Severe Left Ventricular Impairment Research Articles

COVID-19 related myocardial injury is associated with immune dysregulation in symptomatic patients with cardiac MRI abnormalities.

While acute cardiovascular complications of COVID-19 are well-described, less is known about longer-term cardiac sequelae. For many individuals with cardiac signs or symptoms arising after COVID-19 infection, the aetiology remains unclear. We examined immune profiles associated with magnetic resonance imaging (MRI) abnormalities in patients with unexplained cardiac injury after COVID-19. Twenty-one participants (mean age 47 [SD 13] years, 71% female) with long COVID (n=17), raised troponin (n=2), or unexplained new-onset heart failure (n=2), who did not have pre-existing heart conditions or recent steroid/immunosuppression treatment were enrolled a mean 346 (SD 191) days after COVID-19 infection in a prospective observational study. Cardiac MRI and blood sampling for deep immunophenotyping using mass cytometry by time of flight and measurement of proteomic inflammatory markers was performed. Nine of 21 (43%) participants had MRI abnormalities (MRI(+)), including non-ischaemic patterns of late gadolinium enhancement and/or visually overt myocardial oedema in 8 people. One patient had mildly impaired biventricular function without fibrosis or oedema, and 2 had severe left ventricular impairment. MRI(+) individuals had higher blood CCL3, CCL7, FGF-23 and CD4 Th2 cells, and lower CD8 T effector memory (TEM) cells, than MRI(-). Cluster analysis revealed lower expression of inhibitory receptors PD1 and TIM3 in CD8 TEM cells from MRI(+) patients than MRI(-) patients, and functional studies of CD8 T αβ cells showed higher proportions of cytotoxic granzyme B+ secreting cells upon stimulation. CD8 TEM cells and CCL7 were the strongest predictors of MRI abnormalities in a LASSO regression model (composite AUC 0.96, 95%CI 0.88-1.0). CCL7 was correlated with diffuse myocardial fibrosis/oedema detected by quantitative T1 mapping (r=0.47, p=0.04). COVID-19 related cardiac injury in symptomatic patients with non-ischaemic myocarditis-like MRI abnormalities is associated with immune dysregulation, including decreased peripheral CD8 TEM cells and increased CCL7, persisting long after the initial infection.

Long‐Term Outcomes in Patients with ST‐Elevation Myocardial Infarction: A Comparative Study of Direct Admissions versus Interhospital Transfers—Insights from a Single‐Center Experience in the United Kingdom

Background. Primary percutaneous coronary intervention (PPCI) is the treatment of choice for patients with ST‐elevation myocardial infarction (STEMI). Delayed reperfusion leads to increased morbidity and mortality. Secular trends in the impact of interhospital transfers (IT) on long‐term mortality in the United Kingdom (UK) have not been previously investigated. We analyzed the impact of IT on 5‐year mortality in STEMI patients admitted to a tertiary care center in the UK (East Midlands North). Methods. Data of STEMI patients admitted to Nottingham University Hospitals NHS Trust from 2011 to 2016 were acquired from the National Institute for Cardiovascular Outcomes Research dataset (NICOR) and then combined with local patient‐level data and mortality data from National Statistics. The baseline characteristics and mortality data of the interhospital transfer (IT) group were compared to those of a gender and age‐matched direct admission (DA) group. Results. Of the total cohort (N = 2386), 29.9% of patients were admitted to the PPCI center via the interhospital transfer (IT) route. Cardiovascular risk profiles in both DA and IT groups were comparable. Five‐year Kaplan–Meier (KM) survival analysis revealed better survival in the direct admission group (83% vs. 77.3%; p ≤ 0.001). In multivariate analysis, increased mortality was associated with severe left ventricular impairment (HR 4.7, 95% CI 2.9–7.6), the presence of cardiogenic shock (HR 3.6 (2.7–4.8)), chronic kidney disease (HR 2.56 (1.4–4.5)), smoking (HR 1.45 (1.1–1.8)), male gender (HR 1.7 (1.4–2.01)), and diabetes (HR 1.4 (1.07–1.8)). The radial access and call‐to‐balloon time less than 120 minutes were also associated with lower mortality (HR 0.52 (0.43–0.63): HR 0.75 (0.61–0.92)). Conclusion. Despite advancements in communication, technology, patient education, transportation systems, and guidelines within the UK’s NHS over the last decade, the delays incurred by IT for STEMI patients remain substantial and are associated with a poor prognosis.

The everolimus eluting Synergy MegatronTM drug-eluting stent platform: Early outcomes from the European Synergy MegatronTM Implanters' Registry.

