages of IL17A-producing T cells at baseline, 6 and 12 months after onset, and IL-17A (p=0.019) and elevated Th17-promoting cytokines IL-6 (p=0.0001) and TGF-beta (p=0.0076). Decreased T regulatory immunosuppressive cells were significantly (p=0.0006) decreased and correlated with elevated Th17 cytokines in heart failure. Overrepresentation analysis of differentially expressed genes (adj p<0.05) in blood of patients with DCM >1year were identified using Reactome which revealed significant (FDR = 1.52E-13) enrichment of neutrophil degranulation (48 genes). Conclusion Our study illustrates a strong Th17 signature in more severe heart failure early in disease with elevated anti-cardiac myosin autoantibodies in non-recovery of left ventricular function. We observed a strong correlation with Th17-related neutrophil degranulation pathways in later disease, which may be biomarkers of fibrosis progression and disease severity in patients with heart failure. Cardiomyopathy with a Th17 signature might be treated with preventive immunomodulatory therapies such as anti-IL17A. Acknowledgement/Funding National Heart Lung and Blood Institute, Bethesda, MD, USA

Persistent Heart Failure Symptoms at Hospital Discharge Predicts 30-Day Clinical Events

Introduction The relationship between heart failure (HF) symptoms at discharge and 30-day clinical events is unknown. Persistent symptoms at discharge are common and approximately 25% of patients are readmitted within 30 days. Variability in assessment of HF symptoms at discharge may affect capacity to predict readmission risk. Objective To describe symptom burden and symptom profiles of HF patients at hospital discharge. A secondary aim was to examine the relationship between symptom burden at hospital discharge and 30-day clinical event rate. Methods An exploratory descriptive design was used. HF patients (n=129) preparing for hospital discharge were enrolled 24-48 hours pre-hospital discharge. The Heart Failure Somatic Perception Scale (HFSPS) assesses 18 physical signs and symptoms of HF on a range of 0 (I did not have this symptom) to 5 (extremely bothersome). The Patient Health Questionnaire-9 (PHQ-9) was used to measure depressive symptoms. Self-Assessed Health (SAH) and comorbid illnesses were documented. Participants were called 30 days post-discharge to assess clinical event rates. HFSPS scores were divided into tertiles (0-10; 11-19; 20 and higher) to explore symptom burden in a subgroup analysis. Results were analyzed using descriptive statistics, chi-square and logistic regression. Results The sample (n=129) was predominantly Caucasian (87.6%), male (63%), elderly (M=73.6, SD=12.6) and symptomatic (94.6%) at discharge. HFSPS scores ranged 0 to 53, M=15.8 (SD 10.6). Hypertension, hyperlipidemia and diabetes were the most common comorbid illnesses. The most bothersome symptoms at discharge were fatigue (71%), nocturia (66%), need to rest more than usual (61%), and inability to do usual activities due to shortness of breath (61%). Thirty-day readmission rate was 28.7% overall with significant differences between HFSPS groups (43.2% and 40.5% of readmissions occurred in second and third tertiles respectively χ2 (2, N = 129) = 7.85, p=0.02). HFSPS and SAH were significant predictors of readmission with increased likelihood of readmission by OR 3.9 (p=0.02) and OR 2.97 (p=0.02) respectively. PHQ9 scores were not significant predictors of readmission in this sample. Conclusions The majority of patients in this sample had persistent and bothersome symptoms at hospital discharge that predicted likelihood of 30-day readmission. Comprehensive symptom assessment of HF patients at time of discharge is important and may guide care to decrease 30-day clinical events.

Outcome for children following admission to hospital with a first episode of heart failure, due to heart muscle disease, in the ventricular assist device (VAD) era.

Most reports on the outcome of children who present with heart failure, due to heart muscle disease, are from an era when ventricular assist devices were not available. This study provides outcome data for the current era where prolonged circulatory support can be considered for most children. Data was retrieved on 100 consecutive children, who presented between 2010 - 2016, with a first diagnosis of unexplained heart failure. Hospital outcome was classified as either death, transplantation, recovery of function or persistent heart failure. Median age at presentation was 24 months and 58% were < 5 years old. Hospital mortality was 12% and 59% received a heart transplant. Most, 79%, of the transplants were carried out on patients with a device. Recovery of function was observed in 18% and 10% stabilised on oral therapy. Eighty-four percent of the deaths occurred in the <5 year old group. Shorter duration of support was associated with survival (34 days in survivors versus 106 in non-survivors, p = 0.01) and 72% were on an assist device at time of death. Heart failure in children who require referral to a transplant unit is a serious illness with a high chance of either transplantation or death. Modifications in assist devices will be required to improve safety, especially for children < 5 years old where the donor wait may be prolonged. The identification of children who may recover function requires further study.

