Recovery Of Ventricular Function Research Articles

Scleroderma Renal Crisis in Mixed Connective Tissue Disease in a Patient: A Challenging Disease

A 52-year-old woman with Raynaud syndrome diagnosed less than 1 year ago, consulted the emergency room due to 4 months of progressive symmetrical edema in the lower limbs, muscle weakness, dyspnea, hypertension crisis, and dark urine. Investigations revealed left ventricular dysfunction (ejection fraction 14%) without coronary artery disease and acute renal injury. Mixed Connective Tissue Disease was diagnosed and because of the renal and systemic findings in the patient a renal biopsy was performed confirming scleroderma renal crisis. To the best of our knowledge, this is the tenth patient who reported scleroderma renal crisis as a complication in patients with Mixed Connective Tissue Disease, from these 4 patients who became hemodialysis dependent, 1 died, and 4 responded to therapy. The treatment chosen was Angiotensin-converting-enzyme inhibitors and steroids based on what is known in renal scleroderma crisis with a substantial recovery of the left ventricular function and stabilization of the glomerular filtration rate followed by discharge from hospitalization.

Pharmacomechanical Catheter-Directed Thrombolysis With the Bashir Endovascular Catheter for Acute Pulmonary Embolism: The RESCUE Study

BackgroundCatheter-directed thrombolysis (CDT) has been associated with rapid recovery of right ventricular (RV) function. The Bashir catheter was developed for enhanced thrombolysis in large vessels such as the pulmonary arteries (PAs) with lower doses of tissue plasminogen activator (tPA). ObjectivesThe aim of this study was to evaluate the efficacy and safety of tPA infused using a pharmacomechanical (PM) CDT device called the Bashir endovascular catheter in patients with intermediate-risk acute pulmonary embolism (PE). MethodsPatients with symptoms of acute PE with computed tomographic evidence of RV dilatation were enrolled. The Bashir catheter was used to deliver 7 mg tPA into each PA over 5 hours. The primary efficacy endpoint was the core laboratory–assessed change in computed tomographic angiography–derived RV/left ventricular (LV) diameter ratio at 48 hours, and the primary safety endpoint was serious adverse events (SAEs) including major bleeding at 72 hours. ResultsAt 18 U.S. sites, 109 patients were enrolled. The median device placement time was 15 minutes. At 48 hours after PM-CDT, the RV/LV diameter ratio decreased by 0.56 (33.3%; P < 0.0001). PA obstruction as measured by the refined modified Miller index was reduced by 35.9% (P < 0.0001). One patient (0.92%) had 2 SAEs: a retroperitoneal bleed (procedure related) and iliac vein thrombosis (device related). Two other procedure-related SAEs were epistaxis and non–access site hematoma with anemia. ConclusionsPM-CDT with the Bashir endovascular catheter is associated with a significant reduction in RV/LV diameter ratio and a very low rate of adverse events or major bleeding in patients with intermediate-risk acute PE. The notable finding was a significant reduction in PA obstruction with low-dose tPA. (Recombinant tPA by Endovascular Administration for the Treatment of Submassive PE Using CDT for the Reduction of Thrombus Burden [RESCUE]; NCT04248868)

Pulmonary Artery Banding for Dilated Cardiomyopathy in Children: Returning to the Bench from Bedside.

Current treatment paradigms for end-stage dilated cardiomyopathy (DCM) in children include heart transplantation and mechanical support devices. However, waitlist mortality, shortage of smaller donors, time-limited durability of grafts, and thrombo-hemorrhagic events affect long-term outcomes. Moreover, both these options are noncurative and cannot preserve the native heart function. Pulmonary artery banding (PAB) has been reinvented as a possible “regenerative surgery” to retrain the decompensated left ventricle in children with DCM. The rationale is to promote positive ventricular–ventricular interactions that result in recovery of left ventricular function in one out of two children, allowing transplantation delisting. Although promising, global experience with this technique is still limited, and several surgical centers are reluctant to adopt PAB since its exact biological bases remain unknown. In the present review, we summarize the clinical, functional, and molecular known and supposed working mechanisms of PAB in children with DCM. From its proven efficacy in the clinical setting, we described the macroscopic geometrical and functional changes in biventricular performance promoted by PAB. We finally speculated on the possible underlying molecular pathways recruited by PAB. An evidence-based explanation of the working mechanisms of PAB is still awaited to support wider adoption of this surgical option for pediatric heart failure.

Treating Pediatric Myocarditis with High Dose Steroids and Immunoglobulin.