The Synergy MegatronTM is an everolimus-drug eluting stent that may offer advantages in the treatment of aorto-ostial disease and large proximal vessels. To report the short- to medium-term clinical outcomes from the European Synergy MegatronTM Implanters' Registry. This registry was an investigator-initiated study conducted at 14 European centers. The primary outcome was target lesion failure (TLF), defined as the composite of cardiovascular death, target vessel myocardial infarction (MI), and target lesion revascularisation. Five hundred seventy-five patients underwent PCI with MegatronTM between 2019 and 2021. Patients were 69 ± 12 years old, 26% had diabetes mellitus, 24% had moderate-severe left ventricular impairment and 59% presented with an acute coronary syndrome. 15% were deemed prohibitively high risk for surgical revascularisation. The target vessel involved the left main stem in 55%, the ostium of the RCA in 13% and was a true bifurcation (Medina 1,1,1) in 50%. At 1 year, TLF was observed in 40 patients, with 26 (65%) occurring within the first 30 days. The cumulative incidence of TLF was 4.5% at 30 days and 8.6% (95% CI 6.3-11.7) at 1 year. The incidence of stent thrombosis was 0.5% with no late stent thromboses. By multivariate analysis, the strongest independent predictors of TLF were severe left ventricular impairment (HR 3.43, 95% CI: 1.67-6.76, p < 0.001) and a target vessel involving the left main (HR 4.00 95% CI 1.81-10.15 p = 0.001). Use of the Synergy MegatronTM everolimus eluting stent in a 'real-world' setting shows favorable outcomes at 30 days and 1 year.

Feasibility of HEMS performed prehospital extracorporeal-cardiopulmonary resuscitation in paediatric cardiac arrests; two case reports

IntroductionA broad range of pathophysiologic conditions can lead to cardiopulmonary arrest in children. Some of these children suffer from refractory cardiac arrest, not responding to basic and advanced life support. Extracorporeal-Cardiopulmonary Resuscitation (E-CPR) might be a life-saving option for this group. Currently this therapy is only performed in-hospital, often necessitating long transport times, thereby negatively impacting eligibility and chances of survival. We present the first two cases of prehospital E-CPR in children performed by regular Helicopter Emergency Medical Services (HEMS).Case presentationsThe first patient was a previously healthy 7 year old boy who was feeling unwell for a couple of days due to influenza. His course deteriorated into a witnessed collapse. Direct bystander CPR and subsequent ambulance advanced life support was unsuccessful in establishing a perfusing rhythm. While doing chest compressions, the patient was seen moving both his arms and making spontaneous breathing efforts. Echocardiography however revealed a severe left ventricular impairment (near standstill). The second patient was a 15 year old girl, known with bronchial asthma and poor medication compliance. She suffered yet another asthmatic attack, so severe that she progressed into cardiac arrest in front of the attending ambulance and HEMS crews. Despite maximum bronchodilator therapy, intubation and the exclusion of tension pneumothoraxes and dynamic hyperinflation, no cardiac output was achieved.InterventionAfter consultation with the nearest paediatric E-CPR facilities, both patients were on-scene cannulated by regular HEMS. The femoral artery and vein were cannulated (15-17Fr and 21Fr respectively) under direct ultrasound guidance using an out-of-plane Seldinger approach. Extracorporeal Life Support flow of 2.1 and 3.8 l/min was established in 20 and 16 min respectively (including preparation and cannulation). Both patients were transported uneventfully to the nearest paediatric intensive care with spontaneous breathing efforts and reactive pupils during transport.ConclusionThis case-series shows that a properly trained regular HEMS crew of only two health care professionals (doctor and flight nurse) can establish E-CPR on-scene in (older) children. Ambulance transport with ongoing CPR is challenging, even more so in children since transportation times tend to be longer compared to adults and automatic chest compression devices are often unsuitable and/or unapproved for children. Prehospital cannulation of susceptible E-CPR candidates has the potential to reduce low-flow time and offer E-CPR therapy to a wider group of children suffering refractory cardiac arrest.

