Severe Systolic Heart Failure Research Articles

A prospective multicenter feasibility study of a miniaturized implantable continuous flow ventricular assist device in smaller children with heart failure

There is no FDA-approved left ventricular assist device (LVAD) for smaller children permitting routine hospital discharge. Smaller children supported with LVADs typically remain hospitalized for months awaiting heart transplant-a major burden for families and a challenge for hospitals. We describe the initial outcomes of the Jarvik 2015, a miniaturized implantable continuous flow LVAD, in the NHLBI-funded Pumps for Kids, Infants, and Neonates (PumpKIN) study, for bridge-to-heart transplant. Children weighing 8 to 30 kg with severe systolic heart failure and failing optimal medical therapy were recruited at 7 centers in the United States. Patients with severe right heart failure and single-ventricle congenital heart disease were excluded. The primary feasibility endpoint was survival to 30 days without severe stroke or non-operational device failure. Of 7 children implanted, the median age was 2.2 (range 0.7, 7.1) years, median weight 10 (8.2 to 20.7) kilograms; 86% had dilated cardiomyopathy; 29% were INTERMACS profile 1. The median duration of Jarvik 2015 support was 149 (range 5 to 188) days where all 7 children survived including 5 to heart transplant, 1 to recovery, and 1 to conversion to a paracorporeal device. One patient experienced an ischemic stroke on day 53 of device support in the setting of myocardial recovery. One patient required ECMO support for intractable ventricular arrhythmias and was eventually transplanted from paracorporeal biventricular VAD support. The median pump speed was 1600 RPM with power ranging from 1-4 Watts. The median plasma free hemoglobin was 19, 30, 19 and 30 mg/dL at 7, 30, 90 and 180 days or time of explant, respectively. All patients reached the primary feasibility endpoint. Patient-reported outcomes with the device were favorable with respect to participation in a full range of activities. Due to financial issues with the manufacturer, the study was suspended after consent of the eighth patient. The Jarvik 2015 LVAD appears to hold important promise as an implantable continuous flow device for smaller children that may support hospital discharge. The FDA has approved the device to proceed to a 22-subject pivotal trial. Whether this device will survive to commercialization remains unclear because of the financial challenges faced by industry seeking to develop pediatric medical devices. (Supported by NIH/NHLBI HHS Contract N268201200001I, clinicaltrials.gov 02954497).

Transcatheter transfemoral aortic valve replacement in a patient with acromegaly and severe left ventricular myocardial hypertrophy. Case report

Main causes of secondary hypertrophic cardiomyopathy include acromegalic cardiomyopathy. Heart damage in patients with the acromegaly is mediated both by the direct action of growth hormone and insulin-like growth factor-1, and increased deposition of collagen and lymphomononuclear cells in the myocardium, which leads to architectural changes, disturbances in fluid and electrolyte balance, severe left ventricular myocardial hypertrophy, diastolic and systolic left ventricular dysfunction and chronic heart failure. This article presents the world's first described observation demonstrating the possibility of successful transfemoral aortic valve repair to a comorbid patient with severe aortic stenosis according to the potential risks caused by the active form of the acromegaly.

Improvement in Echocardiographic Indexes of Systolic Heart Failure Post-Kidney Transplantation: A Retrospective Analysis

Introduction: End-stage renal disease is a major risk factor for cardiovascular morbidity and mortality, which can be partially eliminated by kidney transplantation. Systolic heart failure might be considered contraindication for kidney transplant, although some patients demonstrate myocardial recovery post-transplant. We aimed to identify and characterize the phenomenon of reverse myocardial remodeling in kidney transplanted patients. Methods: The study is a retrospective cohort of patients undergoing kidney transplants between 2016 and 2019 (n = 604) at Rabin Medical Center. Patients were assessed according to availability of two echocardiographic examinations: pre- and post-kidney transplant. The change in estimated ejection fraction (EF) and possible predictors of myocardial recovery were examined. Results: Data of 293 patients was available for the final analysis. Eighty-one (28%) patients had a LVEF improvement equal to or above 5%, whereas 36 (12%) patients had a LVEF improvement of 10% or more post-transplantation. Twenty-five patients (8.5%) had moderate or severe systolic heart failure with LVEF reduced to 40% or less at baseline. 13 of them (52%) had a LVEF improvement of ≥5%, and 10 patients (40%) had an improvement of ≥10% in their EF. Cox regression analyses identified female gender as the only independent variable associated with LVEF improvement of at least 10%. Conclusion: Renal transplantation might lead to improved LV systolic function in some patients.

