Heart Failure Hospitalization Rates Research Articles

Three-Year Outcomes of Balloon-Expandable Transcatheter Aortic Valve Implantation According to Annular Size

Data on the association between annular size and transcatheter aortic valve implantation (TAVI) outcomes beyond 1 year are limited. The present study assessed the association between the aortic annulus size and TAVI clinical and hemodynamic outcomes at 3years of follow-up. Patients were classified according to the aortic annulus size as having small, intermediate, and large annuli (size <400, 400 to 574, and ≥575mm2, respectively). The co-primary endpoints were all-cause mortality and heart failure hospitalization. Further, the changes in hemodynamic outcomes over the follow-up period (median 37, interquartile range: 26 to 45 months) were assessed. The present analysis included 850 patients, with 182 patients (21.4%), 538 patients (63.3%), and 130 patients (15.3%) in the small, intermediate, and large-sized aortic annulus groups, respectively. The groups had comparable age and pre-TAVI pressure gradients; however, patients with small annuli had higher Society of Thoracic Surgeons risk scores. Adjusted Cox regression analysis showed that compared to patients with intermediate-sized annuli, patients with small and large annuli had similar all-cause mortality (hazard ratio [HR]=1.11, 95% confidence interval [CI] 0.72 to 1.69 and HR=0.74, 95% CI 0.48 to 1.16, respectively) and heart failure hospitalization rates (HR=0.96, 95% CI 0.55 to 1.69 and HR=1.26, 95% CI 0.73 to 2.17, respectively). However, patients with small annuli had consistently higher mean and peak pressure gradients and a higher risk of patient-prosthesis mismatch. The risks of moderate-to-severe regurgitation and structural valve deterioration were similar between the three groups. In conclusion, although patients with small annuli had higher transvalvular gradients, there was no significant association between the aortic annulus size and TAVI clinical outcomes at 3years of follow-up. Future studies should compare the performance of transcatheter valve types in patients with different aortic annulus sizes.

Effects of Intravenous Iron Replacement Therapy on Cardiovascular Outcomes in Patients with Heart Failure: A Systematic Review and Meta-Analysis.

(1) Background: Iron deficiency (ID) is an important adverse prognostic marker in patients with heart failure (HF); however, it is unclear whether intravenous iron replacement reduces cardiovascular mortality in this patient group. Here, we estimate the effect of intravenous iron replacement therapy on hard clinical outcomes following the publication of IRONMAN, the largest trial in this field. (2) Methods: In this systematic review and meta-analysis, prospectively registered with PROSPERO and reported according to PRISMA guidelines, we searched PubMed and Embase for randomized controlled trials investigating intravenous iron replacement in patients with HF and co-existing ID. The primary outcome was cardiovascular mortality and secondary outcomes were all-cause mortality, hospitalizations for HF and a combination of the primary outcome and hospitalizations for HF. (3) Results: A total of 1671 items were identified and after removal of duplicates we screened titles and abstracts of 1202 records. Some 31 studies were identified for full-text review and 12 studies were included in the final review. The odds ratio (OR) for cardiovascular death using a random effects model was 0.85 (95% CI 0.69 to 1.04) and for all-cause mortality it was 0.83 (95% CI 0.59 to 1.15). There was a significant reduction in hospitalizations for HF (OR 0.49, 95% CI 0.35 to 0.69) and the combination of hospitalizations for HF and cardiovascular death (OR 0.65, 95% CI 0.5 to 0.85). (4) Conclusions: This review supports the use of IV iron replacement reducing hospitalization rates for HF, however more research is required to determine the effect on cardiovascular mortality and to identify the patient population most likely to benefit.

The Impact of Complete Revascularization in Symptomatic Severe Left Ventricular Dysfunction between Coronary Artery Bypass Graft and Percutaneous Coronary Intervention.