Nurse-Led Heart Failure Clinics: A Snapshot of Counties Manukau in 2021

Heart failure is a complex clinical syndrome associated with significant morbidity and mortality. Evidence-based heart failure therapies are essential for improving outcomes of heart failure patients and nurse-led clinics can facilitate timely initiation and up-titration of these therapies. First-time and follow-up attendances to the nurse-led heart failure clinics were recorded in a database between May and December 2021. Demographic and diagnosis information was recorded, as well as the medication titration that occurred, the limitations to up-titration, and the follow-up plan. A total of 257 first visits took place, with a cumulative total of 542 visits for these patients. Patients were seen an average of 2.1 times over this time frame; 28% of patients were NZ Māori and 34% Pacific Islander. The average age was 57.9 years. Most patients (60%) have severe left ventricular impairment. Evidence-based heart failure medications were started during 96 clinic visits, and the dose was increased in 312 clinic visits. There were 177 instances where medications were unable to be started or up-titrated, due to the COVID-19 lockdown, and the resultant telehealth mode of delivery was a particular limitation. Nurse-led heart failure clinics are essential for helping patients become established and up-titrated on evidence-based heart failure therapies in a timely manner. While the COVID-19 lockdown had a significant impact in escalating therapy for patients, the data show that significant numbers of new patients are being seen, with a large volume of up-titration activity occurring in the clinics.

DCM Support: cell therapy and circulatory support for dilated cardiomyopathy patients with severe ventricular impairment.

The DCM Support trial (NCT03572660) uses a percutaneous circulatory support device (Impella CP, Abiomed, Danvers, MA, USA) to improve the safety of an intracoronary cell infusion procedure in patients with dilated cardiomyopathy (DCM) and a severely reduced left ventricular ejection fraction (LVEF). DCM Support is a single-site, single-arm Phase II trial enrolling 20 symptomatic DCM patients with an LVEF≤35% despite optimal medical and device therapy. After 5days of granulocyte colony-stimulating factor therapy and a subsequent bone marrow aspiration, patients undergo an intracoronary infusion of autologous bone-marrow-derived mononuclear cells. The Impella CP device is used to provide haemodynamic support during the infusion procedure. The trial's primary endpoint is change in LVEF from baseline at 3months. Secondary efficacy endpoints are change in LVEF from baseline at 12months, and change in exercise capacity, New York Heart Association class, quality of life, and N-terminal pro-B-type natriuretic peptide levels from baseline at 3 and 12months. Safety endpoints include procedural safety and major adverse cardiac events at 3 and 12months. This is the first trial to assess the safety and efficacy of cytokine and autologous intracoronary cell therapy with a procedural circulatory support device for patients with severe left ventricular impairment. This novel combination may allow us to target a patient population most at need of this therapy.

Incidence, characteristics and one-year outcomes of peripartum cardiomyopathy in Reunion Island

Peripartum cardiomyopathy (PPCM) is a form a dilated cardiomyopathy affecting young women, inducing a high morbidity and mortality rate. Little is known about the incidence and outcomes in France. We sought to describe the incidence, clinical characteristics, and one-year outcomes in women with PPCM. We included all women from 18- to 44-year-old hospitalized in Reunion Island University Hospital Center from 2014 to 2019 with a new diagnosis of PPCM. The incidence was 1/2300 births. In our cohort of forty patients, median age was 34 ± 6 years and mean left ventricular ejection fraction (LVEF) was 27 ± 9%. Most patients (42%) were diagnosed during the first month after delivery. 74% presented with severe dyspnea (class III or IV NYHA). Known risk factors for PPCM were: age > 30-year-old (75%), multiparity (65%), gestational hypertension or preexisting chronic hypertension (60%), obesity (40%) and diabetes (28%). Complete recovery (defined by LVEF ≥ 50%) was obtained in 71% of women after one-year follow-up and 6% of patients still had a severe left ventricular impairment (LVEF < 35%). One-year mortality rate was 3%. Prognostic factors were: initial LVEF, left ventricular end-diastolic diameter, and diabetes. Peripartum cardiomyopathy has a particularly high incidence in Reunion Island. Complete recovery is frequent. Targeted screening should be proposed to high-risk patients.

MILD COVID-19 INFECTION PRESENTS FEW WEEKS LATER WITH DEVASTATING CARDIOVASCULAR INVOLVEMENT SEVERE LEFT VENTRICULAR IMPAIRMENT NONISCHEMIC CARDIOMYOPATHY

