Severe Left Ventricle Dysfunction Research Articles

Feasibility and effectiveness of left bundle branch area pacing after TAVR: the single center experience

Abstract Introduction Transcatheter aortic valve replacement (TAVR) is a safe alternative to open-heart surgery in patients with symptomatic severe aortic stenosis and high surgical risk due to multiple comorbidities, advanced age, and severe left ventricle dysfunction. Due to anatomical considerations of the atrioventricular node, conduction abnormalities requiring the implantation of a pacemaker are common findings after TAVR. High-grade atrioventricular block and new-onset left bundle branch block (LBBB) are the most commonly reported conduction abnormalities after TAVR. Purpose The aim of our study was to assess the feasibility, success rates, and effectiveness of LBBAP in patients requiring pacing after TAVR. Methods A total of 302 patients underwent the TAVR procedure in our institution in the period from January 2022 to November 2023. In this cohort, 38 patients required ventricular pacing in the postoperative period. 16 patients who underwent permanent pacing using LBBAP were included in this observational study. Patients undergoing traditional right ventricular pacing biventricular pacing or leadless pacemaker implantation were excluded from the study. Results LBBAP was successfully performed in 16 patients (89%). 2 patients underwent conventional CRT implantation (1 cardiac resynchronization therapy pacemaker and 1 cardiac resynchronization therapy defibrillator) in order to severe calcification and presence of fibrotic tissue in the target area. The mean age was 60.5±2.74 years, and 10 patients (62.5%) were women. According to the patient’s medical history, 14 patients (84%) had hypertension; coronary artery disease – 2 (12.5%), 2 (12.5%) patients had atrial fibrillation and atrial flutter, and 7 (43.5%) patients had diabetes mellitus. The mean left ventricle ejection fraction (LVEF) was 46.2±14.7%. Interventricular septal thickness 11.8 ± 1.9 mm. Type of conduction diseases: Infranodal AV block and LBBB were present in 9 (56.5%) patients. 5 (31,25%) patients had persistent complete AV block and 2 (12,25%) had Mobitz II AV block. In 2 patients we observed congestive heart failure combined with LBBB. Pre-TAVR QRS morphology was normal in 15 (93%), and RBBB morphology in 1 (7%). The mean QRS duration at baseline was 105±20 ms. Pre-implant QRS duration 135±52 ms. The single-chamber pacemaker was implanted in 1 patient, dual-chamber pacemaker - 13 patients, and cardiac resynchronization therapy defibrillators in 2 patients. Procedural duration and fluoroscopy times were 105. ± 31.9 min and 18 ± 11 min, respectively. Conclusion Complete AV block and new-onset LBBB after TAVR is still an important issue. LBBB correction using conduction system pacing technology is an effective strategy for this type of patient. LBBAP is one of the most exciting developments in pacing therapy over the last few years. Long-term clinical outcomes and safety of physiological pacing data are limited and require further investigations

Takotsubo cardiomyopathy following pacemaker insertion complicated with polymorphic ventricular tachycardia: a case report

BackgroundTakotsubo cardiomyopathy is a novel form of rapidly reversible heart failure occurring secondary to a stressor that mimics an acute coronary event. The underlying etiology of the stressor is highly variable and can include medical procedures. Pacemaker insertion is an infrequent cause of Takotsubo cardiomyopathy.Case presentationAn 86-year-old Caucasian woman underwent an uncomplicated pacemaker insertion for symptomatic complete heart block in the background of slow atrial fibrillation. A transient episode of polymorphic ventricular tachycardia was noted on day 1 following the procedure; however, her pacemaker was checked and, as she remained stable, she was discharged home. She presented again 5 days later with symptomatic heart failure. Chest X-ray confirmed pulmonary edema. Echocardiography confirmed new onset severe left ventricle dysfunction. Pacemaker checks were normal and lead placement was confirmed. Though her troponin I was elevated, her coronary angiogram was normal. Contrast enhanced echocardiography suggested apical ballooning favoring Takotsubo cardiomyopathy. She was treated for heart failure and made a good recovery. Her follow-up echocardiography a month later showed significant improvement in left ventricle function.ConclusionsTakotsubo cardiomyopathy is mediated by a neuro-cardiogenic mechanism due to hypothalamic–pituitary–adrenal axis activation. It generally has a good prognosis. Complications though uncommon, can occur and include arrhythmias. Pacemaker insertion as a precipitant stressor is an infrequent cause of Takotsubo cardiomyopathy. As pacemaker insertions are more frequent in the elderly age group, this phenomenon should be recognized as a potential complication.

Severe heart failure and intracardiac thrombosis: going beyond the appearance for diagnosis and treatments.