The study aimed to compare the clinical outcomes between the patients receiving coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) for the patients with symptomatic severe left ventricular (LV) dysfunction and coronary artery disease (CAD). Between February 2007 and February 2020, a total of 745 patients who received coronary artery angiography for reduced LV ejection fraction (LVEF) < 40% and symptomatic New York Heart Association (NYHA) functional class ≥ 3 were recruited. The patients (N = 236) who were diagnosed with dilated cardiomyopathy or valvular heart disease without coronary artery stenosis, those with prior history of CABG or valvular surgery (N = 59), those who presented ST-segment elevated myocardial infarction (STEMI), those with a CAD and SYNTAX score of ≦ 22 (N = 175), those who received emergent CABG for coronary perforation (N = 3), and those who had NYHA class ≦ 2 (N = 65) were excluded. Finally, 116 patients with reduced LVEF and those who had a SYNTAX score >22, who received CABG (N = 47) and PCI (N = 69), were recruited for this study. There was no significant difference in the incidence values of in-hospital course and those of in-hospital mortality, acute kidney injury, and postprocedural hemodialysis. There was no significant difference in the 1-yearfollow-up of recurrent MI, revascularization, or stroke between the groups. The 1-year heart failure (HF) hospitalization rate was significantly lower in the CABG group than in all patients of the PCI group (13.2% vs. 33.3%; p = 0.035); however, there was no significant difference in the same variable between the CABG group and the complete revascularization subgroup (13.2% vs. 28.2%; p = 0.160). The revascularization index (RI) was significantly higher in the CABG group than in all patients of the PCI group or complete revascularization subgroup (0.93 ± 0.12 vs. 0.71 ± 0.25; p < 0.001) and (0.93 ± 0.12 vs. 0.86 ± 0.13; p = 0.019). The 3-year HF hospitalization rate was significantly lower in the CABG group than in all patients of the PCI group (16.2% vs. 42.2%; p = 0.008); however, there was no difference in the same variable between the CABG group and the complete revascularization subgroup (16.2% vs. 35.1%; p = 0.109). In patients with symptomatic (NYHA class ≥ 3) severe LV dysfunction and CAD, CABG brought less HF admission when compared to patients in the PCI group, but this did not differ when compared to the complete revascularization subgroup. Therefore, an extensive revascularization, achieved by CABG or PCI, is associated with a lower HF hospitalization rate during the 3-yearfollow-up period in such populations.

Leadless versus transvenous single-chamber ventricular pacemakers: 3 year follow-up of the Micra CED study.

The Micra Coverage with Evidence Development (CED) Study is a novel comparative analysis of Micra (leadless VVI) and transvenous single-chamber ventricular pacemakers (transvenous VVI) using administrative claims data. To compare chronic complications, device reinterventions, heart failure hospitalizations, and all-cause mortality after 3 years of follow-up. USMedicare claims data linked to manufacturer device registration information were used to identify Medicare beneficiaries with a de novo implant of either a Micra VR leadless VVI or transvenous VVI pacemaker from March 9, 2017 to December 31, 2018. Unadjusted and propensity score overlap-weight adjusted Fine-Gray competing risk models were used to compare outcomes at 3 years. Leadless VVI patients (N = 6219) had a 32% lower rate of chronic complications and a 41% lower rate of reintervention compared with transvenous VVI patients (N = 10 212) (chronic complication hazard ratio [HR] 0.68; 95% confidence interval [CI], 0.59-0.78; reintervention HR 0.59; 95% CI 0.44-0.78). Infections rates were significantly lower among patients with a leadless VVI (<0.2% vs. 0.7%, p < .0001). Patients with a leadless VVI also had slightly lower rates of heart failure hospitalization (HR 0.90; 95% CI 0.84-0.97). There was no difference in the adjusted 3-year all-cause mortality rate (HR 0.97; 95% CI, 0.92-1.03). This nationwide comparative evaluation of leadless VVI versus transvenous VVI de novo pacemaker implants demonstrated that the leadless group had significantly fewer complications, reinterventions, heart failure hospitalizations, and infections than the transvenous group at 3 years, confirming that the previously reported shorter-term advantages associated with leadless pacing persist and continue to accrue in the medium-to-long-term.

Mortality in heart failure with and without autoimmune disease.

Autoimmune diseases (AIDs) are associated with a higher risk of heart failure (HF). However, data on the prognosis of HF patients with a history of AID are limited. The aim was to investigate the rates of all-cause mortality and HF hospitalization in a large, nationwide cohort of patient with HF according to a history of 29 AIDs. Using Danish nationwide registries, each HF patient (diagnosed 2000-18) with a history of AID was matched with four HF patients without AID by age, sex, and year of HF diagnosis. Rates of outcomes were compared by Cox regression models. The prevalence of AID in patients with HF was 10.7%. In total, 21 256 HF patients with a history of AID were matched with 85 024 HF patients without AID (median age 77 years; 58.9% female). During a median follow-up of 3.2 years, the incidence rates per 100 person-years for all-cause mortality were 17.1 (95% confidence interval, 16.9-17.4) and 14.4 (14.3-14.6) in patients with and without AID, respectively. The corresponding rates for HF hospitalization were 5.0 (4.9-5.1) and 5.2 (5.1-5.4), respectively. A history of AID was associated with higher rate of all-cause mortality [hazard ratio (HR) 1.14 (1.12-1.17)], but not HF hospitalization [HR 1.00 (0.96-1.04)] compared with no AID. In a nationwide cohort study, patients with HF and a history of AID had a higher associated rate of mortality than those without a history of AID.

Prognostic value of mitral valve haemodynamic parameters obtained by intraprocedural echocardiography in transcatheter edge-to-edge repair.