TYPE: Late Breaking Case Report TOPIC: Cardiovascular Disease INTRODUCTION: The (COVID 19) outbreak is a novel disease with multi-system involvement. We report a case of a young male who recovered from mild COVID 19 infection, presenting a few weeks later with devastating cardiovascular involvement severe left ventricular impairment non-ischemic cardiomyopathy dependent on a Zoll device. CASE PRESENTATION: Case of a 47 y/o male with PMH of obesity, HTN, who was apparently healthy and able to do strenuous physical activity for many years. Patient states back in March 2021, he presented with symptoms of fatigue, myalgias, and shortness of breath. He seeked medical attention and tested positive for COVID 19 by PCR. He was discharged with home quarantine and no medications given. Few weeks later no improvement at PCP. PE remarkable for acute respiratory distress, coughing, SOB on minimal exertion. Abdomen distended non-tension ascites, lower extremities 2-3 + pitting edema. O2 saturation decreased with 6 min walk to 89-90%. Patient was admitted due to anasarca, decompensated congestive heart failure. BNP elevated (2,271 pg/ml) echocardiogram EF <25% heart catheterization normal coronaries and non-ischemic cardiomyopathy were identified. NYHA stage III medical therapy was optimized Cardiac Zoll device. DISCUSSION: There is limited data about exacerbation of heart failure after mild COVID-19 infection not requiring hospitalization. This case is unique in the presentation and progression of disease with worsening of symptoms after full recovery of mild COVID-19 infection in a short period. CONCLUSIONS: It is important to continue follow up on patients due to exacerbation or complications of chronic conditions and onset of new ones as complication of this unstoppable viral infection. DISCLOSURE: Nothing to declare. KEYWORD: Non-ischemic Cardiomyopathy

Percutaneous coronary intervention in octogenarians: 10-year experience from a primary percutaneous coronary intervention centre with off-site cardiothoracic support.

OBJECTIVETo examine the trends in patient characteristics and clinical outcomes over a ten-year period and to analyse the predictors of mortality in octogenarians undergoing percutaneous coronary intervention (PCI) in our centre.METHODSA total of 782 consecutive octogenarians (aged 80 and above) were identified from a prospectively collected PCI database within our non-surgical, medium volume centre between 1st January 2007 and 31st December 2016. This represented 10.9% of all PCI procedures performed in our centre during this period. We evaluated the demographic and procedural characteristics of the cohort with respect to clinical outcomes (all-cause in-hospital and 1-year mortality, in-hospital complication rates, duration of hospital admission, coronary disease angiographic complexity and major co-morbidities). The cohort was further stratified into three chronological tertiles (January 2007 to July 2012, 261 cases; August 2012 to May 2015, 261 cases; June 2015 to December 2016, 260 cases) to assess for differences over time. Predictors of mortality were identified through a multivariate regression analysis.RESULTSThe number of octogenarians undergoing PCI increased nearly ten-fold over the studied period. Despite this, there were no significant differences in clinical outcomes or patient characteristics, except for the increased use of trans-radial vascular access [11.9% in first tertile vs. 73.2% in third tertile (P < 0.0001)]. The all-cause in-hospital (5.8% vs. 4.6% vs. 3.8%, P = 0.578) and 1-year mortality (12.4% vs. 12.5% vs. 14.4%, P = 0.746) remained constant in all three tertiles respectively. Six independent predictors of mortality were identified - increasing age [HR = 1.12 (1.03−1.22), P = 0.008], cardiogenic shock [HR = 16.40 (4.04–66.65), P < 0.0001], severe left ventricular impairment [HR = 3.52 (1.69−7.33), P = 0.001], peripheral vascular disease [HR = 2.73 (1.22−6.13), P = 0.015], diabetes [HR = 2.59 (1.30−5.17), P = 0.007] and low creatinine clearance [HR = 0.98 (0.96−1.00), P = 0.031]. CONCLUSIONThis contemporary observational study provides a useful insight into the real-world practice of PCI in octogenarians.

The Impact of the Early COVID-19 Pandemic on ST-Segment Elevation Myocardial Infarction Presentation and Outcomes-A Systematic Review and Meta-Analysis.

Background: The influence of the early COVID-19 pandemic on non-COVID-19 emergencies is uncertain. We conducted a systematic review and a meta-analysis to evaluate the impact of the first months of the COVID-19 pandemic on the presentation, management, and prognosis of patients presenting with ST-segment elevation myocardial infarction (STEMI). Methods: We searched the PubMed, Scopus, and Embase databases from January to August 2020. A meta-analysis of studies comparing the profile, STEMI severity at presentation, reperfusion delay, and in-hospital mortality for patients presenting before and during the early COVID-19 pandemic was conducted. Fifteen cross-sectional observational studies including 20,528 STEMI patients from the pre-COVID period and 2190 patients diagnosed and treated during the first months of the COVID-19 pandemic met the inclusion criteria. Results: Patients presenting with STEMI during the pandemic were younger and had a higher comorbidity burden. The time interval between symptoms and first medical contact increased from 93.22 ± 137.37 min to 142 ± 281.60 min (p < 0.001). Door-to-balloon time did not differ significantly between the two periods (p = 0.293). The pooled odds ratio (OR) for low left ventricular ejection fraction at presentation during the pandemic was 2.24 (95% confidence interval (CI) 1.54–3.26) and for a presentation delay >24 h was 2.9 (95% CI 1.54–5.45) relative to before the pandemic. In-hospital mortality did not increase significantly during the outbreak (p = 0.97). Conclusion: During the first months of the COVID-19 pandemic, patients presenting with STEMI were addressed later in the course of the disease with more severe left ventricular impairment. In-hospital emergency circuits and care functioned properly with no increase in door-to-balloon time and early mortality.