Age, Sex and Body Weight Related Echocardiographic Parameters of Clinically Healthy New Zealand White Rabbits

Background: Echocardiography provides useful additional information on cardiac dimensions including heart wall and dimension of the ventricles, atria and conditions. Rabbits have been diagnosed with cardiac diseases, and an understanding of the animals’ cardiac chamber dimensions is vital in assessing the diseases’ severity and prognoses. Changes in cardiac dimensions due to age related and body weight were determined at different animals. The increased incidence of congenital cardiovascular anomalies makes it essential to establish the diagnosis at an early age. The aims of this study 1) establish normal values for the commonly used two-dimensional (2D) M-mode parameters using pre anaesthetics and 2) evaluate the effects of age, sex, and body weight on echocardiographic parameters in clinically healthy New Zealand rabbits.Materials, Methods &amp; Results: In this study we used 49 New Zealand white rabbits (25 male, 24 female) all reared under the same conditions. A general physical and clinical examination including complete blood count was performed for each animal. Body surface area was calculated as BSA= 0.00718 × Height 0.725 × Weight 0.425. Rabbits were sedated with midazolam before echocardiographic examination was performed. Echocardiographic examination was performed using a DC 6-Vet® (Mindray, PRC) ultrasonographic device equipped with a micro-convex 8 MHz probe. Right parasternal short-axis view, B-mode and two-dimensional guided M-mode parameters were measured. Echocardiographic measurements were performed using leading-edge-to-leading-edge conventions outlined by the American Society of Echocardiography. Statistical analyses were employed using the SPSS 19.0 program. Sex had no significant effect on the measured echocardiographic parameters except in the case of interventricular septum thickness in diastole values of the three-month-old rabbits. The increase in the left ventricular systolic and diastolic diameters, E- point to septal separation, diastolic aortic root parameters for the three, six, and nine-month-old groups indicated persistent anatomic heart enlargement. However, it was also discovered that the fractional shortening percentage of the left ventricle and diastolic diameters of left atrium:aortic root were unrelated to age and weight.Discussion: New Zealand rabbits are an important model for cardiovascular research, mainly as they are small and relatively inexpensive however large enough to allow anatomical and physiological experiments. Different ages and sizes of New Zealand rabbits showed no significant difference in fractional shortening despite heart enlargement. The ejection fraciton, which can be calculated from the left ventricular dimensions via M-mode echocardiography, is another parameter of cardiac function. Our echocardiograph calculated the ejection fraction automatically using the Teicholz formula. It was further observed that three-month-old rabbits ejection fraction of the left ventricle was higher than that of the six and nine-month-old rabbits. This might indicate the necessity of periodical analysis of echocardiographic parameters. Transthoracic echocardiography can be considered an applicable method for cardiovascular research using a growing rabbit animal model after appropriate adjustments for age, sex and body size. These findings give a better understanding of the functional changes investigated by echocardiography in rabbits and will be helpful when evaluating echocardiographic data in small experimental animals.

Expression of T-cell populations and molecular markers of human myocardium with checkpoint-induced myocarditis.

79 Background: Checkpoint Inhibitors have become first line therapy for a variety of solid and liquid malignancy. Immunotherapeutic agents predominantly target CTLA-4 and PD-L1. Efficacy has been demonstrated, and toxicities, especially cardiac manifested as myocarditis. The incidence of myocarditis is relatively low, fatality with monotherapy approaches 50% and with dual Immunotherapy is over 75%. No screening biomarkers or cardiac imaging predict a priori whom will develop myocarditis, nor which patients will be at risk. The frequency of these targets are unknown in the human heart. Methods: We present a case study of a patient with a diagnosis of urothelial carcinoma to lung and lymph nodes treated with systemic nivolumab plus NKTR after cycle 2 he presented with one week history of shortness of breath and hemodynamically unstable complete heart block requiring temporary transvenous pacemaker. Initial Troponin = 356, BNP = 2106. Given high suspicion for cardiovascular disease and or myocarditis, a left heart angiogram, right heart catheterization and endomyocardial biopsy of right ventricle were performed. RV biopsies were obtained percutaneously from right internal jugular approach with fluoroscopic guidance. Pulmonary capillary wedge pressure was 23mmHg. Persistent complete heart block was present during weaning attempts from temporary pacemaker and a percutaneous dual chamber pacemaker was implanted. Results: Coronary angiogram showed non obstructive disease, endomyocardial biopsy revealed lymphocytic infiltrate with necrosis based on Dallas Criteria. Immunohistochemistry showed, predominance of CD3,CD4,CD8,CD20,CD68 and PD-L1 staining was grossly positive compared to control samples. The patient was treated with methylprednisone 1mg/kg IV BID, plasmapheresis times 5 cycles, mycophenolate mofetil 500mg IV BID with resolution of symptoms and discharged to home. Conclusions: We present a patient with nivolumab induced myocarditis complicated with myocarditis and complete heart block. The pathological approach of T-Cell phenotyping is unique and identifies a novel approach to precision driven diagnosis, the incidence of PD-L1 expression in the human heart is unknown.