There is considerable variability in practice among pediatric centers for treatment of myocarditis. We report outcomes using high dose steroids in conjunction with IVIG. This is a single center retrospective study of children < 21 years of age diagnosed with myocarditis and treated with high dose steroids and IVIG from January 2004-April 2021. Diagnostic criteria for myocarditis included positive endomyocardial biopsy, cardiac magnetic resonance (CMR) imaging meeting Lake Louise criteria, or strictly defined clinical diagnosis. Forty patients met inclusion criteria. Median age at diagnosis was 11.6 years (0.7–14.6). Diagnosis was made clinically in 70% of cases (N = 28), by CMR in 12.5% (N = 5) and by biopsy in 17.5% (N = 7). Median ejection fraction (EF) at diagnosis was 35% (IQR 24–48). Median duration of IV steroids was 7 days (IQR 4–12) followed by an oral taper. Median cumulative dose of IV immunoglobulin (IVIG) was 2 g/kg. There were no serious secondary bacterial infections after steroid initiation. Ten patients (25%) required mechanical circulatory support. Overall transplant free survival was 92.5% with median follow-up of 1 year (IQR 0–6 years). Six patients required re-admission for cardiovascular reasons. By 3 months from diagnosis, 70% of patients regained normal left ventricular function. High dose steroids in conjunction with IVIG to treat acute myocarditis can be safe without significant infections or long-term side effects. Our cohort had excellent recovery of ventricular function and survival without transplant. Prospective comparison of a combination of high dose steroids with IVIG versus other therapies is needed.

Effect of direct stenting on microvascular dysfunction during percutaneous coronary intervention in acute myocardial infarction: a randomized pilot study.

ObjectiveWhether direct stenting (DS) without predilatation during primary percutaneous coronary intervention (PPCI) reduces microvascular dysfunction in patients with ST-elevation myocardial infarction is unclear. We performed a randomized study to assess the effect of DS on microvascular reperfusion.MethodsSeventy-two patients undergoing PPCI were randomly assigned to the DS or conventional stenting (CS) with predilatation groups. The primary endpoint was the post-PPCI index of microcirculatory resistance (IMR). We compared thrombolysis in myocardial infarction myocardial perfusion (TMP) grades, ST-segment resolution, and long-term clinical outcomes between the groups.ResultsMicrovascular reperfusion parameters immediately after PPCI (e.g., the IMR, TMP grade, and ST-segment resolution) were not different between the groups. However, significantly fewer patients in the DS group had the IMR measured because of no-reflow or cardiogenic shock during PPCI than those in the CS group. No differences were found in left ventricular functional recovery or clinical outcomes between the groups.ConclusionsThis trial showed no effect of DS on the IMR. However, our finding should be interpreted with caution because the number of patients who could not have the IMR measured was higher in the CS group than in the DS group. A larger randomized trial is required (Research Registry number: 8079).

Recovery of left ventricular function is associated with improved outcomes in LVAD recipients.

The significance of recovered left ventricular ejection fraction (LVEF) in LVAD recipients, outside of pump explantation, is unclear. Patients undergoing first LVAD implantation at Duke University Hospital between 2006 and 2017 were evaluated for LVEF recovery up to 2 years following implant. Occurrence of gastrointestinal bleeding (GIB), hospitalization for heart failure (HF), pump thrombosis and death were assessed before and after LVEF recovery. Of 286 patients who met inclusion criteria, 9.8% reached a "threshold" of recovery with an LVEF ≥ 40%. 17.4% achieved "relative" recovery with an increase in LVEF ≥ 10% since LVAD implantation. For either definition, recovered patients had a lower incidence of a composite endpoint of GIB, HF hospitalization, pump thrombosis, or death compared to patients without recovery. Patients with "threshold" recovery had 4.7 events per 100 patient-years (95% CI, 0.7-33.6) compared to 48.8 events per 100 patient-years (95% CI, 39.5-60.3) without "threshold" recovery [p=.020]. Those with "relative" recovery had 14.1 events per 100 patient-years [95% CI, 5.9-33.8] versus 50.7 events per 100 patient-years (95% CI, 40.7-63.0) without "relative" recovery [p=0.005]. However, improved outcomes in the "relative" recovery group were limited to those who also met the "threshold" definition. Importantly, among patients who achieved "threshold" recovery, the incidence of the composite endpoint declines in the postrecovery period, suggesting that LVEF recovery mechanistically results in improved outcomes. An LVEF ≥ 40% associates with better outcomes in LVAD recipients. Methods to promote recovery could reduce morbidity and mortality related to LVAD support.