Incidence, clinical characteristics and one-year outcomes of peripartum cardiomyopathy in Reunion Island

Peripartum cardiomyopathy (PPCM) is a form a dilated cardiomyopathy affecting young women, inducing a high morbidity and mortality rate. Little is known about the incidence and outcomes in France. We sought to describe the incidence, clinical characteristics, and one-year outcomes in women with PPCM. We included all women from 18 to 44-year-old hospitalized in Reunion Island University Hospital Center from 2014 to 2019 with a new diagnosis of PPCM. The incidence was 1/2300 births. In our cohort of forty patients, median age was 34 ± 6 years and mean left ventricular ejection fraction (LVEF) was 27 ± 9%. Most patients (42%) were diagnosed during the first month after delivery. 74% presented with severe dyspnea (class III or IV NYHA). Known risk factors for PPCM were: age > 30-year-old (75%), multiparity (65%), gestational hypertension or preexisting chronic hypertension (60%), obesity (40%) and diabetes (28%). Complete recovery (defined by LVEF≥ 50%) was obtained in 71% of women after one-year follow-up and 6% of patients still had a severe left ventricular impairment (LVEF < 35%). One-year mortality rate was 3%. Prognostic factors were: initial and one-month LVEF, left ventricular end-diastolic diameter, and diabetes. Peripartum cardiomyopathy has a particularly high incidence in Reunion Island. Complete recovery is frequent. Targeted screening should be proposed to high-risk patients.

Eligible-and-enrolled vs. eligible-but-not-enrolled patients with chronic ischaemic heart failure in randomized clinical trials of myocardial regeneration.

Clinical trial applicability to routine clinical practice is a fundamental consideration. Little is known about factors that determine enrolment (vs. non-enrolment) in chronic ischaemic heart failure (CIHF) interventional randomized controlled trials (iRCT). To compare clinical characteristics and medical therapy in eligible-and-enrolled (E-E) vs. eligible-but-not-enrolled (E-NE) patients in CIHF myocardial regeneration iRCTs. Clinical characteristics and medical treatment were compared for E-E and E-NE in 4 periods (32 months): P1 (iRCT#1 recruitment), P2 (between iRCT#1 and iRCT#2), P3 (iRCT#2 recruitment), P4 (post iRCT#2). iRCT#1 and iRCT#2 shared inclusion/exclusion criteria. Evaluation involved 5,436 hospitalized patients (P1-P4; CIHF-526). 283 were iRCT eligible (53.8%). The eligibility rate was similar throughout P1-P4 (43.1-58.5%, p = 0.08). Eligible patient characteristics and pharmacotherapy did not differ in recruitment vs. non-recruitment periods. Principal reasons for ineligibility were recent/planned cardiac intervention outside iRCT (22.8%), age above threshold (14.6%) and coexisting disease as the exclusion criterion (12.2%). Primary reasons for eligible patient non-enrolment (n = 89) were other trial participation (52.8%) and no consent (28.1%). E-E patients did not differ from E-NE in characteristics including CIHF medical management and clinical stage; the exception was more severe left ventricular impairment in E-E (LVEF 31.2 vs. 33.9%, p = 0.039; end-diastolic volume 197.8 vs. 160.4 ml, p < 0.0001). CIHF medical management was similar in E-E and E-NE. Ineligibility resulted mainly from recent/planned intervention outside iRCT and age > 80 years. LV impairment was more severe in E-E patients, consistent with higher-risk patient enrolment in CIHF-iRCTs. This contrasts with typical lower-risk patient enrolment in other cardiovascular RCT types and populations.