PERSISTENT HEART FAILURE IN A PATIENT SUPPORTED BY LEFT VENTRICULAR ASSIST DEVICE CAUSED BY AORTIC VALVE PARAVALVULAR LEAK TREATED SUCCESSFULLY WITH AMPLATZER OCCLUDER

Aortic valve paravalvular leak (PVL) is an under-recognized cause of persistent heart failure in patients supported by left ventricular assist devices (LVAD). A 68 year old male with a history of aortic valve replacement and end stage heart failure status post LVAD presents with persistent heart

Vein of Galen Aneurysmal Malformation and High-output Cardiac Failure in a Newborn

Background: Vein of Galen aneurysm (VGA) is the most common form of symptomatic cerebrovascular malformation in neonates. It develops in a fetus in the first trimester of pregnancy due to unknown reasons, but it is likely to have a genetic etiology. The prognosis of VGA is usually poor, particularly in newborns with heart failure due to high-flow intracerebral shunt. Surgery and endovascular embolization are partially successful treatments for controlling congestive heart failure and pulmonary hypertension. Case report: In this article, we present the case of a 3600-gram, full-term, female neonate hospitalized with respiratory distress and severe heart failure. The neonate was the second child of a 28-year-old mother. After echocardiography and brain sonography, she was diagnosed with the vein of Galen malformation. The case had severe and persistent congestive heart failure and refractory pulmonary hypertension. Conclusion: It is important to perform the auscultation of fontanel in newborns and consider VGA as a differential diagnosis in the neonates with congestive heart failure.

Efficacy and safety of serelaxin when added to standard of care in patients with acute heart failure: results from a PROBE study, RELAX-AHF-EU.

Serelaxin is a recombinant human relaxin-2 hormone, which confers receptor-mediated vasodilatation in a tissue-specific fashion. The RELAX-AHF-EU study assessed the effect of serelaxin when added to standard-of-care (SoC) therapy on worsening heart failure (WHF)/all-cause death through Day 5 in patients hospitalised for acute heart failure (AHF) in Europe. This multicentre, prospective, randomised, open-label, blinded-endpoint validation study enrolled hospitalised AHF patients and randomised (2:1) eligible patients (mild-to-moderate renal impairment and systolic blood pressure ≥ 125 mmHg) within 16 h of presentation with signs/symptoms of AHF, to receive 48 h intravenous infusion of 30 μg/kg/day serelaxin + SoC or SoC alone. The primary endpoint was adjudicated WHF/all-cause death through Day 5. Of 3183 patients targeted, 2666 were randomised when the study was terminated early by the sponsor due to the neutral results of the pivotal RELAX-AHF-2 study. Adjudicated WHF/all-cause death through Day 5 was significantly reduced in the serelaxin + SoC vs. SoC group (5.0% vs. 6.9%; hazard ratio 0.71; 95% confidence interval 0.51-0.98; P = 0.0172) (absolute risk reduction 1.9%, number needed to treat 53). The difference between treatment groups was not significant for WHF/all-cause death/heart failure rehospitalisation through Day 14 and length of hospital stay. A significantly smaller proportion of patients in the serelaxin + SoC vs. SoC group experienced persistent heart failure signs/symptoms at each visit until Day 4, or renal deterioration through Day 5 (all P ≤ 0.01). Overall incidence of treatment-emergent adverse events was comparable between treatment groups. Hypotension and decrease in haemoglobin/haematocrit were more frequent in the serelaxin + SoC group. When added to SoC, serelaxin reduced adjudicated WHF or all-cause death through Day 5 in AHF patients. The results from this open-label study should be considered in the context of the totality of the double-blind, randomised evidence on serelaxin in AHF.