We describe the case of a 45-year-old female affected by asthma and nasal polyposis who presented to the emergency department because of worsening dyspnea and paresthesia of the left lower limb. Comprehensive instrumental examinations revealed the presence of severe left ventricle dysfunction, intra-cardiac thrombus, deep vein thrombosis, pulmonary embolism, lung infiltrates, polyserositis, and neurological involvements. Finally, the patient was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA), formerly Churg-Strauss syndrome, a rare vasculitis of small-medium blood vessels with several organ involvements. Treatment with anticoagulants, corticosteroids, and cyclophosphamide led to a significant clinical improvement. However, a subcutaneous cardiac defibrillator was implanted because of the persistence of severe left ventricular dysfunction and the high cardiovascular risk phenotype. Indeed, several cardiac manifestations may occur in EGPA, particularly in patients with anti-neutrophil cytoplasmic antibody-negative disease. Therefore, clinicians should have high clinical suspicion because cardiac involvement in EGPA results in a poor prognosis if not diagnosed and adequately treated.

Outcomes and predictors of left ventricle recovery in patients with severe left ventricular dysfunction undergoing transcatheter aortic valve implantation.

Data on the likelihood of left ventricle (LV) recovery in patients with severe LV dysfunction and severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) and its prognostic value are limited. We aimed to assess the likelihood of LV recovery following TAVI, examine its association with midterm mortality, and identify independent predictors of LV function. In our multicentre registry of 17 TAVI centres in Western Europe and Israel, patients were stratified by baseline LV function (ejection fraction [EF] >/≤30%) and LV response: no LV recovery, LV recovery (EF increase ≥10%), and LV normalisation (EF ≥50% post-TAVI). Our analysis included 10,872 patients; baseline EF was ≤30% in 914 (8.4%) patients and >30% in 9,958 (91.6%) patients. The LV recovered in 544 (59.5%) patients, including 244 (26.7%) patients whose LV function normalised completely (EF >50%). Three-year mortality for patients without severe LV dysfunction at baseline was 29.4%. Compared to this, no LV recovery was associated with a significant increase in mortality (adjusted hazard ratio 1.32; p<0.001). Patients with similar LV function post-TAVI had similar rates of 3-year mortality, regardless of their baseline LV function. Three variables were associated with a higher likelihood of LV recovery following TAVI: no previous myocardial infarction (MI), estimated glomerular filtration rate >60 mL/min, and mean aortic valve gradient (mAVG) (expressed either as a continuous variable or as a binary variable using the standard low-flow, low-gradient aortic stenosis [AS] definition). LV recovery following TAVI and the extent of this recovery are major determinants of midterm mortality in patients with severe AS and severe LV dysfunction undergoing TAVI. Patients with no previous MI and those with an mAVG >40 mmHg show the best results following TAVI, which are at least equivalent to those for patients without severe LV dysfunction. (ClinicalTrials.gov: NCT04031274).

Transcatheter mitral valve repair and its impact on reverse right ventricular remodelling

Abstract Introduction Transcatheter edge-to-edge repair (TEER) has been proven to reduce cardiovascular events in a particular subset of patients with severe mitral insufficiency (MR) and left ventricle dysfunction. Nevertheless, its short and long-term impact on the right ventricle (RV) remained to be determined. Our goal was to assess the effect of TEER on the RV and right chamber pressures. Methods Patients were consecutively enrolled from Nov 2018 to Jul 2022. Clinical, laboratory echocardiographic and procedural data were collected. Follow-up information of admissions for heart failure, New York Heart Association (NYHA) functional class and survival was collected. The data was analysed prior to and at 3 and 12 months after the procedure. RV dysfunction was defined as Tricuspid Annular Plane Systolic Excursion (TAPSE) &amp;lt; 17mm or S’ &amp;lt; 9cm/s. Changes between baseline and follow-up parameters were assessed using the paired t-test. Results A total of 46 patients were included. Average age was 77.28 ± 7.92 years and 30 were male (65.2%). Twelve patients were on NYHA class III (26.1%) and most had functional mitral insufficiency (25; 54.3%) and mild to moderate tricuspid insufficiency (36; 78.3%). All patients had severe mitral insufficiency (estimated regurgitant orifice area 41.28 ± 16.77mm; regurgitant volume 62 ± 28.96mL). Seventeen patients had diabetes (37.0%), 10 had coronary artery disease (21.7%), 23 had atrial fibrillation (50.0%) and 6 had chronic kidney disease (13.0%). At 3 months, mean right ventricular/right atrial gradient (RV/RAgrad) was significantly lower (37.26 ± 9.66 mmHg vs 30.81 ± 17.36 mmHg; p 0.017) as well as MR (2.98 ± 0.15 vs 1.67 ± 0.63; p &amp;lt; 0.001). There were no differences regarding severity of tricuspid regurgitation (TR) and RV and left ventricle (LV) function. At 1 year follow-up there was a marked improvement of RV/RAgrad (37.49 ± 10.87 mmHg vs 28.12 ± 10.13 mmHg; p 0.009), TAPSE (18.83 ± 4.22 mm vs 20.88 ± 3.08 mm; p 0.035), S’ (10.81 ± 4.00 cm/s vs 13.5 ± 1.97 cm/s, p 0.015) and MR severity (2.98 ± 0.15 vs 1.83 ± 0.71; p &amp;lt;0.001). Number of heart failure readmissions was also lower at 1 year follow-up post TEER (0.35 ± 0.80 vs 0.81 ± 0.87; p 0.032). Over a mean follow-up time of 1.72 ± 1.16 years, only 8.7% of patients died and 17.4% were readmitted due to heart failure. Conclusion TEER has a positive impact on right ventricle function and pressures. This effect was more prominent at 1 year follow-up and suggests reverse remodelling continues even after 3 months. Overall, patients with TEER had low rates of death and heart failure readmissions.