Uric Acid Predicts Recovery of Left Ventricular Function and Adverse Events in Heart Failure With Reduced Ejection Fraction: Potential Mechanistic Insight From Network Analyses.

Background and AimsHeart failure with reduced ejection fraction (HFrEF) still carries a high risk for a sustained decrease in left ventricular ejection fraction (LVEF) even with the optimal medical therapy. Currently, there is no effective tool to stratify these patients according to their recovery potential. We tested the hypothesis that uric acid (UA) could predict recovery of LVEF and prognosis of HFrEF patients and attempted to explore mechanistic relationship between hyperuricemia and HFrEF.MethodsHFrEF patients with hyperuricemia were selected from the National Inpatient Sample (NIS) 2016–2018 database and our Xianyang prospective cohort study. Demographics, cardiac risk factors, and cardiovascular events were identified. Network-based analysis was utilized to examine the relationship between recovery of LVEF and hyperuricemia, and we further elucidated the underlying mechanisms for the impact of hyperuricemia on HFrEF.ResultsAfter adjusting confounding factors by propensity score matching, hyperuricemia was a determinant of HFrEF [OR 1.247 (1.172–1.328); P < 0.001] of NIS dataset. In Xianyang prospective cohort study, hyperuricemia is a significant and independent risk factor for all-cause death (adjusted HR 2.387, 95% CI 1.141–4.993; P = 0.021), heart failure readmission (adjusted HR 1.848, 95% CI 1.048–3.259; P = 0.034), and composite events (adjusted HR 1.706, 95% CI 1.001–2.906; P = 0.049) in HFrEF patients. UA value at baseline was negatively correlated to LVEF of follow-ups (r = −0.19; P = 0.046). Cutoff UA value of 312.5 μmmol/L at baseline can work as a predictor of LVEF recovery during follow-up, with the sensitivity of 66.7%, the specificity of 35.1%, and the accuracy of 0.668 (95% CI, 0.561–0.775; P = 0.006). Moreover, gene overlap analysis and network proximity analysis demonstrated a strong correlation between HFrEF and Hyperuricemia.ConclusionLower baseline UA value predicted the LVEF recovery and less long-term adverse events in HFrEF patients. Our results provide new insights into underlying mechanistic relationship between hyperuricemia and HFrEF.

Effect Evaluation of Echocardiography on Right Ventricular Function in Patients after the Recovering from Coronavirus Disease 2019.

This research was aimed at exploring the changes in right ventricular function in patients after the recovery of coronavirus disease 2019 (COVID-19) under echocardiography and providing a reference for the rehabilitation and treatment of COVID-19 patients. Three echocardiographic follow-up examinations were performed on 40 recovered COVID-19 patients and 40 healthy people. Right ventricular function between patients after COVID-19 rehabilitation and healthy people was compared. The mean values of right ventricular fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), right ventricular ejection fraction (RVEF), right myocardial performance index (RMPI), and tricuspid annular plane systolic speed (S') were compared between patients after COVID-19 rehabilitation and healthy subjects. The technical parameters of two-dimensional speckle tracking were compared. The results showed that the differences in RVFAC, TAPSE, RVEF, and RMPI between COVID-19 patients and healthy controls were not significant during the three follow-up periods (P > 0.05). At the first follow-up, the S' was 12.78 cm/s in COVID-19 patients and 13.18 cm/s in healthy subjects. At the second follow-up, the S' was 11.98 cm/s in COVID-19 patients and 12.77 cm/s in healthy subjects. At the third follow-up, the S' was 12.79 cm/s in COVID-19 patients and 13.12 cm/s in healthy subjects. There was no significant difference between the two groups (P > 0.05). In addition, there was no significant difference in right ventricular function between COVID-19 patients and healthy controls, and there was no significant difference in cardiovascular symptoms (P > 0.05). In summary, COVID-19 had no substantial effect on right ventricular function and better recovery in patients.