Optimal left ventricular lead positioning during cardiac resynchronisation therapy; a comparison of 2 methods

Abstract Background/Introduction Superior response to CRT and improved clinical outcomes can be achieved when placing the left ventricular (LV) lead at the site of latest mechanical activation and avoiding regions of scar during cardiac resynchronisation therapy (CRT). The site of latest mechanical activation can be identified using speckle-tracking echocardiography, whilst the area of latest electrical activation can be assessed by measuring QLV, the time from the initial deflection of the surface QRS complex to sensing at the LV lead electrode. It remains unclear if the two techniques are interchangeable and whether the site of latest mechanical activation is related to the site of latest electrical activation, or sensed electrical signals correspond to sites of scar. Purpose To determine whether electrical targeting of LV lead position corresponds to echo-guided mechanical targeting and whether myocardial electrogram signals can predict areas of myocardial scar Methods This was a pilot study of patients receiving CRT, in sinus rhythm with severe LV impairment (ejection fraction ≤35%) and left bundle branch block (LBBB) with QRS ≥130ms. Ethics approval was obtained, and written consent was sought. Participants underwent echocardiographic speckle-tracking 2-dimensional radial strain imaging to identify amplitude and time to peak contraction of posterior, posterolateral, lateral, anterolateral and anterior segments. During CRT implant, the sensed R wave and QLV were measured at the respective branch of the coronary sinus, where the anatomy permitted. The site of latest mechanical was compared to the site of latest electrical activation and classified as concordant (same site), adjacent (within 1 segment), or remote (2 segments away). The strain amplitude was compared to the sensed R wave and time to mechanical activation with QLV. Results Seventeen patients (13 male) were studied, mean age 74.2 (SD 8.7). Mean QRS was 161 ms (SD 18), mean PR 186 ms (SD 37). A modest and significant positive correlation was found between the site of latest mechanical and latest electrical activation (Pearson r=0.66, p 0.004). The site of latest electrical activation was concordant with latest mechanical activation in 13 patients (76.5%), adjacent in 4 patients (23.5%) and remote in none. There was no apparent association between sensed R wave and strain amplitude (Pearson r=0.2, p=0.12) or between QLV and time to mechanical activation (Pearson r=0.1, p=0.5). Conclusion A significant positive correlation was found between the site of latest mechanical and latest electrical activation in patients undergoing CRT implant. Electrical targeting might be a suitable alternative to mechanical targeting particularly when imaging is not available, however, does not appear to discriminate scar. Future larger studies are needed to confirm our findings and determine whether QLV can be used as an alternative method for targeting LV lead placement. Funding Acknowledgement Type of funding sources: None.

Racial Disparities in Management and Outcomes of Out-of-Hospital Cardiac Arrest Complicating Myocardial Infarction: A National Study From England and Wales

BackgroundStudies of racial disparities in care of patients admitted with an out-of-hospital cardiac arrest (OHCA) in the setting of acute myocardial infarction (AMI) have shown inconsistent results. Whether these differences in care exist in the universal healthcare system in United Kingdom is unknown. MethodsPatients admitted with a diagnosis of AMI and OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. All patients were stratified based on ethnicity into a Black, Asian, or minority ethnicity (BAME) group vs a White group. We used multivariable logistic regression models to evaluate the predictors of clinical outcomes and treatment strategy. ResultsFrom 14,287 patients admitted with AMI complicated by OHCA, BAME patients constituted a minority of patients (1185 [8.3%]), compared with a White group (13,102 [91.7%]). BAME patients were younger (median age [interquartile range]) for BAME group, 58 [50-70] years; for White group, 65 [55-74] years). Cardiogenic shock (BAME group, 33%; White group, 20.7%; P < 0.001) and severe left ventricular impairment (BAME group, 21%; White group, 16.5%; P < 0.003) were more frequent among BAME patients. BAME patients were more likely to be seen by a cardiologist (BAME group, 95.9%; White group, 92.5%; P < 0.001) and were more likely to receive coronary angiography than the White group (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-1.88). The BAME group had significantly higher in-hospital mortality (OR 1.26, 95% CI 1.04-1.52) and re-infarction (OR 1.52, 95% CI 1.06-2.18) than the White group. ConclusionsBAME patients were more likely to be seen by a cardiologist and receive coronary angiography than White patients. Despite this difference, the in-hospital mortality of BAME patients, particularly in the Asian population, was significantly higher.