ACE Inhibitors-Induced Skin Reaction: A Case Report

Angiotensin-converting enzyme (ACE) inhibitors are widely used as antihypertensives, remodeling agents in heart failure, to stop the progression of diabetic nephropathy, as well as for a variety of other clinical purposes. Some side effects of ACE inhibitors are well recognized such as dry cough, hypotension, hyperkaliemia, proteinuria, renal failure. Also, these substances are known to have a wide range of dermatological side effects in addition to their adverse effects on other systems. (1,2) We report the case of a 46-year-old man treated for dilated cardiomyopathy with severe left ventricle dysfunction, who developed a cutaneous reaction secondary to the introduction of an ACE inhibitor.

Impact of Impella protected-percutaneous coronary intervention on left ventricle function recovery of patients with extensive coronary disease and poor left ventricular function

BackgroundThe use of Impella support is increasingly adopted to “protect” patients with severe coronary artery disease (CAD) and left ventricle (LV) dysfunction undergoing percutaneous coronary intervention (PCI). AimsTo evaluate the impact of Impella-protected (Abiomed, Danvers, Massachusetts, USA) PCIs on myocardial function recovery. MethodsPatients with significant LV dysfunction undergoing multi-vessel PCIs with pre-intervention Impella implantation were evaluated by echocardiography before PCI and at median follow up of 6 months: global and segmental LV contractile function were assessed by LV ejection fraction (LVEF) and wall motion score index (WMSI), respectively. Extent of revascularization was graded using the British Cardiovascular Intervention Society Jeopardy score (BCIS-JS). Study endpoints were LVEF and WMSI improvement, and its correlation with revascularization. ResultsA total of 48 high surgical risk (mean EuroSCORE II 8) patients with median LVEF value of 30%, extensive wall motion abnormalities (median WMSI 2.16), and severe multi-vessel CAD (mean SYNTAX score 35) were included. PCIs brought a significant reduction of ischemic myocardium burden with BCIS-JS decrease from mean value of 12 to 4 (p < 0.001). At follow-up, WMSI reduced from 2.2 to 2.0 (p = 0.004) and LVEF increased from 30% to 35% (p = 0.016). WMSI improvement was proportional to the baseline impairment (R − 0.50, p < 0.001), and confined to revascularized segments (from 2.1 to 1.9, p < 0.001). ConclusionsIn patients with extensive CAD and severe LV dysfunction, multi-vessel Impella-protected PCI was associated to an appreciable contractile recovery, mainly determined by regional wall motion improvement in revascularized segments.

P105: Pre-Emptive Use of Mechanical Circulatory support in sudden cardiac death- A contrasting case series