The Coronary Angiography-Derived Index of Microcirculatory Resistance Predicts Left Ventricular Performance Recovery in Patients with ST-Segment Elevation Myocardial Infarction

Objectives The present study is designed to investigate the impact of coronary angiography-derived index of microcirculatory resistance (caIMR) on left ventricular performance recovery. Background IMR has been established as a gold standard for coronary microvascular assessment and a predictor of left ventricular recovery after ST-segment elevation myocardial infarction (STEMI). CaIMR is a novel and accurate alternative of IMR. Methods The present study retrospectively included 80 patients with STEMI who underwent primary percutaneous coronary intervention (PCI). We offline performed the post-PCI caIMR analysis of the culprit vessel. Echocardiography was performed within the first 24 hours and at 3 months after the index procedure. Left ventricular recovery was defined as the change in left ventricular ejection fraction (LVEF) more than zero. Results The mean age of the patients was 58.0 years with 80.0% male. The average post-PCI caIMR was 43.2. Overall left ventricular recovery was seen in 41 patients. Post-PCI caIMR (OR: 0.948, 95% CI: 0.916–0.981, p = 0.002), left anterior descending as the culprit vessel (OR: 3.605, 95% CI: 1.23–10.567, p = 0.019), and male (OR: 0.254, 95% CI: 0.066–0.979, p = 0.047) were independent predictors of left ventricular recovery at 3 months follow-up. A predictive model was established with the best cutoff value for the prediction of left ventricular recovery 2.33 (sensitivity 0.610, specificity 0.897, and area under the curve 0.765). In patients with a predictive model score less than 2.33, the LVEF increased significantly at 3 months. Conclusions The post-PCI caIMR can accurately predict left ventricular functional recovery at 3 months follow-up in patients with STEMI treated by primary PCI, supporting its use in clinical practice.

Aortic valve replacement using On-X valve in a child postorthotopic heart transplantation.

A 20-month-old girl presented with severe dilated cardiomyopathy and decompensated congestive cardiac failure. Despite escalating inotropic and mechanical ventilation support, she required placement on extracorporeal membrane oxygenation and transfer to the transplant centre in Newcastle, England. She was placed on biventricular assist device and then Berlin Heart but failed to show any recovery of ventricular function. She underwent orthotopic heart transplantation at 2 years of age. She developed bacterial endocarditis with Enterococcus faecalis resulting in severe aortic valve regurgitation requiring aortic valve replacement with a 19 mm On-X valve (Airtivion) 11 days after her transplant. Given the size of the donor heart, it was possible to implant a 19-mm valve in this 12 kg child with minimal risk of patient prosthesis mismatch. She was anticoagulated with warfarin (On-X valve INR 2-3 for first 3 months; INR 1.5-2.0 thereafter). Although she suffered several other post-operative complications, including malabsorption, nasojejunal feeding, liver dysfunction, vertebral fractures, renal impairment and renal calcification, and need for repeat opening of her tracheostomy site following her initial decannulation, her aortic valve function has remained stable.

Absolute Resting 13N-Ammonia PET Myocardial Blood Flow for Predicting Myocardial Viability and Recovery of Ventricular Function after Coronary Artery Bypass Grafting

ObjectiveWe aimed to evaluate the feasibility of resting myocardial blood flow (rMBF), quantified with dynamic 13 N-Ammonia (NH3) PET, for identifying myocardial viability and predicting improvement of left ventricular ejection fraction (LVEF) after coronary artery bypass grafting (CABG). MethodsNinety-three patients with coronary artery disease (CAD) and chronic LVEF < 45%, scheduled for CABG, had dynamic 13NH3 PET and 18F-FDG PET imaging. The perfusion/metabolism polar maps were categorized in four patterns: normal (N), mismatch (M1), match (M2) and reverse mismatch (RM). The value of rMBF for identifying viable myocardium (M1, RM) and post CABG improvement of LVEF≥8% was analyzed by receiver operating characteristic (ROC) curves. Correlations of rMBF in segments to ΔLVEF post CABG were verified. ResultsMean rMBFs were significantly different (N=0.60±0.14; M1=0.44±0.07, M2=0.34±0.08, RM=0.53±0.09 ml/min/g, P<0.001). The optimal rMBF cutoff to identify viable myocardium was 0.42 ml/min/g (sensitivity=88.3%, specificity=82.0%) and 0.43 ml/min/g for predicting improvement of LVEF ≥8% (74.6%, 80.0%). The extent and rMBF of combined M1/RM demonstrated a moderate to high correlation to improved LVEF (r=0.78, 0.71, P<0.001). ConclusionResting MBF, derived by dynamic 13NH3 PET, may be positioned as a supplement to 18F-FDG PET imaging for assessing the presence of viable myocardium and predicting potential improvement of LVEF after CABG.