In Hospital Outcomes for High-Risk Percutaneous Coronary Intervention (PCI) in Patients Referred From a Rural Centre to Metropolitan Sites

Cardiac Society of Australia and New Zealand (CSANZ) guidelines recommend elective high-risk percutaneous coronary intervention (PCI) is not performed in sites greater than 1 hour from cardiac surgery. In hospital outcomes for all patients from Orange Health Service (OHS) from January 2017 to January 2020 who were transferred electively to tertiary centres in Sydney for high risk PCI were examined. One hundred and fourteen (114) patients were identified, with 1,259 PCIs performed at OHS over the same period without transfer. The mean age of these 114 patients was 71 years, with 74.6% male. Receiving hospitals were Royal Prince Alfred Hospital, Sydney, NSW (66.7%), Concord Repatriation General Hospital, Concord, NSW (19.3%) and Strathfield Private Hospital, Strathfield, NSW (14%). The definition of high risk and indication for transfer included at least one of: moderate or greater calcification of the target lesion or proximal segment (34%), single or multiple target lesions that in aggregate jeopardised over 50% of remaining viable myocardium (27%), degenerated saphenous vein grafts (14.8%), chronic total occlusions (7.0%) and severe left ventricular (LV) impairment (3.9%). American Heart Society/American College of Cardiology (AHA/ACC) lesion types were A (1%), B1 (4.2%), B2 (40.2%), and C (54.6%). PCI was performed via the femoral route in 96.2%. The mean procedure duration was 72 minutes, mean combined fluoroscopy time was 19 minutes and mean radiation dose as defined by Reference Air Kerma was 1,630mGy. Complications occurred in 13 patients and were: acute vessel dissection requiring stenting (4), perforation (2), acute vessel closure (4), puncture site related (1), and life-threatening arrhythmia (2). There were no cases of emergent coronary artery bypass graft (CABG) or death. This contemporary cohort of high-risk patients transferred electively from a regional PCI centre to a tertiary cardiac unit underwent lengthy PCI procedures, with high radiation doses, and a modest rate of peri-procedural complications, but had otherwise excellent procedural and clinical outcomes.

Sex differences in investigations and outcomes among patients with type 2 myocardial infarction

ObjectivesType 2 myocardial infarction (MI) is a heterogenous condition and whether there are differences between women and men is unknown. We evaluated sex differences in clinical characteristics, investigations and outcomes...

Paediatric dilated cardiomyopathy in Khartoum state, Sudan: a prospective study

BackgroundDilated cardiomyopathy (DCM) is a disease of the heart muscle that affects ventricular function; it is a debilitating disease that can lead to heart failure and death in children. There...

A comparison of standard and high dose adenosine protocols in routine vasodilator stress cardiovascular magnetic resonance: dosage affects hyperaemic myocardial blood flow in patients with severe left ventricular systolic impairment

BackgroundAdenosine stress perfusion cardiovascular magnetic resonance (CMR) is commonly used in the assessment of patients with suspected ischaemia. Accepted protocols recommend administration of adenosine at a dose of 140 µg/kg/min increased up to 210 µg/kg/min if required. Conventionally, adequate stress has been assessed using change in heart rate, however, recent studies have suggested that these peripheral measurements may not reflect hyperaemia and can be blunted, in particular, in patients with heart failure. This study looked to compare stress myocardial blood flow (MBF) and haemodynamic response with different dosing regimens of adenosine during stress perfusion CMR in patients and healthy controls.Methods20 healthy adult subjects were recruited as controls to compare 3 adenosine perfusion protocols: standard dose (140 µg/kg/min for 4 min), high dose (210 µg/kg/min for 4 min) and long dose (140 µg/kg/min for 8 min). 60 patients with either known or suspected coronary artery disease (CAD) or with heart failure and different degrees of left ventricular (LV) dysfunction underwent adenosine stress with standard and high dose adenosine within the same scan. All studies were carried out on a 3 T CMR scanner. Quantitative global myocardial perfusion and haemodynamic response were compared between doses.ResultsIn healthy controls, no significant difference was seen in stress MBF between the 3 protocols. In patients with known or suspected CAD, and those with heart failure and mild systolic impairment (LV ejection fraction (LVEF) ≥ 40%) no significant difference was seen in stress MBF between standard and high dose adenosine. In those with LVEF < 40%, there was a significantly higher stress MBF following high dose adenosine compared to standard dose (1.33 ± 0.46 vs 1.10 ± 0.47 ml/g/min, p = 0.004). Non-responders to standard dose adenosine (defined by an increase in heart rate (HR) < 10 bpm) had a significantly higher stress HR following high dose (75 ± 12 vs 70 ± 14 bpm, p = 0.034), but showed no significant difference in stress MBF.ConclusionsIncreasing adenosine dose from 140 to 210 µg/kg/min leads to increased stress MBF in patients with significantly impaired LV systolic function. Adenosine dose in clinical perfusion assessment may need to be increased in these patients.