A case report of Mycobacterium abscessus infective endocarditis in rheumatic heart disease

Infective endocarditis owing to Mycobacterium abscessus infection is extremely rare and is usually seen as prosthetic valve endocarditis. A 34-year-old male with rheumatic heart disease presented to us with undiagnosed pyrexia. He had vegetation on anterior mitral leaflet, and his blood cultures grew M. abscessus. The patient responded transiently to amikacin, clarithromycin, and minocycline. His course was complicated by recurrent cardioembolic strokes. The patient was not willing for surgery and had downhill course with persistent fever and heart failure leading to death. Native valve M. abscessus endocarditis is extremely rare. Early surgical intervention is recommended along with intravenous antibiotics, but the course is usually fatal.

Indication of permanent cardiac pacing after transcatheter aortic valve implantation (TAVISTIM NCT02337140)

Regarding the extent of TAVI's indication to patients with intermediary risks, it seems essential to lower its complication. Conduction disturbances after TAVI remains a major complication without any standardized guidelines to help with its treatment. The primary end-point of this study is to confirm that standard criterion for pacing are reliable in post-TAVI conduction disorders and to analyze the contribution of a systematic electrophysiological study. In TAVI patients, indications for pacing were persistent high-degree atrioventricular block or bundle branch block appearance associated to HV interval longer than 70 ms, 24 hours after the procedure. After a two-month follow-up, clinical and ECG evaluation and 24-hour ECG Holter monitoring were realized in patients without pacemaker and compared to data obtained from the devices in pacemaker implanted patients (% of ventricular pacing > 1%; presence of more than 1 AVB episode). A total of 165 consecutive patients who underwent TAVI were prospectively included. Out of the 165 patients included, 157 were sampled: 20 in the high grade persistent AV block, 5 in the persistent bundle branch heart block with HV interval > 70 ms, 13 with HV interval < 70 ms, and 119 in the temporary conduction disturbances group. Amongst the 22 patients implanted with PMK following the protocol, only 1 had conduction recovery. On the other hand there were 14 patients who didn’t benefit from a PMK implant but should have. HV interval in the bundle branch block group has an 88% specificity and a 44% sensibility. None of the pacing indication would have been missed if considered at day 3 instead of day 2, independently of HV measurement. From this experimental protocol it appears that an HV based algorithm has a good specificity but a poor sensibility. Conduction disorders are stable at day 3 and allow to decide if pacing is needed. Besides QRS duration, PR interval might be of interest in predicting risk of AV block after TAVI.

Adenosine plasma level in patients with paroxysmal or persistent atrial fibrillation and normal heart during ablation procedure and/or cardioversion.

The mechanism of atrial fibrillation (AF) in patients with normal heart remains unclear. While exogenous adenosine can trigger AF, nothing is known about the behavior of endogenous adenosine plasma level (APL) at the onset of AF and during ablation procedure. Ninety-one patients (68 with paroxysmal AF: 40 males, 66 ± 16years; 23 with persistent AF: 14 males, 69 ± 11years) and 18 controls were included. Among paroxysmal patients: i) medical therapy alone was performed in 45 cases and ablation procedure in 23. AF was spontaneously resolutive in 6 cases; ii) 23 underwent ablation procedure and blood was collected simultaneously in a brachial vein and in the left atrium; 17 were spontaneously in sinus rhythm while 6 were in sinus rhythm after direct current cardioversion. Among persistent patients: i) in 17 patients, blood samples were collected in a brachial vein before and after direct current cardioversion; ii) in 6 patients, blood samples were collected simultaneously in a brachial vein and in left atrium before and after cardioversion during ablation procedure. CV-APL was higher in patients with persistent AF vs patients with paroxysmal AF (median [range]: 0.9[0.6-1.1] vs 0.7[0.4-1.1] μM; p < 0.001). In patients with paroxysmal AF, LA-APL increased during the AF episode (0.95[0.85-1.4] vs 2.7[1.5-7] μM; p = 0.03) and normalized in sinus rhythm after DCCV. In patients with persistent AF, LA-APL was higher than CV-APL (1.2[0.7-1.8] vs 0.9[0.6-1.1] μM; p < 0.001), and both normalized in sinus rhythm (CV-APL: 0.8[0.6-1.1] vs 0.75[0.4-1] μM; p = 0.03), (LA-APL: 1.95[1.3-3] vs 1[0.5-1.15] μM; p = 0.03). The occurrence of AF is associated with a strong increase of APL in the atrium. The cause of this increase needs further investigations.