To assess whether intraprocedural transesophageal echocardiographic (TEE)-derived haemodynamic parameters predict outcomes in patients undergoing transcatheter edge-to-edge repair (TEER) for mitral regurgitation (MR). This is a single-centre, retrospective analysis encompassing 458 (IQR, 104-1035) days of follow-up after 926 consecutive patients [481 (52%) with functional MR] referred to an isolated mitral TEER between 2013 and 2020. Cases without actual clip deployment, or in whom prior mitral procedures had taken place, were excluded. The primary outcome was the combined rate of all-cause mortality or heart failure (HF) hospitalizations. Secondary endpoints included single components of the primary outcome, as well as MR severity at one month and one year following the procedure. A multivariable analysis identified two intraprocedural echocardiographic observations made after clip deployment as independent predictors of the primary outcome: an above mild MR (HR for whole study period 1.49, 95% CI 1.05-2.13, P = 0.026) and a 100% or more increase from baseline in the transmitral mean pressure gradient (TMPG) (HR for whole study period 1.32, 95% CI 1.01-1.72, P = 0.039). Also, MR grade of above mild and the absence of a normal pulmonary venous flow pattern (PVFP) bilaterally were associated with an increased risk for HF hospitalizations and greater-than-mild 1-month MR. No prognostic role was demonstrated for the change in MR severity, the absolute TMPG, or the mere improvement in PVFP. Immediate post-TEER MR severity and the relative change in TMPG are predictive of clinical and echocardiographic outcomes following the procedure.

Applicability of Vericiguat to Patients Hospitalized for Heart Failure in the United States

BackgroundIn January 2021, vericiguat, a soluble guanylate cyclase stimulator, was approved by the U.S. Food and Drug Administration (FDA) to reduce the risk of cardiovascular death and heart failure (HF) hospitalization among patients with a recent worsening HF event based on the VICTORIA (VerICiguaT Global Study in Subjects with Heart Failure with Reduced Ejection Fraction) trial. ObjectivesThis study sought to leverage a contemporary U.S. registry of patients hospitalized for heart failure (HF) to characterize patients who may be candidates for vericiguat based on FDA label and the VICTORIA trial eligibility criteria. MethodsThe authors studied patients hospitalized for HF with ejection fraction (EF) <45% across 525 sites in the GWTG-HF (Get With The Guidelines–Heart Failure) registry between January 2014 and December 2020. Approximate FDA label criteria (excluding estimated glomerular filtration rate [eGFR] <15 mL/min/1.73 m2, dialysis, or patients with heart transplantation or durable mechanical circulatory support) and eligibility criteria for the VICTORIA trial were applied to the GWTG-HF cohort. ResultsAmong 241,057 patients with EF <45% in the GWTG-HF registry, 221,730 (92%) could be candidates for vericiguat under the FDA label and 92,249 (38%) would have been eligible for the VICTORIA trial. The most frequent reasons for ineligibility for the FDA label were eGFR <15 mL/min/1.73 m2 (5.7%) and dialysis (1.6%). Although there were greater proportions of women and Black patients in the GWTG-HF registry, most clinical characteristics were qualitatively similar with patients enrolled in the VICTORIA trial. Among Medicare beneficiaries in the GWTG-HF registry eligible for vericiguat by either FDA label or VICTORIA trial criteria, 12-month postdischarge rates of mortality (36%-37%), HF hospitalization (33%-35%), all-cause hospitalization (64%-66%), and mean health care expenditure (U.S. $25,106-$25,428) were high. ConclusionsData from a large, contemporary U.S. registry of patients actively hospitalized for HF with EF <45% suggest that approximately 4 in 10 patients meet the criteria of the VICTORIA trial and that more than 9 in 10 patients are potential candidates for vericiguat based on the FDA label. Contemporary Medicare beneficiaries hospitalized for HF with EF <45% and eligible for vericiguat face high rates of postdischarge mortality and readmission and accrue substantial health care costs.

Increased Risk of Heart Failure in Elderly Patients Treated with Beta-Blockers After AV Node Ablation.

Controversy exists regarding the indication of beta-blockers (BB) in different scenarios in patients with cardiovascular disease. We sought to evaluate the effect of BB on survival and heart failure (HF) hospitalizations in a sample of pacemaker-dependent patients after AV node ablation to control ventricular rate for atrial tachyarrhythmias. A retrospective study including consecutive patients that underwent AV node ablation was conducted in a single center between 2011 and 2019. The study's primary endpoints were the incidence of all-cause mortality, first HF hospitalization and the cumulative incidence of subsequent hospitalizations for HF. Competing risk analyses were employed. A total of 111 patients with a mean age of 73.9 years were included in the study. After a median follow-up of 45.5 months, 43 patients had died (38.7%) and 31 had been hospitalized for HF (27.9%). The recurrent HF hospitalization rate was 74/1000 patients/year. Patients treated with BB had a non-significant trend to higher mortality rates and a higher risk of recurrent HF hospitalizations (incidence rate ratio 2.23, 95% confidence interval 1.12-4.44; p = 0.023). After an AV node ablation, the use of BB is associated with an increased risk of HF hospitalizations in a cohort of elderly patients.