A new prediction model for left ventricular systolic function recovery after catheter ablation of atrial fibrillation in patients with heart failure and reduced ejection fraction, The ANTWOORD Study

Abstract Funding Acknowledgements Type of funding sources: None. Background In patients with heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation (AF), pulmonary vein isolation (PVI) improves left ventricular ejection fraction (LVEF), along with prognosis, in a variable percentage of patients. Aim To investigate the predictors of LVEF recovery after PVI and to develop a prediction model for individualized assessment. Methods We conducted an observational, retrospective, single-center study on 111 consecutive patients with AF and HFrEF undergoing PVI. Patients were divided into Responder vs. Non-Responder according to the "Universal definition of HF". Clinical predictors were evaluated by multivariate logistic regression analysis and cross-validation technique. Independent predictors were used to build an internally validated prediction model. Results Responders (54%) had significantly shorter QRS duration and less dilated left atria. Persistent AF and absence of a known etiology more frequent among Responders. AF recurrence was non-significantly different between the two groups (p=0.2), although clinical AF burden was lower in Responders, after PVI (p&amp;lt;0.001). Absence of known etiology, presence of persistent AF, left atrial volume index&amp;lt;50ml/m2, and QRS&amp;lt;120msec were independent predictors of LVEF recovery and composed the "Antwerp Score". Patients with Antwerp Score ≤1 had 90% likelihood of LVEF recovery, compared to 5% in patients with 3-6. Conclusions Patients with wide QRS complex, known HF etiology, dilated left atria, and paroxysmal AF were less likely to recover LVEF after PVI. A new score system based on the above-mentioned parameters adequately predict LV function recovery after PVI. These results warrant confirmation and prospective validation.

P223 THYROTOXIC DILATED CARDIOMYOPATHY

Abstract Hyperthyroidism can strongly impact cardiac function. Thyrotoxicosis enhances myocardiocytes metabolism and it can be responsible for hyperdynamic circulation state leading to heart failure with preserved ejection fraction, but also left ventricle dilatation and severe contractile function impairment. It can furthermore provoke arrhythmias, mostly atrial fibrillation, but, as we are going to discuss in this case, even ventricular arrhythmias. A 40–year–old woman came to our emergency department for chest pain. ECG showed reduced R waves voltage in precordial leads and troponin I values were normal. The echocardiogram showed severe left ventricle disfunction with global hypokinesia (EF 35%) and enlarged left ventricle (LVEDD 65 mm). Blood tests revealed severe hyperthyroidism with extremely low level of TSH, FT3 13,45 pg/ml, FT4 3,4 ng/ml and thyroid echography documented multiple solid nodular formations with hypo–isoechogenic signal. She underwent a coronary angiography that showed patent coronary arteries, and a cardiac magnetic resonance confirming severe contractile impairment and hypertrabeculation of the apex and lateral wall. On the assumption of a dilated cardiomyopathy secondary to hyperthyroidism, we started treatment with methimazole, ACE inhibitors and propranolol. During hospitalization, continuous ECG monitoring recorded several episodes of non–sustained ventricular tachycardia, the longest lasting 22 seconds, so the patient was discharged with a wearable cardioverter–defibrillator. It did not record any arrhythmias and it was dismissed a month later. After almost two months of therapy, the echocardiogram showed mild left ventricular contractility improvement (EF 45%), and blood tests documented partial reduction of hyperthyroidism. A 24–hour ECG Holter did not record any arrhythmias and the patient remained asymptomatic during all the period after discharge. Even if rare, scientific literature confirms that dilated cardiomyopathy with reduced ejection fraction can occur as a complication of hyperthyroidism. After the exclusion of an ischemic cause, we underline the need for adequate initiation of treatments for thyrotoxicosis and heart failure, in order to improve chance of left ventricular function recovery. In the case discussed, after two months of therapy, EF was still not completely restored but improved from 35% to 45%, and concurrently arrhythmic risk did clearly decrease.

Percutaneous approach to left ventricular assist device decommissioning.

ObjectiveTo assess the outcomes of a single‐center experience with percutaneous left ventricular assist device (LVAD) decommissioning.BackgroundPatients with LVADs may eventually require their removal, either due to recovery of left ventricular function or recurrent complications. Traditionally, withdrawal of LVAD support has been managed with surgical device explantation, which carries significant procedural risks. Transcatheter LVAD decommissioning, with outflow graft occlusion and driveline transection, has recently been described as an alternative to surgical removal.MethodsHere, we report on a retrospective cohort of five consecutive cases treated with transcatheter LVAD decommissioning.ResultsThe procedure was effective in all cases, and no patient experienced procedure‐related complications. At midterm follow‐up, the three patients who had myocardial function recovery were alive and had not experienced heart failure‐related symptoms or complications.ConclusionPercutaneous LVAD decommissioning appears to be a safe and effective approach to LVAD treatment discontinuation.