Life-threatening ventricular tachycardia(VT) and fibrillation(VF) are the most important causes of sudden cardiac death(SCD). Patients who survive are often predisposed to recurrent VT secondary to scar tissue and require definitive ablation therapies. However given the unpredictable nature of arrhythmias, patients can degenerate into VT storm even as outpatient and become hemodynamically unstable which precludes ablation therapies. Using preemptive mechanical circulatory support in such patients as a bridge to ablation can be a game changer, especially in the event of a fresh VT. We present two contrasting cases, where preemptive use of Impella showed better outcomes in neurological status post cardiac arrest. Our patient is a 16-year-old competitive basketball player who suffered an out-of-hospital VT arrest during match practice requiring bystander CPR and multiple shocks. He was stabilized in an outside hospital and brought to us intubated, paralyzed, on multiple pressors and maintained on IV amiodarone and lidocaine. ECHO demonstrated a very large right ventricle (RV) with severe left ventricle(LV) dysfunction, ejection fraction(EF) 10-15% with basal RV diameter 6.8cm. Cardiac MRI(CMRI) showed an area of late gadolinium enhancement (LGE) of the RV-free wall near the apex. Endomyocardial biopsy, Cardiac catheterization, and CT angiogram were unremarkable. With improvement in volume status, he was weaned off all inotropes and antiarrhythmics, received an AICD, and maintained only on sotalol and lisinopril. On outpatient follow-up, repeat CMRI confirmed Arrhythmogenic RV dysplasia. Unfortunately, four months later, the patient had another episode of cardiac arrest secondary to a VT storm with 20 minutes of downtime. He was deemed too unstable for VT ablation and thus emergently underwent a stellate ganglion block. The patient remained encephalopathic post-cardiac arrest with very slow neurologic recovery. He subsequently underwent cardiac transplantation The second case is that of a 63-year-old male with a past medical history of nonischemic cardiomyopathy with LVEF of 10% status post-ICD placement, and VT on amiodarone who presented with episodes of monomorphic VT followed by ICD shocks and syncope. Heart catheterization showed diffuse three-vessel disease. Due to recurrent VT patients, he received an Impella CP as a bridge to VT ablation. Interestingly during ablation, the patient goes into cardiac arrest requiring CPR for 90 minutes. He had successful VT ablation and with no neurological deficit post-procedure. Multiple trials have shown an improved 30-day survival rate without neurological sequelae with early implantation of Impella during ongoing CPR for cardiac arrest. Impella has several favorable properties by unloading the LV which limits the infarct size and maintains cerebral perfusion during the arrest. Preemptive Impella use is often used as a bridge to transplant, however using it as a bridge to ablation is yet to gain prominence.

Off-pump versus on-pump coronary artery bypass graft surgery outcomes in patients with severe left ventricle dysfunction: inverse probability weighted study

ObjectiveIn this study we aimed to compare on-pump and off-pump coronary artery bypass grafting (CABG) outcomes in patients presented with low left ventricular ejection fraction (EF) as a high-risk group of patients.MethodsIn this registry-based study from 2014 and 2016, all patients with severe left ventricular dysfunction (EF less than 35%) were included and followed until 2020. The median follow-up period was 47.83 [38.41, 55.19] months. Off pump CABG (OPCABG) was compared with on-pump CABG (ONCABG) in terms of mid-term non-fatal cardiovascular events (CVEs) and all-cause mortality. Propensity score method (with inverse probability weighting technique) was used to compare these two groups.ResultsFrom 14,237 patients who underwent isolated CABG, 2055 patients with EF ≤ 35% were included; 1705 in ONCABG and 350 patients in OPCABG groups. Although OPCABG was associated with lower risk of 30-days mortality (Odds Ratio [OR]: 0.021; Confidence Interval [CI] 95% [0.01, 0.05], P < 0.001); there was no significant difference between OPCABG and ONCABG in term of mid-term mortality and non-fatal CVEs ((Hazard ratio [HR]: 0.822; 95%CI [0.605, 1.112], p = 0.208) and (HR: 1.246; 95%CI [0.805, 1.929], p = 0.324), respectively). Patients with more than three traditional coronary artery disease risk factors, had more favorable outcomes (in terms of mid-term mortality) if underwent OPCABG (HR: 0.420; 95%CI [0.178, 0.992], p = 0.048).ConclusionOPCABG was associated with lower risk of 30-days mortality; however, mid-term outcomes were comparable in both OPCABG and ONCABG techniques.

C74 ESCALATION AND DE–ESCALATION OF MECHANICAL CIRCULATORY SUPPORT IN PATIENT WITH CARDIOGENIC SHOCK DUE TO ELECTRICAL STORM