Management of Heart Failure with Reduced Ejection Fraction Globally and in Lebanon: Where Do SGLT-2is Stand?

Heart failure (HF) is a clinical syndrome due to structural and/or functional cardiac anomalies, accompanied by elevated natriuretic peptide levels and/or cardiogenic pulmonary or systemic congestion; severely compromising patients’ health, performance and quality of life. The advancement of novel treatment and their endorsement by international medical and scientific societies have shifted the treatment of HF with reduced ejection fraction (HFrEF) towards quadruple therapy: an angiotensin receptor-neprilysin inhibitor or an angiotensin-converting enzyme inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist and a sodium/glucose co-transporter-2 inhibitor (SGLT2i). This paper reviews the available literature on state-of-the-art diagnostic and therapeutic advances in HFrEF, discusses landmark trials that shifted the paradigm towards quadruple therapy in HFrEF, visits the potential challenges in Lebanon and globally, proposes an algorithm for treatment introduction and sequencing in HFrEF and highlights clinical considerations for HFrEF management and patient education and follow-up. This practical guidance could serve cardiologists and other medical specialists in identifying clinical signs of HFrEF, diagnosing patients, referring them or prescribing the components of quadruple therapy, and offering medical advice and follow-up. We highlight the role of SGLT2is in HF management and their effectiveness in reducing rates of hospitalization for HF as well as cardiovascular deaths, with satisfactory safety profile.

Renin Trajectories and Outcome in Stable Heart Failure with Reduced Ejection Fraction (HFrEF) on Contemporary Therapy: A Monocentric Study from an Austrian Tertiary Hospital Outpatient Clinic

Introduction. The renin-angiotensin system (RAS) is the main target of neurohumoral therapy in heart failure with reduced ejection fraction (HFrEF) effectively reducing mortality. Reasonably, renin might serve as a biomarker for risk prediction and therapy response. Renin indeed bears some additional value to clinical risk models, albeit the effect is not pronounced. Whether assessing renin trajectories can overcome the weaknesses of single renin measurements has not been reported. Methods. A total of 505 patients with stable HFrEF were enrolled prospectively and followed through routine clinical visits. Active plasma renin concentration was documented up to 5 years. Changes in renin were analyzed throughout the disease course, and survival was compared for different renin trajectories within the first year. Results. Baseline renin levels were not related to all-cause mortality (crude HR for an increase of 100 μiE/ml: 1.01 (95% CI: 0.99–1.02), [Formula: see text]) but associated with unplanned HF hospitalizations (crude HR: 1.01 (95% CI: 1.00-1.02), [Formula: see text]). Renin increased during the disease course from baseline to 1-year and 2-year FUP (122.7 vs. 185.6 μIU/ml, [Formula: see text], and 122.7 vs. 258.5 μIU/ml, [Formula: see text]). Both survival and unplanned HF hospitalization rates were comparable for different renin trajectories at 1-year FUP ([Formula: see text], [Formula: see text]). Conclusions. Intriguingly, renin is not a good biomarker to indicate prognosis in HF, while renin trajectories over a 1-year period do not have an additional value. Rapid physiologic plasma renin variations, but also opposing effects of angiotensinogen-derived metabolites under presence of RAS blockade, might obscure the predictive ability of renin.

Worse In-Hospital Outcomes Among Patients With Heart Failure (HF) and Concomitant Influenza Infection.

A sizable proportion of heart failure (HF) admissions is precipitated by respiratory infections. Influenza has been linked to higher rates of HF hospitalizations and in-hospital morbidity and mortality. We aimto describe the in-hospital outcomes of systolic HF vs. diastolic HF admissions with concomitant influenza infection in US hospitalizations from 2016 to 2017. Materials and Methods:We queried the National Inpatient Sample (NIS) from 2016 to 2017 for discharge diagnosis for SHF and DHF and influenza per ICD-10 CM codes. Using binominal logistic regression analysis and adjusting for demographic and comorbid conditions, we compared the outcomes of SHF vs. DHF admissions with concomitant influenza as an independent risk factor for inpatient mortality, acute respiratory failure, ICU admission,assisted ventilation, as well as length of stay, and total hospital costs. A total of 7,490,596 HF weighted admissions were analyzed, among which 0.9% had concomitant influenza infection. SHF and DHF admissions with influenza had higher mortality, ICU admission, ventilation assistance, and acute respiratory failure when compared to those without influenza. Among influenza admissions, those with SHF had higher mortality (6.6% vs. 5%, adjusted odds ratio - aOR 1.31, p<0.001) compared to DHF. While intensive care unit (ICU) admission(7.8% vs. 5.2%, aOR 1.30, p<0.001) and ventilation assistance rates (22.1% vs. 18.9%, aOR 1.15, p<0.001) were greater among SHF patients with influenza, acute respiratory failure was more common amongst diastolic HF with influenza (46.6% vs. 51.2%, aOR 0.86, p<0.001).Finally, SHF patients with concomitant influenza had higher inpatient costs ($82,788) when compared to diastolic HF patients ($66,373) and a longer in-hospital stay (7.29 days compared to 6.98 days in the diastolic HF group)p <0.001. Concomitant influenza infection in hospitalized patients with HF is associated with higher mortality, ICU admission, and the need for assisted ventilation, especially in those with SHF. A greater emphasis on vaccination against influenza may improve in-patient outcomes among HF patients.