A new prediction model for left ventricular systolic function recovery after catheter ablation of atrial fibrillation in patients with heart failure: The ANTWOORD Study

Backgroundin patients with heart failure (HF) and atrial fibrillation (AF), AF ablation improves left ventricular ejection fraction (LVEF), along with prognosis, in a variable percentage of patients. We aimed to investigate the predictors of LVEF recovery after AF ablation and to develop a prediction model for individualized assessment. Methodswe conducted an observational, retrospective, single-centre study on 111 consecutive patients with AF and HF with impaired LVEF (<50%) undergoing ablation. Patients were divided into Responder vs. Non-Responder according to the “Universal definition of HF”. Clinical predictors were evaluated by multivariate logistic regression analysis and cross-validation technique. Independent predictors were used to build an internally validated prediction model. ResultsResponders (54%) had significantly shorter QRS duration and less dilated left atrium. Persistent AF and absence of a known etiology were more frequent among Responders. AF recurrence was similar between the two groups (p = 0.2), but the percentage of patient with persistent AF after ablation was significantly lower among Responders (p < 0.001). Absence of known etiology, presence of persistent AF, left atrial volume index<50 mL/m2, and QRS < 120 msec were independent predictors of LVEF recovery and composed the Score (AUC 0.93;95%CI 0.88–0.98–p < 0.001). Patients with Score ≤ 1 had 90% likelihood of LVEF recovery, compared to 5% in patients with 3–6. ConclusionsPatients with wide QRS, known HF etiology, dilated left atrium, and paroxysmal AF were less likely to recover LVEF after AF ablation. A new score system based on the above-mentioned parameters adequately predicts LVEF recovery after AF ablation. These results warrant confirmation and prospective validation.

Contemporary Outcomes of Pediatric Patients with Acute Fulminant Myocarditis Supported with Extracorporeal Membrane Oxygenation

<h3>Purpose</h3> Despite extracorporeal membrane oxygenation (ECMO) utilization in up to 20% of cases, there are limited outcome data in pediatric patients with acute fulminant myocarditis (AFM) requiring mechanical circulatory support. <h3>Methods</h3> Retrospective cohort of patients <18 years with AFM admitted to a single center cardiac ICU and supported with ECMO from 1997-2021. Patients had ≤14 days of symptoms, rapid cardiogenic shock, and normal LV size. We compared clinical variables in patients who survived to discharge without heart transplant (HT) to those who did not. In addition, we assessed long-term LV function in survivors. <h3>Results</h3> Among 29 patients (median age 9 years; IQR 3,14), 22 (76%) survived to discharge without HT. Patients were supported on ECMO for a median of 6 days (IQR 5,8). Three patients were bridged to HT with durable ventricular assist devices (VAD). Four patients died, 2 of whom were supported with VAD. At presentation, 7 patients (24%) had high grade or complete atrioventricular block and 8 (28%) had ventricular tachycardia. CPR prior to ECMO occurred in 22 (76%) including all patients in the death/HT group. The death/HT group had higher peak troponin levels (12.5 vs 0.9 ng/mL, p=0.01). All patients underwent cardiac catheterization. Initial LA pressure was higher in the death/HT group (27 vs 18 mmHg, p=0.02) and LA decompression was performed in 23 patients (79%). Twenty-two (76%) had biopsy findings consistent with AFM. Among transplant-free survivors, 19 (86%) had normalization in LV function (median 16 days from presentation, IQR 9,449); the remaining 3 patients had persistent mild LV dysfunction at last follow up. Nine patients underwent cardiac MRI (median 752 days post-diagnosis), among whom 4 exhibited late gadolinium enhancement. <h3>Conclusion</h3> Transplant-free survival of pediatric patients with AFM supported on ECMO was 76% and associated with lower initial LA pressure. Recovery of ventricular function among survivors was rapid and durable.