Abstract We describe a case of a 63 year–old man with familiar dilated cardiomyopathy, with severe left ventricle dysfunction (EF 20%) and severe mitral regurgitation.A progressive worsening of functional status was detected (peak VO2 11 ml/kg/min, NYHA III) with some episodes of VT interrupted by bicameral ICD,for which the patient was referred to our center and included in the heart transplant (HT) list. In the following months sustained VT with hemodynamic impact were recorded, with consequent worsening in class INTERMACS 2. The patient underwent to endocardial and epicardial VT ablation, complicated with electrical storm with deterioration towards cardiogenic shock (INTERMACS 1), requiring vaso–inotropic drugs,mechanical ventilation and femoro–femoral VA–ECMO.The patient was centralized in our ICCU, where he maintained a adequate MAP, SvcO2 50% and active diuresis but at echocardiography left ventricle appeared dilated with high filling pressure, X–ray and pulmonary ultrasonography showed congestion, lactate value rapidly increased (5 mmol/mol), renal and hepatic function worsened (creat 2 mg/dl, bil 2.8 mg/dl). After multidisciplinary discussion an escalation of mechanical circulatory support (MCS) was performed, changing ECMO configuration: an arterial cannula was positioned in the right axillary artery and venting cannula positioned in the apex of the left ventricle. The hemodynamic and respiratory parameters quickly improved,the right pulmonary catheterization showed good pulmonary resistence,organ perfusion improved and neurological status was intact, therefore the patient was inserted in emergency list for HT. After few days a de–escalation of MCS was performed,removing venous cannula and oxygenator, changing the circuit in para–corporeal left ventricle mid–term support as bridge to transplantation. The patient maintained conscious, in spontaneous breathing,able to perform physiotherapy and spontaneous nutrition. The de–escalation of MCS allowed to reduce potential complications of MCS and achieve the HT intervention in a better general and functional condition. After 36 days the patient underwent HT with positive outcome. Conclusion MCS are device that require a continuous re–assessment a re–modulation to ensure in the early stages the optimization of haemodynamic support, perfusion of vital organs and unloading of the Vsx and in the following stages an adjustment to long–term strategies (bridge to recovery, bridge to VAD, bridge to heart transplantation).

Chagasic heart failure in a pregnant woman in a non-endemic area: case report and long-term follow-up

Abstract Objectives Chagas disease (CD) is caused by infection with the protozoan Trypanosoma cruzi, a parasite that nests in various tissues, causing irreversible cardiac damage in 30% of patients with chronic disease and neurological or digestive lesions in 10%. CD is now found in areas receiving migrant populations where no vector-borne transmission occurs. Chagasic cardiomyopathy (CC) is the most serious complication of the chronic phase of CD and the major cause of morbidity and mortality among patients with CD. Case presentation Bolivian woman at 38 weeks of gestation was admitted at the emergency room with the diagnosis of congestive heart failure. Cesarean section was performed and maternal hypotension and uterine atony occurred. Dilated myocardiopathy with severe left ventricle dysfunction was diagnosed. The patient referred positive serology for T. cruzi and polymerase chain reaction (PCR) was positive so benznidazole therapy was started. She was discharged due to progressive improvement with cardiological treatment and implantable cardioverter defibrillator was placed 5 years later for the prevention of sudden cardiac death. Conclusions The diagnosis of CC in non-endemic areas requires a high index of suspicion and it is based on serology. Antiparasitic drugs are almost 100% effective in infected newborn babies and highly effective in the treatment of patients in the acute stage of the disease. However, the efficacy of both drugs decreases the longer a person has been infected. Treatment of CC that causes chronic heart failure is similar to that in non-Chagasic etiology.

A case of middle aortic syndrome in takayasu arteritis with left ventricle dysfunction and heart failure

Left ventricular dysfunction is an uncommon complication of Takayasu arteritis (TA) with a prevalence of about 10%–15%. We report a case of a 27-year-old girl who presented with dyspnea, bipedal edema, loss of weight, and easy fatigability for 3 months. Patient also developed right hemiparesis 3 months ago. Computed tomography of the brain was suggestive of the left temporal infarct, on evaluation she was diagnosed as left ventricle (LV) dysfunction and she was treated for CVA and heart failure. Clinical examination revealed the absence of the left upper limb and bilateral lower limb pulses with right upper limb hypertension. Echocardiography revealed severe LV dysfunction (ejection function ~20%). Computed tomography angiogram and other inflammatory markers confirmed the diagnosis of TA and revealed the presence of coaraction of the thoracic and abdominal aorta. Coaractoplasty was done, and immunosuppressant therapy with oral prednisolone and weekly oral methotrexate was started. On follow-up, patient is asymptomatic with improved LV function. Any patient with LV dysfunction or dilated cardiomyopathy, reversible causes have to be ruled out and TA has to be thought of as a differential diagnosis particularly in young females. Checking of all four limbs pulses and blood pressure is strictly recommended. TA is a systemic vasculopathy that can progress to cause vital organ ischemia. Therefore, early diagnosis and management as well as long-term follow-up is recommended.

353 SARS-CoV-2 pulmonary vasculitis and Takotsubo myocarditis syndrome. Hypoxia, endothelial dysfunction, and inflammation are the trigger?

353 SARS-CoV-2 pulmonary vasculitis and Takotsubo myocarditis syndrome. Hypoxia, endothelial dysfunction, and inflammation are the trigger?