Artificial intelligence-augmented electrocardiography for left ventricular systolic dysfunction in patients undergoing high-sensitivity cardiac troponin T.

Our goal was to evaluate a previously validated artificial intelligence-augmented electrocardiography (AI-ECG) screening tool for left ventricular systolic dysfunction (LVSD) in patients undergoing high-sensitivity-cardiac troponin T (hs-cTnT). Retrospective application of AI-ECG for LVSD in emergency department (ED) patients undergoing hs-cTnT. AI-ECG scores (0-1) for probability of LVSD (left ventricular ejection fraction ≤ 35%) were obtained. An AI-ECG score ≥0.256 indicates a positive screen. The primary endpoint was a composite of post-discharge major adverse cardiovascular events (MACEs) at two years follow-up. Among 1977 patients, 248 (13%) had a positive AI-ECG. When compared with patients with a negative AI-ECG, those with a positive AI-ECG had a higher risk for MACE [48 vs. 21%, P < 0.0001, adjusted hazard ratio (HR) 1.39, 95% confidence interval (CI) 1.11-1.75]. This was largely because of a higher rate of deaths (32 vs. 14%, P < 0.0001; adjusted HR 1.26, 95% 0.95-1.66) and heart failure hospitalizations (26 vs. 6.1%, P < 0.001; adjusted HR 1.75, 95% CI 1.25-2.45). Together, hs-cTnT and AI-ECG resulted in the following MACE rates and adjusted HRs: hs-cTnT < 99th percentile and negative AI-ECG: 116/1176 (11%; reference), hs-cTnT < 99th percentile and positive AI-ECG: 28/107 (26%; adjusted HR 1.54, 95% CI 1.01-2.36), hs-cTnT > 99th percentile and negative AI-ECG: 233/553 (42%; adjusted HR 2.12, 95% CI 1.66, 2.70), and hs-cTnT > 99th percentile and positive AI-ECG: 91/141 (65%; adjusted HR 2.83, 95% CI 2.06, 3.87). Among ED patients evaluated with hs-cTnT, a positive AI-ECG for LVSD identifies patients at high risk for MACE. The conjoint use of hs-cTnT and AI-ECG facilitates risk stratification.

931 EVALUATION OF IATROGENIC ATRIAL SEPTAL DEFECT CLOSURE AFTER TEER

Abstract Iatrogenic atrial septal defect (iASD) represents one of the main access-related cardiac complications after trancatheter edge to edge (TEER) mitral valve repair with Mitraclip system. Transesophageal echocardiography (TEE) guiding supports a controlled and safe transseptal puncture. The rate of persistent iASD is 57, 50, and 25% after 1, 6, and 12 months post procedure. An elevated left atrial pressure after clip positioning correlates with iASD persistence. Its clinical impact is controversially discussed: Post-TEER iASD has been associated with right heart volume overload, as well as increased rates of heart failure (HF) hospitalization and death in some studies. In contrast, other studies have shown an association between post-TEER iASD and improved hemodynamics. In theory, creation of an iASD can decompress an overloaded left atrium, mitigating heart failure. Some studies have demonstrated that iASD closure can reduce significantly both right and left heart failure symptoms. We did a retrospective study enrolling in the period 2012-2022 twenty-one patients with severe mitral regurgitation treated with TEER. Our aim was to evaluate the clinical outcomes (symptoms, signs of heart failure, NYHA functional class) and echocardiographic parameters (PAPs, TAPSE, Right Atrium Area) in two group of patients: Group A underwent iASD closure during the TEER and Group B after one month following the TEER. At 1-month follow-up all patients with repaired mitral regurgitation showed an improvement in the NYHA class (from IV-III to II-I) and no need for re-hospitalization with no significant differences between two groups. In the Group A there were two adverse events during the recovery (2 major bleeding); while there were no adverse events in patients undergoing iASD closure after wise. There was 1 death in the first month after the procedure in group A, while there wasn't any in group B. Statistical analysis showed no significant differences in terms of NYHA class improvement in the two groups (p=0.91). We observed a greater reduction in PAPs in patients going to encounter intraprocedural DIA closure which was found to be statistically significant (p=0.01). Regarding TAPSE, there was a difference in terms of improvement which was found to be greater in the group A. However, this finding was not found to be statistically significant. We also assessed the right atrium area: in group A, we registered a mean preprocedural value of 28 cmq and a postprocedural value of 34 cmq; in group B the values were 20 cmq and 24 cmq, respectively, with a nonstatistically significant difference in terms of atrial enlargement post device placement. In conclusion, we can assume that the improvements in symptomatology are not closely related to iASD closure. However, it must considered that patients in group A had more unfavorable echocardiographic values before the procedure than those in group B, and probably, if we had not closed the iASD immediately during the procedure, these patients would have had worse symptomatology. Therefore, targeted patient selection is essential.