Recovery Of Allograft Right Ventricular Diastolic Dysfunction Post Heart Transplantation

Background Diastolic dysfunction after heart transplantation is a well-recognized phenomenon that is associated with high mortality. However, it is clinically well recognized that most allografts demonstrate stiffness in the early phase that recovers to a variable extent in most patients. The pattern of this recovery has not been well defined.ObjectivesWe aim to describe the natural course of allograft right ventricular (RV) diastolic function recovery in those without significant rejection or primary graft dysfunction events. Methods We retrospectively reviewed 22 patients who underwent orthotropic heart transplantation at UFhealth between September of 2015 and June of 2018. Exclusion criteria were significant acute cellular rejection (2R or more), primary graft dysfunction, and death due to any cause during the first year after transplantation. Invasive hemodynamics obtained during routine surveillance biopsies were recorded. We registered RV end diastolic and nadir pressures at 2 weeks, 1, 3, 6 and 12 months post-transplant. Results In our sample, the median age at transplant was 48 years, 63.6% were male, 4.6% were Hispanic, 72.3% were White, 22.7% were Black, 4.6% belonged to other racial groups. Looking at cardiovascular risk factors, 27.3% had diabetes, 90.9% had hypertension, and 18.2% had obesity with median BMI of 27. Figure 1 shows the trend of RV pressures overtime. Cold ischemic time was on average 211 min and did not correlate with RV end diastolic pressure (R = 0.49). Conclusions Early post transplantation period is associated with RV diastolic dysfunction that usually recovers by 12 weeks post operatively. Diastolic dysfunction after heart transplantation is a well-recognized phenomenon that is associated with high mortality. However, it is clinically well recognized that most allografts demonstrate stiffness in the early phase that recovers to a variable extent in most patients. The pattern of this recovery has not been well defined.ObjectivesWe aim to describe the natural course of allograft right ventricular (RV) diastolic function recovery in those without significant rejection or primary graft dysfunction events. We retrospectively reviewed 22 patients who underwent orthotropic heart transplantation at UFhealth between September of 2015 and June of 2018. Exclusion criteria were significant acute cellular rejection (2R or more), primary graft dysfunction, and death due to any cause during the first year after transplantation. Invasive hemodynamics obtained during routine surveillance biopsies were recorded. We registered RV end diastolic and nadir pressures at 2 weeks, 1, 3, 6 and 12 months post-transplant. In our sample, the median age at transplant was 48 years, 63.6% were male, 4.6% were Hispanic, 72.3% were White, 22.7% were Black, 4.6% belonged to other racial groups. Looking at cardiovascular risk factors, 27.3% had diabetes, 90.9% had hypertension, and 18.2% had obesity with median BMI of 27. Figure 1 shows the trend of RV pressures overtime. Cold ischemic time was on average 211 min and did not correlate with RV end diastolic pressure (R = 0.49). Early post transplantation period is associated with RV diastolic dysfunction that usually recovers by 12 weeks post operatively.

Cardiogenic Shock Following Successful CTO Revascularization

<h3>Introduction</h3> The role of urgent mechanical circulatory support (MCS) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is not well studied. This case highlights myocardial recovery in a patient with ventricular fibrillation following a CTO PCI supported with MCS. <h3>Case Report</h3> A 45 year-old man with recent non-ST elevation myocardial infarction, found to have triple vessel coronary artery disease treated with drug-eluting stent to LAD and OM1, due to patient preference, presents for an elective revascularization of CTO of RCA. Left ventricular function at time of discharge from his prior hospitalization was preserved. Revascularization of CTO was accomplished with placement of Resolute Onyx 3.5x38 mm stent and Resolute Onyx 3.0x26 mm stent to the mid RCA and a Resolute Onyx 3.0x22 mm stent to the distal RCA. There were no complications, and the patient was transferred to a telemetry floor. Soon after transfer he suffered cardiac arrest with ventricular fibrillation. He was defibrillated with return of spontaneous circulation however remained hemodynamically tenuous. Bedside echocardiogram demonstrated severe biventricular dysfunction. Coronary angiography showed stable anatomy with patent stents. Given declining hemodynamic status an Impella CP was placed emergently via the left femoral artery. He was transferred to the cardiac critical care unit where he subsequently developed monomorphic ventricular tachycardia with further hemodynamic deterioration. He was cannulated for VA ECMO and hemodynamic stability was achieved. Due to ongoing hemolysis, Impella CP was exchanged for an axillary Impella 5.5. As results of medical management and aggressive supportive care, subsequent echocardiograms demonstrated recovery of left and right ventricular function. He was decannulated from VA ECMO and Impella 5.5 after four days. Outpatient transthoracic echocardiogram performed four weeks later demonstrate preserved biventricular function. LV ejection fraction was measured at 55% and global longitudinal strain -16.7%. RV longitudinal strain -21.4%. He is tolerating guideline-directed medical therapy for heart failure. <h3>Summary</h3> This case describes ventricular fibrillation following CTO revascularization and highlights the positive outcomes associated with early recognition of deteriorating cardiogenic shock and rapid escalation of mechanical circulatory support.