Significance of preoperative left ventricular ejection fraction in 5-year outcome after isolated CABG

BackgroundPre-operative ejection fraction (EF) and comorbidities affect post-op outcomes. We aimed to compare the mortality and adverse events of patients with different baseline EF and also to evaluate the distribution of comorbidities in each EF group.MethodsA total of 20,937 patients who underwent isolated coronary artery bypass graft (CABG) surgery from January 2006 to December 2016 was included. Patients were divided into three groups based on their pre-operative left ventricular EF as follows; (1) Normal: EF ≥ 50%; (2) Mild to moderately reduced: 50% < EF ≤ 35%; and (3) Severely reduced: EF < 35%. The backward elimination method was considered for multivariate Cox-regression analysis to locate predictors of mortality and non-fatal cerebro-cardiovascular events (CCVEs). The median follow-up time was 5.61 [3.12–8.0] years.ResultsThe mean age in the total population was 60.94 ± 9.51 years and 73.6% of the total population was male. Diabetes mellitus was the common risk factor of mortality and CCVE in all EF groups. Impaired renal function (GFR < 60 ml/min) was associated with a higher risk of mortality after CABG regardless of EF level. The median 5-year mortality rate in patients with normal EF, mild-moderately reduced EF and severely reduced EF were 9.5%, 12.8%, and 22.7% respectively (P < 0.001). Although the trend of CCVEs was higher in severe left ventricle (LV) dysfunction, it was not statistically significant (p = 0.071).ConclusionPatients with severely reduced EF are at higher risk of mortality after CABG compared to those with higher EF levels; however, the rate of CCVEs may not be necessarily higher after adjustment for multiple pre-operative comorbidities.

Cardiogenic shock in patients presenting with acute left main coronary artery occlusion

Abstract Background and purpose Acute myocardial infarction (AMI) due to left main coronary artery (LMCA) occlusion is a rare event, often catastrophic. Limited data are available about management and outcomes of patients with acute LMCA occlusion, including those presenting with cardiogenic shock (CS) at hospital admission. This study sought to describe patients with AMI due unprotected LMCA occlusion presenting with CS and to evaluate their in-hospital outcomes and 1-year mortality. Methods In this retrospective 2-center study, we identified 7630 patients with ST-segment elevation myocardial infarction (STEMI) or hight risk non-ST segment elevation myocardial infarction who underwent to emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analysed 94 patients who presented with unprotected LMCA occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and divided them in 2 groups according to presence of signs of cardiogenic shock at admission: CS and no-CS. Results Of 94 patients with AMI due LMCA occlusion, 52 patients presented with CS (53.3%). Mean age was 62.8±11.5 years in CS and 62.0±15.9 years in no-CS patients, p=0.766. In both groups, most patients were male. STEMI presentation was more frequent in CS group (80.4% vs. 52.4%, p=0.004). Severe systolic dysfunction of left ventricle was more frequent in CS patients (81.1% vs. 33.3%, p&amp;lt;0.001). Compared to no-CS patients, CS group shown more often TIMI=0 (67.3% vs. 26.2%, p&amp;lt;0.001), collateral coronary circulation Rentrop 0–1 (95.3% vs. 75.0%, p=0.008), and slow-reflow/no-reflow phenomena (30.6% vs 3.8%, p=0.019) in emergent coronary angiography. The need of invasive mechanical ventilation (68.9% vs. 21.4%, p&amp;lt;0.001), and haemodialysis (20.5% vs. 2.4%, p=0.010) were more prevalent in CS patients. Likewise, mechanical circulatory support (MCS) was more frequently used in patients presented with CS (52.9% vs. 26.2%, p=0.009). In subgroup analysis, MCS implantation was not a survival predictor in CS patients (Odds ratio: 3.9 [95% confidence interval: 0.4 to 36.3], p=0.229). Ultimately, in-hospital mortality (78.8% vs. 16.7%, p&amp;lt;0.001) was higher in CS patients. On the other hand, in hospital survivors, there was no significant differences in 1-year mortality (11.1% vs. 23.5%, p=0.42) between both groups. Conclusions Nearly half of patients with AMI due LMCA occlusion presented with CS signs at first medical evaluation. This subgroup of patients had higher in-hospital mortality compared to those without CS, despite MCS implantation. Whether the use of a specific MCS device or whether early use of MCS can change the outcome remains to be elucidated. CS patients who survive to index-hospitalization, had similar long-term outcomes compared to no-CS patients. Further studies are imperative in this population to refine initial medical treatment in order to improve their prognosis. Funding Acknowledgement Type of funding sources: None.

Acute heart failure due to COVID-19 related myocardial injury and de novo hypertensive cardiomyopathy: a challenging diagnosis.