The cardiac computed tomography-derived extracellular volume fraction predicts patient outcomes and left ventricular mass reductions after transcatheter aortic valve implantation for aortic stenosis

BackgroundTranscatheter aortic valve implantation (TAVI) improved outcome of patients with severe aortic valve stenosis (AS). Myocardial fibrosis is associated with AS-related pathological left ventricular (LV) remodeling and predicts cardiovascular mortality after TAVI. The present study aimed to investigate the impact of preoperative extracellular volume (ECV) assessed by computed tomography (CT) on left ventricular mass (LVM) regression and clinical outcomes in severe AS patients after TAVI. MethodsWe examined 71 consecutive severe AS patients who underwent CT with ECV determination before TAVI. ECV was calculated as the ratio of the change in Hounsfield units in the myocardium and LV blood before and after contrast administration, multiplied by (1-hematocrit). Delayed scan was performed at 5 min after contrast injection. Echocardiography was performed before and 6 months after TAVI. The primary endpoint was heart failure (HF) hospitalization after TAVI. Patients were divided into two subgroups according to the median value of global ECV with 32 % (Low-ECV group: n = 35, and High-ECV group: n = 36). ResultsNo significant differences were observed in background characteristics between the 2 groups. However, the preoperative LV ejection fraction and LVM index were similar between the 2 groups, the Low-ECV group had greater LVM index reduction than the High-CV group after 6 months (p < 0.001). Kaplan-Meier curves demonstrated that the High-ECV group had significantly higher rate of HF hospitalization than the Low-ECV group (p = 0.016). In addition, multivariate analyses identified high global ECV as an independent predictor of HF hospitalization (HR 10.8, 95 % confidence interval 1.36 to 84.8, p = 0.024). ConclusionThe low preoperative ECV assessed by CT is associated with the greater LVM regression, and predict better outcome in AS patients after TAVI.

Meta-Analysis on Drug and Device Therapy of New York Heart Association Functional Class IV Heart Failure With Reduced Ejection Fraction

Heart failure with reduced ejection fraction (HFrEF) is associated with significant morbidity and mortality, particularly in patients with New York Heart Association (NYHA) functional class IV symptoms. Decades of discovery have heralded significant advancements in the pharmacologic management of HFrEF. However, patients with NYHA IV symptoms remain an under-represented population in almost every clinical trial to date, leaving clinicians with limited evidence with which to guide drug treatment decisions in this patient group with severe heart failure. Randomized controlled trials of adult patients with NYHA IV symptoms of HFrEF randomized to current guideline-recommended medical therapy were included in this systematic review and meta-analysis. The outcomes of interest included the rate of all-cause mortality, cardiovascular mortality, and heart failure hospitalization. A total of 39 randomized controlled trials were included. A total of 6 studies examined angiotensin converting enzyme inhibitors, with meta-analyses of 2 demonstrating a reduced risk of all-cause mortality (relative risk (RR) 0.76, 95% confidence interval 0.59 to 0.97, p=0.03). A total of 11 studies examined β blockers, with meta-analysis of 6 demonstrating a reduced risk of all-cause mortality (risk ratio 0.74, 95% confidence interval 0.60 to 0.92, p=0.008). A study examined the mineralocorticoid antagonist spironolactone, reporting a reduced risk of all-cause mortality in the NYHA IV subgroup. A total of 6 studies examined device therapy, demonstrating the benefit of cardiac resynchronization therapy with or without an implantable cardiac defibrillator in reducing hospitalization in the NYHA IV subgroup. Although trial evidence exists for angiotensin converting enzyme inhibitors, β-blockers, and mineralocorticoid antagonist therapy in the NYHA IV population, the role of angiotensin receptor blockers is unclear. Ivabradine, angiotensin receptor neprilysin inhibitors, and sodium-glucose transport protein 2 inhibitors remain underinvestigated and have not been proved to provide any benefit above standard heart failure therapy in patients with HFrEF and NYHA IV symptoms.