Residual mitral regurgitation impact on outcomes after mitraclip therapy: five-year follow-up from the GRASP registry

Abstract Funding Acknowledgements Type of funding sources: None. Background – Although percutaneous mitral valve repair is an attractive alternative treatment option for patients with severe mitral regurgitation (MR) at high surgical risk, residual MR is commonly observed after the procedure and little is known about its impact on outcomes after MitraClip therapy, expecially in patients with severe left ventricular (LV) impairment. Purpose – The aim of this prospective, observational study was to evaluate the impact of residual MR (MR ≤1+ vs. MR &amp;gt;1+) on long-term outcomes of mitral valve repair with the MitraClip System in high surgical risk patients presenting with moderate-to-severe or severe MR and with severe reduction of LV ejection fraction (EF). Methods – Patients enrolled in the prospective Getting Reduction of Mitral Insufficiency by Percutaneous Clip Implantation (GRASP) with functional MR and EF ≤30% who were eligible at almost five-year follow-up were included in the present analysis. The primary endpoint was death at 5-year follow-up. Also echocardiographic parameters at baseline and 5-year follow-up and rehospitalization rates were assessed. Results – A total of 139 patients were included: 92 (66.2%) with post-procedural residual MR ≤1+ and 47 (33.8%) with residual MR &amp;gt; 1+ (41 patients with residual MR 2+, 5 with residual MR 3+, 1 with residual MR 4+). Comparable clinical and echocardiographic baseline characteristics were observed between the two groups except for NYHA functional class IV and implanted pace-maker (more frequent in patients with residual MR &amp;gt;1+) and previous myocardial infarction (more frequent in patients with residual MR ≤1+). At 5-year follow-up, no significant differences were reported in the primary endpoint (49.6% in patients with residual MR ≤ 1+ vs. 65.3% in patients with residual MR &amp;gt; 1+, p 0.203) and in cardiac death (37.8% in patients with residual MR ≤ 1+ vs. 42.6% in patients with residual MR &amp;gt; 1+, p 0.921). Cox regression analysis identified residual MR &amp;gt; 1+ as an independent predictor of re-hospitalization (HR 0.51, 95% CI 0.28-0.92, p =0.026). At 5-year follow-up, a significant reduction in left ventricular end-systolic volume was observed in patients with residual MR ≤ 1+. Conclusions – At 5-year follow no significant differences in survival emerged in patients with severe LV dysfunction undergoing MitraClip therapy regardless residual MR. Nevertheless residual MR &amp;gt; 1+ emerged as an indipendent predictor of re-hospitalization.

COAPT-Like Profile Predicts Long-Term Outcomes in Patients With Secondary Mitral Regurgitation Undergoing MitraClip Implantation.

The aim of this study was to evaluate whether fulfilling COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for HeartFailure Patients With Functional Mitral Regurgitation) criteria identifies patients with better outcomes after MitraClip treatment for secondary mitral regurgitation (SMR). To date, COAPT is the only trial showing a prognostic benefit of MitraClip implantation compared with conservative management. Three hundred four patients with SMR undergoing MitraClip placement in addition to optimal medical therapy at 3 European centers were analyzed. A COAPT-like profile was defined as absence of all the followingcriteria: severe left ventricular impairment, moderate to severe right ventricular dysfunction, severe tricuspid regurgitation, severe pulmonary hypertension, and hemodynamic instability. Freedom from all-cause death and from a composite endpoint (cardiovascular death and heart failure hospitalization) were evaluated at 2- and 5-year follow-up. A COAPT-like profile was observed in 65% of the population. Compared with non-COAPT-like patients, those fulfilling COAPT criteria had greater survival free from all-cause death and from the composite endpoint at both 2 year (75% vs. 55% and 67% vs. 47%; p<0.001 for both) and 5-year (49% vs. 25% and 40% vs. 19%; p<0.001 for both) follow-up. Among the non-COAPT-like patients, similar outcomes were observed in those fulfilling 1 or≥1 criterion. Left ventricular impairment had a late impact on outcomes, while right ventricular impairment, pulmonary hypertension, andhemodynamic instability had early effects. COAPT-like profile was an independent predictor of long-term outcomes, as well as administration of neurohormonal antagonists, European System for Cardiac Operative Risk Evaluation II score, and previous heart failure hospitalization. A COAPT-like profile, including specific echocardiographic and clinical criteria, identifies patients with SMR who have a better prognosis after MitraClip implantation.