Rationale and study protocol for the BRITISH randomized trial (Using cardiovascular magnetic resonance identified scar as the benchmark risk indication tool for implantable cardioverter defibrillators in patients with nonischemic cardiomyopathy and severe systolic heart failure)

BackgroundFor patients with nonischemic cardiomyopathy (NICM), current guidelines recommend implantable cardioverter defibrillators (ICD) when left ventricular ejection fraction (LVEF) is ≤35%, but the DANISH trial failed to confirm that ICDs reduced all-cause mortality for such patients. Circumstantial evidence suggests that scar on CMR is predictive of sudden and arrhythmic death in this population. The presence of myocardial scar identified by cardiac magnetic resonance imaging (CMR) in patients with NICM and an LVEF ≤35% might identify patients at higher risk of sudden arrhythmic death, for whom an ICD is more likely to reduce all-cause mortality. Methods/DesignThe BRITISH trial is a prospective, multicenter, randomized controlled trial aiming to enrol 1,252 patients with NICM and an LVEF ≤35%. Patients with a nonischemic scar on CMR will be randomized to either: (1) ICD, with or without cardiac resynchronization (CRT-D), or (2) implantable loop recorder (ILR) or cardiac resynchronization (CRT-P). Patients who are screened for the trial but are found not to be eligible, predominantly due to an absence of scar or those who decline to be randomized will be enrolled in an observational registry. The primary endpoint is all-cause mortality, which we plan to assess at 3 years after the last participant is randomized. Secondary endpoints include clinical outcomes, appropriate and inappropriate device therapies, symptom severity and well-being, device-related complications, and analysis of the primary endpoint by subgroups with other risk markers. ConclusionThe BRITISH trial will assess whether the use of CMR-defined scar to direct ICD implantation in patients with NICM and an LVEF ≤35% is associated with a reduction in mortality.

C42 OR 1896 EXERTS POSITIVE INOTROPIC EFFECTS IN ISOLATED HUMAN RIGHT ATRIAL MUSCLE

Abstract Levosimendan is approved for use as an intravenous agent to treat temporarily patients with severe systolic heart failure. It is thought, but hitherto never tested in isolated human cardiac tissue, that the main metabolite of levosimendan, called OR 1896, might cause the positive inotropic effect of levosimendan in patients. For comparison, we studied mouse atrial preparations. OR alone (up to 10 µM) failed to increase force of contraction in mouse atrial preparations while in the presence of the phosphodiesterase (PDE) IV–inhibitor rolipram (0.1 µM) profound positive inotropic effects and positive chronotropic effects of OR 1895 were recorded in mouse atrial preparations. In contrast to mouse atrium, we noticed that OR 1896 alone (0.01 µM to 10 µM cumulatively applied) exerted time– and concentration–dependent positive inotropic effects 1 µM increase by 72 ± 14.7%, p<0.05, n=7) and shortened the time of relaxation (by 7 .3 %, p<0.05, n=7) in isolated electrically paced human right atrial muscle preparations (obtained during cardiac surgery), that started at 0.1 µM and plateaued at 1 µM OR 1896. The positive inotropic effect of OR 1896 was antagonized by 10 µM propranolol. The positive inotropic effect of OR 1896 in mouse atrial preparations and human right atrial preparations was less effective than that of 1 µM isoprenaline (human atrium by 154 %). The positive inotropic effect of OR 1896 was diminished by pre–incubation of the samples with the PDE III inhibitor cilostamide (10 µM). EMD 57033 (10 µM), a calcium sensitizer, increased force of contraction further in the additional presence of 1 µM OR 1896. Our data suggest that OR 1896 is indeed a positive inotropic agent in the human heart and that OR 1896 acts mainly as a PDE III – inhibitor because the effect of OR 1896 was attenuated by a β–adrenoceptor antagonist and thus OR 1896 is unlikely to act as a calcium sensitizer in the human heart.