Assessing Cardiac Recovery for Decommissioning of LVAD Support: Structure versus Function

<h3>Introduction</h3> Recovery of left ventricular (LV) function during LVAD support occurs in only 1-3% of patients. Assessment for recovery and LVAD removal is desirable given the risks of infection, stroke, and device malfunction. This case of a patient with an LVAD, with recovered LV systolic function but abnormal exercise hemodynamics, illustrates the potential utility of right heart catheterization studies for clinical decisions. <h3>Case Report</h3> A 35-year-old man presented with cardiogenic shock after a late-presentation ST elevation myocardial infarction, requiring short-term veno-arterial extracorporeal membrane oxygenation post-angioplasty. Then, a HeartMate II LVAD was inserted. Four months after implantation, the patient was well (NYHA I). Serial echocardiography demonstrated recovery of LVEF to 50-55% by 7 months. Repeated hemodynamic assessments were performed over 11 months. Hemodynamics were recorded at supine rest with baseline LVAD speed, with speed reduced to the equivalent of unsupported (8000 rpm) and then during cycle ergometer exercise at a constant work rate (Table). Between baseline and unsupported speeds, minimal change in the mixed venous O2 saturation and smaller increases in mean pulmonary arterial wedge pressure (mPAWP) and mean pulmonary artery pressures (mPAP) were noted during the 3rd and 4th studies. However, during exercise, the patient displayed persistently limited increases in cardiac output (CO) and the relationship between PAWP and CO (∆PAWP/∆CO) was persistently elevated above 2 mmHg/L/min. As such, the patient was listed for transplant rather than explanted. <h3>Summary</h3> Although echocardiographic imaging showed recovery of LV systolic function, exercise at unsupported speed was associated with abnormal ∆PAWP/∆CO, prompting concern of recurrent symptomatic heart failure if the LVAD was explanted. This case illustrates ongoing efforts to evaluate appropriate structural and functional markers of myocardial recovery to support decisions regarding LVAD explantation.

Full Recovery of Right Ventricular Systolic Function in Children Undergoing Bilateral Lung Transplantation for Severe PAH

<h3>Purpose</h3> We investigated whether RV function recovers in children with pulmonary arterial hypertension (PAH) and RV failure undergoing lung transplantation (LuTx). The major research questions were how completely and how quickly after LuTx systolic RV function recovers in children with PAH. <h3>Methods</h3> Prospective observational study of 15 consecutive children (age range: 1.9-17.6 years) with severe PAH who underwent bilateral lung transplantation between December 2013 and January 2021. We performed advanced echocardiography (Echo) and cardiac magnetic resonance imaging (MRI), followed by conventional and strain analysis, pre and ∼6 weeks post LuTx. <h3>Results</h3> All patients had PAH, i.e. group 1 pulmonary hypertension: idiopathic (n=6), heritable (n=4), PAH-congenital heart disease (n=2), pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis (PVOD/PCH; n=3). Six weeks after LuTx, RV/LV endsystolic diameter ratio (Echo), RV volumes and systolic RV function (RVEF 63 vs. 30 %; p<0.05) by MRI completely normalized, even in children with severe RV failure (RVEF < 40%). The echocardiographic end-systolic LV eccentricity index nearly normalized post LuTx (1.0 vs. 2.0, p<0.0001) while RV hypertrophy regressed more slowly and was still evident. We found especially the end-systolic RV/LV ratios by Echo (RV/LV diameter; 0.6 vs. 2.6) or MRI (RV/LV volumes: 0.8 vs. 3.4 excellent diagnostic tools (p<0.05): Together with RVEF by MRI, these ratios were superior to tricuspid annular plane systolic excursion (TAPSE; p>0.05) in assessing global systolic RV dysfunction. Moreover, children with severe PAH had reduced RV 2D longitudinal strain (Echo, MRI; p<0.05) and decreased RV 2D radial and circumferential strain (MRI; p<0.01), all of which greatly improved following LuTx. One year survival after LuTx for PAH was 100% (15/15 patients alive; 1 retransplant 9 months status post LuTx because of cellular rejection). No PAH LuTx candidate died on the transplant waiting list. <h3>Conclusion</h3> We demonstrate full recovery of RV systolic function in children within two months after LuTx for severe PAH, independently of the patients' age, weight, and hemodynamic compromise preceding the LuTx. Even in end-stage pediatric PAH with poor RV function and low cardiac output, LuTx should be preferred over heart-lung transplantation.