Parameters associated with therapeutic response using peritoneal dialysis for therapy refractory heart failure and congestive right ventricular dysfunction.

BackgroundIn patients with refractory heart failure (HF) peritoneal dialysis (PD) is associated with improved functional status and decrease in hospitalization. However, previous studies did not focus on right ventricular dysfunction as an important pathophysiologic component of cardiorenal syndrome.MethodsIn a prospective cohort study PD was started in 40 patients with refractory right HF (with/without left HF). Refractoriness to conservative therapy was defined as persistent right heart congestion/ascites with intensified diuretic treatment and/or ≥2 hospitalizations within 6 months because of cardiac decompensation despite optimal medical treatment, and/or acute renal failure during intensified conservative treatment of cardiac decompensations.ResultsPatient survival was 55.0% at 1 year, 35.0% at 2 years and 27.5% at 3 years. The number of hospitalization days declined after initiation of PD for both cardiac [13 (IQR 1–53) days before vs. 1 (IQR 0–12) days after start of PD, p<0.001] and unplanned reasons [12 (IQR 3–44) days before vs. 1 (IQR 0–33) days after start of PD, p = 0.007]. Using a combined endpoint including survival time of ≥1 year and either improvement in quality of life or decline in hospitalizations we found that patients with extended ascites, higher systolic pulmonary artery pressure, more marked impairment of right ventricular function and tricuspid valve insufficiency, higher residual renal function as well as those who could perform PD without assistance have benefited most from this therapy.ConclusionsPatients with more pronounced backward failure, less marked residual renal functional impairment and those not depending on assistance for therapy are likely to profit most from PD.

Epidemiology of Esophageal Cancer (EC) In Oromia Region, Ethiopia 2016: A 4-Year Medical Record Review

Background: It is difficult to determine the prevalence/incidence of EC without an established functional national cancer registry, which helps to demarcate the population at-risk and monitor cancer trends over time. The review of medical records can help to identify areas in a country with high number of diagnosed EC cases and help set public health priorities. Aim: To describe EC hospital case series during a period of 4 years at the main cancer treatment center in Ethiopia and two hospitals in the EC high-risk zones in the Oromia region, concentrating on residents of Oromia region and to offer recommendations for public health officials. Methods: All EC malignancy data from the period 2013-2016 were collected by reviewing patient charts at the selected hospitals: Tikur Anbessa Teaching hospital (TATH) in Addis Ababa, Adama General and Medical Teaching Hospital (AGMTH) and Adama Referral and Medical Teaching Hospital (ARMTH). Cases with insufficient residence information and residents of other regions were excluded from the summary. The number of EC cases is presented by age, sex and site as well as method of diagnosis. Data were expressed as percentages (%). Statistical analysis was done using SPSS 20 software. Results: Over the study period, a total of 669 EC cases who resided in Oromia region were identified in the selected hospitals out of 2211 registered in the referral surgical departments of hospitals in the study, with insignificant difference by sex. A total of 457 (68%) were residents from high risk Arsi/Bale zones and the rest 212 (32%) from other zones of the region. The mean age at diagnosis was 52.4 years with the majority of cases in the age range 45-69 years. A total of 34 (5%) EC cases were younger at diagnosis (15-29 years). A total of 258 (38.5%) cases were identified at TATH, 305 (46%) from AGHMT/ARHMT and 106 (16%) cases from both TATH/AGHMT. Data were gathered from patient charts at endoscopy departments 227 (34%), endoscopy and pathology departments 246 (37%) and all other sources (ie surgical department) 196 (29%). Most patients complained dysphagia for solids 664 (99%) and weight loss 352 (53%). Cases were histopathology proven (256, 38%), identified through endoscopy investigation (385, 58%) or radiology (28, 4%). Squamous cell carcinoma was the predominant histology type with 160 cases (62.5%) of those histologically proven. Among the total of 420 cases whose risk factor history was recorded, 401 (97%) had a previous history of digestive disease, 49% reported hot beverage consumption and 34% persistent heart burn. Conclusion: Two thirds of EC incident cases came from Arsi and Bale zones with decreasing trends over the period considered. Such trends warrant in depth investigation for possible reasons and future study to investigate local based risk factors associated with the disease.

Working Toward an Improved Understanding of Chronic Cardiorenal Syndrome Type 4.