Diabetes mellitus type 1 and coronary artery disease with severe systolic heart failure in 25 year-old adult

Diabetes mellitus (DM) type 1 accounts for up to 90% of all cases of diabetes among children, adolescents and young adults (10 % are represented by T2DM, MODY, etc.). DM is characterized not only by glucose metabolism disorder, but also by abnormal protein and lipid metabolism, leading to severe macrovascular complications. A clinical case of diabetes type 1, hyperlipidemia, coronary artery disease (CAD) and chronic heart failure (HF) in a 25-year-old adult has been demonstrated. The medical examination revealed lipid metabolism disorders, multivessel coronary artery disease, which required myocardial revascularization, and severe heart failure with a reduced ejection fraction (HFrEF). The clinical case demonstrates that proper cardiovascular examination should be performed in all patients with diabetes and lipid disorders, regardless of age and type of diabetes. The authors also consider the use of sodium-glucose

Abstract 15617: Severe Heart Failure: Fistulous Connection Between Ectatic Left Anterior Descending Artery, Coronary Sinus, and Left Ventricular Cavity

Introduction: Arteriovenous coronary fistula of LAD to the coronary sinus is a rare vascular anomaly present in 0.002% of the general population. We report a rare case of fistulous connection between exceptionally large LAD and coronary sinus into the LV cavity leading to severe systolic heart failure. Case: A 39-year-old male with no past medical history presented to the ED with complaints of dyspnea, chest pain and lower extremity edema for the past 3 months. The chest pain was substernal, squeezing, non-radiating, 2/10 in intensity, exacerbated by exertion and alleviated with rest. The patient did not have any cardiology work up in the past. Vitals were stable. The patient had irregular rhythm with prominent JVD and bilateral lower extremity edema on examination. Troponins were negative, BNP was elevated and thyroid function was normal. Chest x-ray showed cardiomegaly. EKG showed atrial fibrillation with no significant ST segment changes or Q waves. Echocardiogram showed severe systolic left ventricular dysfunction with an ejection fraction of 15-20% and moderate to severe secondary mitral regurgitation. Cardiac catheterization showed large ectatic LAD with mild stenosis in mid segment. An abnormal connection was noted between LAD and coronary sinus draining directly into the left ventricle. He was discharged on guideline directed medical therapy for heart failure. Discussion: Fistula between LAD, coronary sinus and LV cavity is a unique organic heart disease. Our patient presented with heart failure with no apparent identifiable cause. On angiography an ectatic LAD was connected to the coronary sinus and LV cavity which created a high output state on the LV. The management of this rare pathology is complex due to variable presentation and lack of specific treatment guidelines. Careful selection of certain cases for therapeutic intervention can result in better outcomes than medical therapy alone.

ODP462 Amiodarone Induced Thyrotoxicosis-Treatment Challenges

Abstract Amiodarone induced thyrotoxicosis (AIT) presents a diagnostic and treatment challenge. Importantly, uncontrolled thyrotoxicosis can be associated with significant morbidity and mortality. The following presentation depicts a case of AIT with persistent thyrotoxicosis despite optimal and prolonged medical therapy. The case was complicated by patient's high-risk cardiovascular profile postponing definitive therapy with thyroidectomy. Patient was a 58-year-old female with past medical history of coronary artery disease, severe systolic heart failure, atrial fibrillation, and ventricular tachycardia maintained on amiodarone therapy since 2019, who was noted to have abnormal thyroid function labs in 2021 with TSH of 0. 04 uIU/mL (0.45-5.3), free T3 of 4.6 pg/mL (2.2-4.1) and free T4 of 2.7 ng/dL (0.58-1.64) indicative of hyperthyroidism. Her evaluation included negative family history of thyroid disorder, negative thyroid antibody profile, as well as a thyroid ultrasound that demonstrated no thyroid enlargement, no nodules and normal vascularity. At the time of initial evaluation, patient was suffering from episodes of atrial fibrillation with rapid ventricular response. Patient was diagnosed with AIT (presumably type 1). Amiodarone was discontinued and patient was initiated on methimazole 10 mg twice daily. Unfortunately, three weeks after initiation of methimazole treatment, patient's clinical status deteriorated and she was hospitalized for multifactorial shock requiring multidisciplinary approach and vasopressor/ionotropic support. At that time her free T4 had risen to >5.6 ng/dL and free T3 peaked at 6.17 pg/mL. The most probable diagnosis was AIT type 2 and her medical therapy was augmented to methimazole 20 mg three times daily and prednisone 50 mg daily. After clinical stabilization, she was discharged home on this regimen. Unfortunately, her thyroid function tests remained persistently elevated for almost three months despite maximum medical therapy. At that point, patient was referred for thyroidectomy despite severe cardiomyopathy and high-risk surgical profile. Fortunately, her thyroid function tests began to improve prior to planned surgery and medical therapy was successfully de-escalated, precluding the need for surgical intervention. While most cases of AIT can be successfully treated with medical therapy, refractory cases can present a clinical challenge, especially in patients at high risk for thyroidectomy. Weighing the risks and benefits of each treatment plan requires a multi-disciplinary approach and close communication with all parties involved. Presentation: No date and time listed