We report a COVID-19 case with acute heart and kidney failure in a healthy young male. Echocardiography showed severe systolic and diastolic left ventricle dysfunction, with diffuse myocardial thickening. Cardiac MRI showed aspects of focal myocarditis, and hypertensive cardiomyopathy. Renal biopsy demonstrated limited acute tubular injury, and hypertensive kidney disease. Coronary angiography excluded critical stenoses. Unlike what we initially suspected, myocardial inflammation had a limited extent in our patient; severe hypertension causing cardiomyopathy and multi-organ damage, not diagnosed before, was primarily responsible for severe illness. Correct diagnosis and guidelines-directed treatment allowed a favorable course.

Determinants of worse prognosis in patients with cardiac resynchronization therapy defibrillators. Are ventricular arrhythmias an adjunctive risk factor?

Cardiac resynchronization therapy (CRT) is indicated in patients with systolic heart failure (HF), severe left ventricle (LV) dysfunction and interventricular dyssynchrony.In prospective observational research, we aimed to evaluate whether CRT-induced LV reverse remodelling and occurrence of ventricular arrhythmias (VT/VF) independently contribute to prognosis in patients with CRT defibrillators (CRT-D). In 95 Italian cardiological centres, after a screening period of 6 months, patients were categorized according to VT/VF occurrence and CRT response, defined as LV end-systolic volume relative reduction >15% or LV ejection fraction absolute increase >5%. The main endpoint was death or HF hospitalizations. Among 1308 CRT-D patients (80% male, mean age 66 years), at 6 months, follow-up 71% were identified as CRT responders and 12% experienced appropriate VT/VF detections. The main endpoint was significantly and independently associated with previous myocardial infarction, New York Heart Association Class, VT/VF occurrence and with CRT response. CRT nonresponder patients who suffered VT/VF in the screening period had a risk of death or HF hospitalizations [HR = 7.82, 95% confidence interval (CI) = 3.95-15.48] significantly (P < 0.001) higher than CRT responders without VT/VF occurrence. This risk is mitigated without VT/VF occurrence (HR = 3.47, 95% CI = 2.03-5.91, P < 0.001) or in case of CRT response (HR = 3.11, 95% CI = 1.44-6.72, P = 0.004). Our data show that both CRT response and occurrence of VT/VF independently contribute to the risk of death or HF-related hospitalizations in CRT-D patients. Early VT/VF occurrence may be identified as a marker of disease severity than can be mitigated by CRT response both in terms of all-cause mortality and long-term VT/VF onset. URL: https://www.clinicaltrials.gov. Unique identifier: NCT00147290 and NCT00617175.

In-hospital outcomes of sustained ventricular tachycardia in the setting of Acute Coronary Syndrome

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf on behalf of the Investigators of " Portuguese Registry of ACS " Introduction Sustained ventricular tachycardia (SVT) complicates up to 20% of acute coronary syndromes (ACS) and it is, therefore, important to access its impact on prognosis and identify patients with higher risk of SVT. Objective To evaluate predictors of early onset (&amp;lt;48h) and late onset (≥48h) SVT. Methods Based on a multicenter retrospective study, data collected from admissions between 1/10/2010 and 4/09/2019. Patients (pts) were divided in two groups (G): A – pts that presented early onset SVT (ESVT), and B – pts that presented late onset SVT (LSVT). Pts without data on previous cardiovascular history or uncompleted clinical data were excluded. Logistic regression was performed to assess predictors of SVT in ACS. Results Between 29851 pts with ACS, 364 (1.2%) presented SVT. ESVT – 251 pts (69%); LSVT – 91 pts (25%). LSVT G was older (74 ± 13 vs 68 ± 14, p = 0.003), was admitted directly to cat lab less frequently (10.1% vs 24.8%, p = 0.003), had longer times from first symptoms to admission (440min vs 261 min, p &amp;lt; 0.001) and had higher rates of previous stroke (14.4% vs 6.8%, p = 0.028). LSVT G had higher rates of non-ST-elevation myocardial infarction (MI) (35.2% vs 23.1%, p = 0.025) and lower rates of ST-elevation MI (53.8% vs 71.7%, p = 0.002), although both G were similar regarding MI location (anterior – p = 0.135, inferior – p = 0.097). LSVT G had higher systolic blood pression (130 ± 33 vs 122 ± 33, p = 0.050), presented more frequently in Killip-Kimball class ≥2 (52.5% vs 35.5%, p = 0.005) and with atrial fibrillation (21.2% vs 12.4%, p = 0.045), and had higher brain-natriuretic peptide (1075 vs 329, p &amp;lt; 0.001). LSVT G was treated more frequently with diuretics (80.0% vs 47.8%, p &amp;lt; 0.001), amiodarone (62.2% vs 48.8%, p = 0.029), digoxin (8.9% vs 2.4%, p = 0.013) and levosimendan (11.1% vs 2.8%, p = 0.004). ESVT G had higher rates of performed coronarography (88.4% vs 79.1%, p = 0.028) but lower rate of 3 vessels disease (58.5% vs 70.8%, p = 0.017). LSVT G had higher rates of severe (&amp;lt;30%) left ventricle dysfunction (32.9% vs 15.4%, p &amp;lt; 0.001) and need to non-invasive ventilation (23.1% vs 6.8%, p &amp;lt; 0.001). Regarding in-hospital complications, ESVT G had higher rates of heart failure (34.7% vs 19.1%, p = 0.006), atrioventricular block (15.7% vs 1.1%, p &amp;lt; 0.001), atrial fibrillation (20.4% vs 7.7%, p = 0.006) and major haemorrhage (5.2% vs 0.0%, p = 0.024). LSVT G had higher rates of in-hospital death (44.4% vs 20.9%, p &amp;lt; 0.001) and in-hospital stay (14 days vs 7 days, p &amp;lt; 0.001). The G were similar regarding re-infarction (p = 0.216), shock (p = 0.179), mechanical complications (p = 1.00), cardiac arrest (p = 0.097) and stroke (0.348) rates. Logistic regression confirmed ESVT was predictive in-hospital heart failure (p = 0.010, OR 2.67) and de novo AF (p = 0.001, OR 5.56), whether LSVT was predictive of in-hospital death (p = 0.002, OR 2.70). Conclusion LSVT was associated with higher rates of in-hospital complications, but ESVT was associated with higher in-hospital mortality.