Improving outpatient care for heart failure through digital innovation: a feasibility study

BackgroundHeart failure (HF) affects over 26 million people worldwide. Multidisciplinary management strategies that include symptom monitoring and patient self-care support reduce HF hospitalization and mortality rates. Ideally, HF follow-up and self-care support includes lifestyle-change recommendations and remote monitoring of weight and HF symptoms. Providing these via a digital solution may be ideal for improving HF disease outcomes and reducing the burden on providers and healthcare systems. This study’s main objective was to assess the feasibility of a digital solution including remote monitoring, lifestyle-change, and self-care support for HF outpatients in Iceland.MethodsTwenty HF patients (mean age 57.5 years, 80% males) participated in an 8-week study. They were provided with a digital solution (SK-141), including lifestyle-change and disease self-care support, a remote symptom monitoring system, and a secure messaging platform between healthcare providers and patients. This feasibility study aimed to assess patient acceptability of this new intervention, retention rate, and to evaluate trends in clinical outcomes. To assess the acceptability of SK-141, participants completed a questionnaire about their experience after the 8-week study. Participants performed daily assigned activities (missions), including self-reporting symptoms. Clinical outcomes were assessed with the Hospital Anxiety and Depression Scale and the Kansas City Cardiomyopathy Questionnaire at the study's beginning and end with an online survey.ResultsOf the 24 patients invited, 20 were elected to participate. The retention rate of participants throughout the 8-week period was high (80%). At the end of the 8 weeks, thirteen participants completed a questionnaire about their experience and acceptability of the SK-141. They rated their experience positively including on questions whether they would recommend the solution to others (6.8 on a scale of 1–7), whether the solution had improved their life and well-being (5.7 on a scale of 1–7), and whether it was user friendly (5.5 on a scale of 1–7). Many of the clinical parameters studied exhibited a promising trend towards improvement over the 8-week period.ConclusionThe digital solution, SK-141, was very acceptable to patients and also showed promising clinical results in this small feasibility study. These results encourage us to conduct a longer, more extensive, adequately powered, randomized-controlled study to assess whether this digital solution can improve the quality of life and clinical outcomes among HF patients.

Racial and Socioeconomic Differences in Heart Failure Hospitalizations and Telemedicine Follow-up During the COVID-19 Pandemic: Retrospective Cohort Study.

Low rates of heart failure (HF) hospitalizations were observed during the 2020 peak of the COVID-19 pandemic. Additionally, posthospitalization follow-up transitioned to a predominantly telemedicine model. It is unknown whether the shift to telemedicine impacted disparities in posthospitalization follow-up or HF readmissions. The aim of this paper is to determine whether the shift to telemedicine impacted racial and ethnic as well as socioeconomic disparities in acute decompensated heart failure (ADHF) follow-up and HF readmissions. We additionally sought to investigate the impact of the COVID-19 pandemic on the severity of ADHF hospitalizations. This was a retrospective cohort study of HF admissions across 8 participating hospitals during the initial peak of the COVID-19 pandemic (March 15 to June 1, 2020), compared to the same time frame in 2019. Patients were stratified by race, ethnicity, and median neighborhood income. Hospital and intensive care unit (ICU) admission rates, inpatient mortality, 7-day follow-up, and 30-day readmissions were assessed. From March 15, 2019, to June 1, 2020, there were 1162 hospitalizations for ADHF included in the study. There were significantly fewer admissions for ADHF in 2020, compared with 2019 (442 vs 720; P<.001). Patients in 2020 had higher rates of ICU admission, compared with 2019 (15.8% vs 11.1%; P=.02). This trend was seen across all subgroups and was significant for patients from the highest income quartile (17.89% vs 10.99%; P=.02). While there was a trend toward higher inpatient mortality in 2020 versus 2019 (4.3% vs 2.8%; P=.17), no difference was seen among different racial and socioeconomic groups. Telemedicine comprised 81.6% of 7-day follow-up in 2020, with improvement in 7-day follow-up rates (40.5% vs 29.6%; P<.001). Inequities in 7-day follow-up for patients from non-Hispanic Black racial backgrounds compared to those from non-Hispanic White backgrounds decreased during the pandemic. Additionally, those with telemedicine follow-up were less likely to be readmitted in 30 days when compared to no follow-up (13.8% vs 22.4%; P=.03). There were no major differences in HF ICU admissions or inpatient mortality for different racial and socioeconomic groups during the COVID-19 pandemic. Inequalities in 7-day follow-up were reduced with the advent of telemedicine and decreased 30-day readmission rates for those who had telemedicine follow-up.

Reduction in 90day readmission rates utilizing ambulatory pulmonary pressure monitoring.