LBSUN255 Recurrent Hypoglycemia In A Patient With Beckwith-Wiedemann Syndrome Secondary To Insulinoma

Abstract Background Beckwith-Wiedemann Syndrome (BWS) is a genetic condition characterized by macrosomia, childhood tumors, and neonatal hypoglycemia and hyperinsulinemia. The cause of this hyperinsulinemic hypoglycemia is unknown, but it is believed to be caused by chromosomal mutations at 11p15.5 and genes encoding beta-cell ATP-sensitive potassium channels. In our case, we have an adult patient with a history of BWS who is experiencing hypoglycemia due to a different cause: an insulinoma. This is the first report of insulinoma in an adult with this syndrome. Case Presentation The patient is a 53-year-old male with a history of BWS. Due to shortness of breath, the patient was admitted and discovered to have new and severe systolic heart failure. Patient was started on beta blockers by cardiology. During his hospital stay, he developed hypoglycemia, with glucose levels in the 20s. As the hypoglycemia became more frequent, he was placed on dextrose. Dextrose was turned off to obtain hypoglycemia labs such as insulin, proinsulin, C-peptide, and hydroxybutyrate, but his blood sugar never fell below 80mg/dL. His hypoglycemia was attributed to a beta-blocker side effect or rebound from a dextrose infusion. He was discharged from hospital and sent home. After a loss of consciousness episode at home two weeks later, the patient was readmitted. When he arrived at the emergency department, his blood glucose level was 18mg/dL, and he was given dextrose. After being admitted to the hospital, dextrose was again discontinued, and blood glucose levels dropped to 45mg/dL on serum testing. At the time, C-peptide levels were elevated at 25.7ng/mL, B-hydroxybutyrate levels were 0. 06mmol/L, and insulin levels were above 700uIU/mL. At the time, the choice was between insulin autoantibody syndrome and insulinoma. The patient then had an abdominal computed tomography scan, which revealed a 3.7×2.9cm neuroendocrine tumor in the distal pancreas. Changes in the liver were found to be alarming for metastases, thus an MRI was conducted to confirm this. There was no sign of liver metastases on the MRI. In the interim, the patient was started on subcutaneous octreotide 50 mcg twice daily. Given the patient's underlying heart problems, diazoxide was not pursued. Octreotide was increased to 100mcg subcutaneously three times daily throughout his hospital stay, and he was discharged home with a continuous glucose monitor and intentions to operate later that month. Conclusions Although BWS has been linked to a higher risk of childhood malignancies, it's uncertain whether BWS could be a predisposing factor for the development of insulinoma. Because this is such a rare disorder, there is a paucity of information on predisposition or risk factors. However, the link between macrosomia and tumor growth in BWS suggests that there may be a predisposition to insulinoma that has yet to be investigated. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Diagnostic and therapeutic approach of central sleep apnea in heart failure – the role of adaptive servo-ventilation. A statement of the Portuguese society of pulmonology and the Portuguese sleep association