Safety and Feasibility of MitraClip Implantation in Patients with Acute Mitral Regurgitation after Recent Myocardial Infarction and Severe Left Ventricle Dysfunction.

Patients with severe mitral regurgitation (MR) after myocardial infarction (MI) have an increased risk of mortality. Transcatheter mitral valve repair may therefore be a suitable therapy. However, data on clinical outcomes of patients in an acute setting are scarce, especially those with reduced left ventricle (LV) dysfunction. We conducted a multinational, collaborative data analysis from 21 centers for patients who were, within 90 days of acute MI, treated with MitraClip due to severe MR. The cohort was divided according to median left ventricle ejection fraction (LVEF)—35%. Included in the study were 105 patients. The mean age was 71 ± 10 years. Patients in the LVEF < 35% group were younger but with comparable Euroscore II, multivessel coronary artery disease, prior MI and coronary artery bypass graft surgery. Procedure time was comparable and acute success rate was high in both groups (94% vs. 90%, p = 0.728). MR grade was significantly reduced in both groups along with an immediate reduction in left atrial V-wave, pulmonary artery pressure and improvement in New York Heart Association (NYHA) class. In-hospital and 1-year mortality rates were not significantly different between the two groups (11% vs. 7%, p = 0.51 and 19% vs. 12%, p = 0.49) and neither was the 3-month re-hospitalization rate. In conclusion, MitraClip intervention in patients with acute severe functional mitral regurgitation (FMR) due to a recent MI in an acute setting is safe and feasible. Even patients with severe LV dysfunction may benefit from transcatheter mitral valve intervention and should not be excluded.

In-Hospital and Mid-Term Outcomes of ECMO Support During Coronary, Structural, or Combined Percutaneous Cardiac Intervention in High-Risk Patients – A Single-Center Experience

IntroductionEvidence regarding the impact of prophylactic implantation of Extracorporeal Membrane Oxygenation (ECMO) during coronary or structural procedures is limited. The purpose of this paper is to evaluate the in-hospital and medium term outcomes of ECMO support in complex percutaneous coronary or structural intervention. MethodsThe present is an observational prospective study including consecutive patients who underwent to prophylactic ECMO implantation for percutaneous coronary intervention (PCI), structural or combined interventions between July 2018 and July 2020 in Maria Pia Hospital GVM Care & Research, Turin, Italy. Primary endpoints were in-hospital and medium term all-cause death. Secondary endpoints were vascular complication, bleeding and procedural success. Results27 patients were included with a mean age of 80 ± 6 years, 10 (37%) being diabetics and 19 (70%) with severe left ventricle dysfunction. Mean Logistic Euroscore was 28.7 ± 18.7. Seven patients (26%) underwent complex coronary revascularization, 7 (26%) combined PCI + TAVI, 5 (19%) combined PCI + Mitraclip, 5 (19%) TAVI alone and finally 3 (11%) combined TAVI + Mitraclip. The procedural success was 96%, with only one in-hospital death due to major vascular complication at the ECMO vascular access. At a mean follow-up of 11 ± 6.8 months 4 deaths were recorded (3 from not cardiovascular causes). ConclusionsProphylactic use of ECMO may be beneficial for high risk patients undergoing complex combined coronary/structural percutaneous interventions with good in-hospital and mid-term outcomes in term of safety and procedural success.