In the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in New York Heart Association Functional Class III Heart Failure Patients) trial, heart failure hospitalization (HFH) rates were lower in patients with ambulatory pulmonary artery pressure (PAP) monitoring guidance. We investigated the effect of ambulatory haemodynamic monitoring on 90day readmission rates after HFH. We retrospectively analysed patients across the Advocate Aurora Health hospital network who had undergone PAP sensor implantation between 1 October 2015 and 31 October 2019. Patients with a ventricular assist device (VAD) or transplant prior to implantation were excluded. Rates of total HFH and 30 and 90day all-cause readmission up to 12months after implantation were collected, while censoring for an endpoint of heart transplantation, VAD, or death. Event rates were compared using Poisson regression. Of 459 patients included, there were 404 HFHs before and 179 after implantation. Compared with pre-implantation, 30day all-cause readmission [incidence rate ratio (IRR): 0.55 (0.39-0.77), P=0.0006] and 90day all cause readmission rates were lower post-implantation [IRR: 0.45 (0.35-0.58), P<0.0001]. The effect of PAP sensor implantation on 90day all-cause readmission incidence rates was consistent across multiple subgroups. Across a large hospital network, ambulatory haemodynamic monitoring was associated with lower HFH rates, as well as 30 and 90day all-cause readmission rates. This supports the utility of ambulatory PAP monitoring to improve HF management in the era of value-based medicine.

Clinical and echocardiographic outcomes with new-onset left bundle branch block after SAPIEN-3 transcatheter aortic valve replacement.

New-onset left bundle branch block (LBBB) can develop after transcatheter aortic valve replacement (TAVR) resulting in worse outcomes. Describe clinical and echocardiographic outcomes with new-onset LBBB after TAVR. We included consecutive patients who underwent transfemoral-TAVR with SAPIEN-3 (S3) valve between April 2015 and December 2018. Exclusion criteria included pre-existing LBBB, right BBB, left anterior hemiblock, left posterior hemiblock, wide QRS ≥ 120ms, prior permanent pacemaker (PPM), and nontransfemoral access. Among 612 patients, 11.4% developed new-onset LBBB upon discharge. The length of stay was longer with new-onset LBBB compared with no LBBB [3 (2-5) days versus 2 (1-3) days; p < 0.001]. New-onset LBBB was associated with higher rates of 30-day PPM requirement (18.6% vs. 5.4%; p < 0.001) and 1-year heart failure hospitalizations (10.7% vs. 4.4%; p = 0.033). There was no difference in 3-year mortality between both groups (30.9% vs. 30.6%; p = 0.829). Further, new-onset LBBB was associated with lower left ventricular ejection fraction (LVEF) at both 30 days (55.9 ± 11.4% vs. 59.3 ± 9%; p = 0.026) and 1 year (55 ± 12% vs. 60.1 ± 8.9%; p = 0.002). These changes were still present when we stratified patients according to baseline LVEF (≥50% or <50%). New-onset LBBBs were associated with a higher 1-year LV end-diastolic volume index (51.4 ± 18.6 vs. 46.4 ± 15.1 ml/m2 ; p = 0.036), and LV end-systolic volume index (23.2 ± 14.1 vs. 18.9 ± 9.7 ml/m2 ; p = 0.009). Compared with resolved new-onset LBBB, persistent new-onset LBBB was associated with worse LVEF and higher PPM at 1 year. New-onset LBBB after S3 TAVR was associated with higher PPM requirement, worse LVEF, higher LV volumes, and increased heart failure hospitalizations, with no difference in mortality.

Abstract 12767: Sodium-Glucose Cotransporter-2 Inhibitors Are Associated With Lower Risks of Hospitalization for Heart Failure and All-Cause Mortality in Patients With Diabetes Mellitus and Cancer

Introduction: Patients with cancer face a heightened risk of cardiovascular (CV) events and mortality. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce CV events in at-risk patients and may possess antitumor effects. Therefore, we examined the effect of SGLT2i on CV events and mortality among patients with cancer and diabetes. Methods: This was a retrospective propensity score-matched cohort study conducted at two tertiary referral centers in Taiwan. We included all adult patients with type 2 diabetes mellitus diagnosed with cancer between January 2010 and December 2021. The primary outcomes were hospitalization for incident heart failure (HF) and all-cause mortality. The secondary outcomes were a composite of myocardial infarction, ischemic stroke, and cardiac arrhythmias, and serious adverse events associated with SGLT2i. Results: From a total of 8640 patients, 878 SGLT2i-recipients were matched to non-recipients. During a median follow-up period of 18.8 months, SGLT2i recipients had a lower rate of hospitalization for incident HF compared with non-SGLT2i recipients (2.92 vs. 8.95 per 1000 patient-years, p=0.018). In both Cox regression and competing regression models, SGLT2i were associated with a 70% reduction in the risk for hospitalization for incident HF (HR, 0.28 [95% CI: 0.11-0.77], p = 0.013; SHR, 0.32 [95% CI: 0.12-0.84], p = 0.021). The use of SGLT2i was associated with a higher overall survival (85.3% vs. 63.0% at 2 years, p&lt;0.001). The risk of myocardial infarction, ischemic stroke, cardiac arrhythmias, and serious adverse events such as hypoglycemia, urosepsis, and sepsis was similar between the SGLT2i and non-SGLT2i cohorts. Conclusions: The use of SGLT2i was associated with a lower rate of hospitalization for incident HF and prolonged overall survival in cancer patients with diabetes mellitus.