It is known that patients with heart failure (HF) have an increased risk of developing central sleep apnoea (CSA), with Cheyne-Stokes respiration. The development of servo-ventilation aimed to treat CSA and improve the quality of life (QoL) of these patients. A large randomized clinical study, SERVE-HF, was conducted in order to test this theory in patients with HF and reduced ejection fraction (HFrEF). The results from this trial seemed to indicate that, in these patients, there was no beneficial effect of the assisted ventilation in CSA treatment. More surprisingly, an increased rate of all-cause or cardiovascular mortality was observed. This has led to dramatic changes in clinical practice, with decreased frequency of servo-ventilation prescription across Europe, including Portugal, due to changes in the guidelines. However, SERVE-HF was conducted only in severe systolic HF patients with CSA, and caution must be taken when extrapolating these results to HF patients with preserved ejection fraction or CSA patients without HF.The study also showed poor adherence, methodological and statistical gaps, including study design, patient selection, data collection and analysis, treatment adherence, and group crossovers, which have not been discussed in the trial as potential confounding factors and raise several concerns. Moreover, the adaptive servo-ventilation (ASV) device used in SERVE-HF was unable to lower the minimum support pressure below 3 mm H20, and this has been suggested as one of the probable contributing reasons to the excess mortality observed in this study. This limitation has since been solved, and this ASV device is no longer used.This paper describes the results of a Portuguese Task Force on the treatment of central sleep apnoea in patients with chronic HF.

Systolic pulmonary regurgitation affects the outcome of patients with severe systolic heart failure.

AimsLittle is known of the impact of systolic pulmonary regurgitation (PR) on acute decompensated heart failure (HF). We assessed the prevalence and prognostic significance of systolic PR in patients with severe HF.Methods and resultsAccording to recent 10 year echocardiographic database of E‐Da Hospital, 533 patients admitted for first systolic heart failure (HF) and left ventricular ejection fraction <35% were under investigation. Systolic PR was defined as the presence of pulmonary backward flow persistent after QRS in electrocardiogram. Isovolumic contraction/relaxation time and myocardial performance index were derived by tissue Doppler imaging. Right ventricular (RV) function was assessed by RV fractional area change. Estimated pulmonary vascular resistance (PVR) was assessed by the ratio of peak tricuspid regurgitation velocity to the RV outflow tract time–velocity integral. The factors associated with systolic PR were assessed by multivariate logistic regression. Cox proportional regression analyses were used to estimate the impact of cardiovascular events including HF rehospitalization and cardiovascular death. For estimated prevalence of 5480 control subjects, echocardiographic screens in those with normal left ventricular ejection fraction were performed. Of 533 systolic HF cases, 143 (26.8%) had systolic PR during indexed hospitalization. Among 143 cases, 86% systolic PR disappeared during late follow‐up. In control subjects, 0.3% (18/5480) had systolic PR. Systolic PR correlated to RV dysfunction, estimated PVR, E/e′, sign of low cardiac output, and pulmonary oedema. Systolic PR was associated independently with further cardiovascular events (hazard ratio 2.266, 95% confidence interval 1.682–3.089, P < 0.0001) including cardiovascular death and HF rehospitalization.ConclusionsSystolic PR is not uncommon in systolic HF and is associated with high PVR and RV dysfunction. Systolic PR significantly impacts cardiovascular outcome.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1.

Background: Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases. Methods: The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the “Association of the Scientific Medical Societies in Germany” (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation. Results: Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on “treatment intensity” including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs. Conclusions: These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.

Malnutrition Affects the Outcomes of Patients with Low-Output Heart Failure and Congestion.

This study aimed to investigate the relationship between malnutrition and outcomes in patients with decompensated severe systolic heart failure (HF) focusing on clinical presentations and medication use. This study prospectively enrolled 108 patients admitted for severe systolic HF with a left ventricular (LV) ejection fraction < 35%, low cardiac output, and high LV filling pressure. Five patients died during the index hospitalization, and the remaining 103 patients were followed up for 2 years. The primary endpoints were HF rehospitalization and all-cause mortality. Nutritional risk index (NRI) was calculated as (1.519 × serum albumin, g/L) + (41.7 × body weight/ideal body weight). Forty-four patients reached the study endpoints. An NRI ≤ 93 predicted events. The NRI ≤ 93 group had higher pulmonary artery systolic pressure, more edema over dependent parts, longer hospital stay, and more primary endpoints compared to the NRI > 93 group. The NRI ≤ 93 group received fewer evidence-based medications and more loop diuretics compared to the NRI > 93 group. NRI was an independent predictor of cardiovascular events [hazard ratio 0.902; 95% confidence interval (CI) 0.814-0.982 per 1 point increase; p = 0.012]. Low NRI was associated with a significantly higher use of loop diuretics [odds ratio (OR) 2.75; 95% CI 1.046-5.647; p = 0.004] and significantly lower use of beta blockers (OR 0.541; 95% CI 0.319-0.988; p = 0.002). Malnutrition assessed using the NRI was associated with cardiovascular events in the patients with severe systolic HF with low cardiac output and high LV filling pressure. Low NRI was associated with more diuretic and less beta blocker use.