Chronic diseases of the heart and of the kidneys commonly coexist in individuals. Certainly combined and persistent heart and kidney failure can arise from a common pathologic insult, for example, as a consequence of poorly controlled hypertension or of severe diffuse arterial disease. However, strong evidence is emerging to suggest that cross talk exists between the heart and the kidney. Independent processes are set in motion when kidney function is chronically diminished, and these processes can have distinct adverse effects on the heart. The complex chronic heart condition that results from chronic kidney disease (CKD) has been termed cardiorenal syndrome type 4. This review will include an updated description of the cardiac morphology in patients who have CKD, an overview of the most likely CKD-sourced culprits for these cardiac changes, and the potential therapeutic strategies to limit cardiac complications in patients who have CKD.

P6597Personalized ablation strategy in patients with long-standing persistent atrial fibrillation and chronic heart failure

P6597Personalized ablation strategy in patients with long-standing persistent atrial fibrillation and chronic heart failure

Galectin-3 level predicts response to ablation and outcomes in patients with persistent atrial fibrillation and systolic heart failure.

IntroductionMechanisms of maintenance of both atrial fibrillation and structural left ventricular disease are known to include fibrosis. Galectin-3, a biomarker of fibrosis, is elevated both in patients with heart failure and persistent atrial fibrillation. We sought to find whether galectin-3 has a prognostic value in patients with heart failure and a reduced left ventricular ejection fraction undergoing ablation of persistent atrial fibrillation.MethodsSerum concentrations of galectin-3 were determined in a consecutive series of patients with an ejection fraction ≤40%, addressed for ablation of persistent atrial fibrillation. Responders to ablation were patients in sinus rhythm and with an ejection fraction ≥50% at 6 months. A combined endpoint of heart failure hospitalization, transplantation and/or death was used at 12 months.ResultsSeventy-five patients were included (81% male, age 63±10 years, ejection fraction 34±7%, galectin-3 21±12 ng/mL). During follow-up, eight patients were hospitalized for decompensated heart failure, 1 underwent heart transplantation, and 4 died; 50 patients were considered as responders to ablation. After adjustment, galectin-3 level independently predicted both 6-month absence of response to ablation (OR = 0.89 per unit increase, p = 0.002). Patients with galectin-3 levels <26 had a 95% 1-year event-free survival versus 46% in patients with galectin-3 ≥26 ng/mL (p<0.0001).ConclusionsGalectin-3 levels independently predict outcomes in patients with reduced left ventricular systolic function addressed for ablation of persistent AF, and may be of interest in defining the therapeutic strategy in this population.

363Long-term outcome of pulmonary vein isolation versus amiodarone therapy in patients with coexistent persistent atrial fibrillation and congestive heart failure

363Long-term outcome of pulmonary vein isolation versus amiodarone therapy in patients with coexistent persistent atrial fibrillation and congestive heart failure

Best Paper Award.

Best Paper Award.

Day-case device implantation-A prospective single-center experience including patient satisfaction data.

Many centers perform day-case cardiac rhythm management (CRM) device implantation. However, there is a paucity of prospective data concerning this approach. We performed a prospective single-center study of day-case device implantation, including data on patient satisfaction. All patients scheduled for a new elective device were considered for a day-case procedure. Exclusion criteria were living alone or without a suitable carer, advancing age/frailty, a metallic valve, and persistent complete heart block. Following discharge, patients were reviewed in device clinic at 6weeks with an anonymized questionnaire. During the study period (May 2014-August 2016), 797 new CRM devices were implanted. Of these, 232 were elective and included in the analysis; 101 were planned to be day-case and 131 scheduled for overnight stay. Of the 101 day-case patients, 52 had a pacemaker, 28 an implantable cardioverter defibrillator (ICD), 16 a cardiac resynchronization therapy pacemaker/defibrillator, and five a subcutaneous-ICD. Complications were similar in the day-case (n=12, 12%) and overnight stay (n=15, 11%) groups (P=0.92). In the day-case group, 93 (92%) patients went home the same day. An estimated 111 overnight bed days were saved, translating to a cost saving of £61,912 (euro 70,767, $79,211). Note that 99% (n=100) of patients returned the questionnaire. Patient satisfaction was universally high. The majority (n=98, 98%) felt ready to go home on discharge; only a minority (n=5, 5%) would have preferred an overnight stay. A significant proportion of elective new CRM device implants can be performed as day-case procedures. With appropriate selection patient acceptability of same-day discharge is high.

54Treating underlying conditions improves quality of life in patients with persistent atrial fibrillation and heart failure - data from the RACE 3 study

54Treating underlying conditions improves quality of life in patients with persistent atrial fibrillation and heart failure - data from the RACE 3 study