Abstract 16124: Implantable Cardioverter Defibrillators in Patients With Hereditary Transthyretin Cardiac Amyloidosis

Introduction: Implantable cardioverter defibrillator (ICD) implantation in patients with cardiac amyloidosis is controversial, with no clear guidelines for clinical decision-making.. The role of ICD implantation in hereditary Transthyretin Amyloid Cardiomyopathy (hATTR-CM) is unclear. We sought to establish the burden of ventricular arrhythmias and the outcomes of ICD implantation in a single center cohort of hATTR-CM patients. Methods: A total of 69 patients with a confirmed diagnosis of hATTR-CM from genetic testing, and technetium pyrophosphate (PYP) scanning, or endomyocardial biopsy underwent retrospective chart review for demographic, clinical, and arrhythmia data. Results: Seventy-four percent of the cohort was male, with a mean age at diagnosis of 68 (SD=18 years). Sixty-five patients (94.2%) patients were African-American; all of whom carried the Valine 122 Isoleucine mutation. Most had systolic heart failure (New York Heart Association Staging II [18, 26%] and III [40, 58.8%]); 37 (54%) patients had an LVEF ≤ 35%. Thirty-six (52.2%) patients had documented episodes of non-sustained ventricular tachycardia (NSVT), three (4.3%) with ventricular tachycardia (VT), and one (1.5%) with ventricular fibrillation (VF). A total of 15 (21.7%) patients had ICDs placed for prevention of sudden cardiac death in the setting of low LVEF (EF &lt;35%). All recorded VT/VF episodes occurred in three patients with ICDs. Of these patients, one experienced two episodes of VT each successfully abated by antitachycardia pacing (ATP), another experienced a single episode of VT abated by ATP, while the final experienced VF with successful 36J shock as well as two episodes of VT each successfully treated with 36J shocks. No inappropriate ICD shocks were delivered, however, there were two instances of ATP for inappropriately detected atrial arrhythmias. Conclusions: In a cohort of patients with hATTR-CM, we observed a high incidence of NSVT, yet only 41% of patients with severe systolic heart failure had ICDs implanted. A high rate of successful defibrillation and no inappropriate ICD shocks were noted, suggesting that ICDs should be strongly considered, and may be underutilized, in patients with systolic heart failure and/or arrhythmias in the setting of hATTR-CM.

Objective Evidence of Pulsus Alternans by Echocardiography in Acute Severe Heart Failure

Acute coronary syndrome may leads to heart failure. Severity of heart failure is identified by NYHA classification clinically. Color Doppler echocardiography is the key investigation to identify the acute systolic heart failure. For the quantification of systolic heart failure diagnosis, Ejection fraction (EF) can be measured by Simpson method. EF &gt; 30% is defined as severe systolic heart failure. Pulsus alternans is found in severe heart failure patients. Pulsus alternans is a poor prognostic sign of severe heart failure patients in acute MI setting. This cross sectional observation study was aimed to identify the objective evidence of Pulsus alternance noninvasively by Echocardiography. Color Doppler echocardiography was done 100 acute coronary syndrome with heart failure NYHA III and IV patients in department of Cardiology, BSMMU, from July 2018 to June 2019. Age 18 to 70 yrs, male is 79 and female is 21. Pulsus alternans was found in 32 patients, 39 had low volume and 29 had normal volume pulse. 50% patients had ST depression and T inversion and diagnosed as case of Unstable Agina or Non STEMI, 44 had STEMI and 7 had developed new onset of LBBB. 87 Patients who have EF &lt; 30 % was marked as Severe LV systolic dysfunction. Among them, 3 had mild, 14 had moderate and rest 70 had severe Mitral regurgitation. 38 (43.67%) patients had Doppler alternans in severe LV systolic dysfunction group. P value for Doppler alternans is 0.039 which is significant. Doppler alternans by Echocardiography in Severe LV systolic dysfunction patients showed 49% sensitivity and 78% specificity. 38 patients had Severe RV systolic dysfunction by M- mode echo measurement of TAPSE&lt;10 mm. 22 (57.89%) had Doppler alternans across Tricuspid valve in case of severe RV systolic dysfunction. Sensitivity of Doppler alternans by Doppler Echocardiography in TV severe RV systolic dysfunction is 51% and specificity for it is 82%.&#x0D; University Heart Journal Vol. 16, No. 2, Jul 2020; 92-98

A Case Report of a Young Pregnant Woman with Preeclampsia and Acute Pulmonary Edema in Severe Transient Heart Failure

Introduction: Young pregnant woman (32 weeks) following one-month illnessesm, including peripheral edema, paresthesia and shortness of breath, for which no specific diagnosis was made in the evaluations; she was hospitalized with severe respiratory distress and pulmonary edema. Re-examination revealed severe systolic heart failure (left ventricular ejection fraction: 10-15%) with preeclampsia. After the relative stabilization of the patient's vital signs, the pregnancy was terminated. One week after termination of pregnancy, the patient's heart failure improved.

Mechanical Circulatory Support for Biventricular Heart Failure Using Advanced Ventricular Assist Device

In patients with severe biventricular heart failure (HF) and cardiogenic shock, use of biventricular assist device (BVAD) can be a treatment of choice. We are developing an advanced ventricular assist device (AVAD) intended to serve as universal pump for left and/or right heart failure (Fig.1 A,B). The purpose of this initial in silico simulation study was to demonstrate that AVAD design can be suitable for biventricular support. The virtual mock loop (VML) was developed (MATLAB; MathWorks®) to simulate hemodynamic parameters as they surge through the BVAD-supported systolic HF cardiovascular system. The AVAD used as in BVAD configuration was in 2 speeds (3400 rpm left, 2000 rpm right) to get comparable systemic flow and pressure outputs. LVAD support was adjusted to maintain 5.0 L/min total systemic flow. For BVAD, the added RVAD support was adjusted to maintain left and right atrial pressure (LAP-RAP) at 3-5 mm Hg. The BVAD performance was maintained very well for both left ventricular (L-AVAD) and right ventricular (R-AVAD) support within specified speed range (Fig1 C,D). L- AVAD speed of 3000 - 3500 rpm provided sufficient support for the case of severe left and right systolic heart failure, assuming there was no aortic valve regurgitation. At the simulated condition, with L-AVAD support, the aortic valve remains closed and the systemic pressure has reduced pulse. A stable hemodynamics were maintained. The atrial pressure difference (LAP-RAP) resulted to be sensitive to the right pump speed, though was balanced whenever there was any positive flow through the pulmonary valve. Introduction of R-AVAD support to the L-AVAD support caused the left atrial pressure to increase resulting in increased filling of the left ventricle and a corresponding increase in aortic pulsatility. These initial in silico study demonstrated that use of the universal AVAD as BVAD supports cardiac output and arterial pressure in biventricular HF condition.

Fatal arrhythmias despite early recognized successful treatment of digoxin toxicity

Introduction: Digoxin is used to treat severe systolic heart failure and atrial fibrillation. Due to its narrow therapeutic window, toxicity has been well documented. Prompt treatment with the reversal agent, Digoxin Immune Fab is required in cases of digoxin toxicity to decrease mortality. However, little is known regarding the sequela following immediate successful reversal of toxicity. We report the case of a patient who developed potentially fatal ventricular arrhythmias following early recognized successful treatment of digoxin toxicity with Digoxin Immune Fab. Case Report: We report a case of a 69-year-old man with a history of systolic heart failure and atrial fibrillation who presented with altered mental status and gait instability. Polypharmacy was first considered; hence his medications were discontinued, or dose adjusted. Normal pressure hydrocephalus was another diagnosis considered. However, when laboratory data revealed elevated potassium of 5.2 mmol/L, acute kidney injury, elevated serum digitalis at 2.6 ng/mL, prompt diagnosis of digoxin toxicity was made. Digoxin Immune Fab was administered with immediate improvement of patient’s symptoms and labs. However, he experienced runs of ventricular tachycardia and supraventricular tachycardia with aberrancy in the days following. The patient then had further cardiac work-up requiring transfer to a tertiary care center for an ablation procedure. Conclusion: While arrhythmias associated with digoxin toxicity have been well documented, little is known of delayed arrhythmias following the use of a reversal agent. We report a rare case of potentially fatal delayed ventricular arrhythmias after early recognized successful treatment of digoxin toxicity with Digoxin Immune Fab.

Ventricular Dyssynchrony is Associated with Worse Left Ventricular Ejection Fraction Trajectories in Severe Decompensated Systolic Heart Failure

Introduction Increased QRS duration (QRSd) and left ventricular dyssynchrony are associated with worse outcomes in heart failure (HF). The implication of QRSd on left ventricular ejection fraction (LVEF) trajectories among patients with severe decompensated systolic HF is unclear. Methods Patients hospitalized with HF between 2014-2018 with an LVEF ≤ 35% and at least two echocardiograms with LVEF assessments were included. Patients received guideline-directed medical and device therapies. Survival was assessed for up to 4 years after the index admission. LVEF trajectory was defined as the difference between the lowest LVEF and the highest LVEF, multiplied by -1 if the lowest LVEF was more recent than the highest LVEF. Linear regression was used to evaluate the association between LVEF trajectory and QRSd, and logistic regression was used to assess survival based on QRSd and LVEF trajectory. Results Among 1,674 patients (65.3 ± 14.2 years, 35.9 % female), 39% had QRSD > 120 ms. The lowest LVEF was 26.7% ± 9.7%, the highest LVEF was 45.5% ± 14.5%, and the LVEF trajectory had a median of 5% with an interquartile range of -10% to +25%. The frequency of QRSd less than 120 ms, 120-149 ms, and greater than or equal to 150 ms were 60.5%, 20.5%, and 19.5% respectively. Increasing QRSd was associated with more negative LVEF trajectories (r = -0.24, p Conclusions Increasing QRS duration in HF is associated with worsening LVEF trajectories and increased mortality despite contemporary guideline-directed medical and device therapy. The effect of QRS duration on survival appears to be mediated both by its impact on LVEF trajectory and mechanisms independent of the LVEF trajectory.

Heart diseases and echocardiography in rural Tanzania: Occurrence, characteristics, and etiologies of underappreciated cardiac pathologies.

BackgroundLittle is known about heart diseases and their treatment in rural sub-Saharan Africa. This study aimed to describe the occurrence, characteristics, and etiologies of heart diseases, and the medication taken before and prescribed after echocardiography in a rural referral Hospital in Tanzania.MethodsThis prospective descriptive cohort study included all adults and children referred for echocardiography. Clinical and echocardiographic data were collated for analysis.ResultsFrom December 2015 to October 2017, a total of 1’243 echocardiograms were performed. A total of 815 adults and 59 children ≤15 years had abnormal echocardiographic findings; in adults 537/815 (66%) had hypertension, with 230/537(43%) on antihypertensive drugs, and 506/815 (62%) were not on regular cardiac medication; 346/815 (42%) had severe eccentric or concentric left ventricular hypertrophy, and 182/815 (22%) had severe systolic heart failure. Only 44% demonstrated normal left ventricular systolic function. The most frequent heart diseases were hypertensive heart disease (41%), valvular heart disease (18%), coronary heart disease (18%), peripartum cardiomyopathy (7%), and other non-hypertensive dilated cardiomyopathies (6%) in adults, and congenital heart disease (34%) in children. Following echocardiography, 802/815 (98%) adults and 40/59 (68%) children had an indication for cardiac medication, 70/815 (9%) and 2/59 (3%) for oral anticoagulation, and 35/815 (4%) and 23/59 (39%) for cardiac surgery, respectively.ConclusionHypertension is the leading etiology of heart diseases in rural Tanzania. Most patients present with advanced stages of heart disease, and the majority are not treated before echocardiography. There is an urgent need for increased awareness, expertise and infrastructure to detect and treat hypertension and heart failure in rural Africa.