Significant Increase In Left Ventricular Ejection Fraction Research Articles

Aldosterone Antagonist Therapy and Mortality in Patients With ST-Segment Elevation Myocardial Infarction Without Heart Failure

Treatment with aldosterone antagonists is recommended and has been shown to have beneficial effects in patients with ST-segment elevation myocardial infarction (STEMI) and left ventricular ejection fraction (LVEF) less than 40%. However, the role of aldosterone antagonists in patients with ejection fraction greater than 40% or without congestive heart failure is not well known. To perform a systematic review and meta-analysis using standard techniques to determine the role of therapy with aldosterone antagonists in this patient population. PubMed, Embase, CINAHL, and Cochrane Central databases were searched and a manual search for relevant references from the selected articles and published reviews was performed from database inception through June 2017. Randomized clinical trials that evaluated treatment with aldosterone antagonists in patients with STEMI without clinical heart failure or LVEF greater than 40% were included. Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to conduct and report the meta-analysis, which used a random-effects model. Two investigators independently performed the database search and agreed on the final study selection. A manual search was performed for relevant references from the selected articles and published reviews. The outcomes analyzed were mortality, new congestive heart failure, recurrent myocardial infarction, ventricular arrhythmia, and changes in LVEF, serum potassium level, and creatinine level at follow-up. In all, 10 randomized clinical trials with a total of 4147 unique patients were included in the meta-analysis. In patients who presented with STEMI without heart failure, treatment with aldosterone antagonists compared with control was associated with lower risk of mortality (2.4% vs 3.9%; odds ratio [OR], 0.62; 95% CI, 0.42-0.91; P = .01) and similar risks of myocardial infarction (1.6% vs 1.5%; OR, 1.03; 95% CI, 0.57-1.86; P = .91), new congestive heart failure (4.3% vs 5.4%; OR, 0.82; 95% CI, 0.56-1.20; P = .31), and ventricular arrhythmia (4.1% vs 5.1%; OR, 0.76; 95% CI, 0.45-1.31; P = .33). Similarly, treatment with aldosterone antagonists compared with control was associated with a small yet significant increase in LVEF (mean difference, 1.58%; 95% CI, 0.18%-2.97%; P = .03), a small increase in serum potassium level (mean difference, 0.07 mEq/L; 95% CI, 0.01-0.13 mEq/L; P = .02), and no change in serum creatinine level (standardized mean difference, 1.4; 95% CI, -0.43 to 3.24; P = .13). Treatment with aldosterone antagonists is associated with a mortality benefit in patients with STEMI with LVEF greater than 40% or without heart failure.

One-year outcomes of concomitant mitral reduction annuloplasty repair with coronary artery bypass grafting for moderate ischemic mitral regurgitation

BackgroundMitral valve repair for chronic ischemic mitral regurgitation (IMR) in the published literature has contradictory outcomes. Here, we report our center outcomes of reduction annuloplasty technique in addition to myocardial revascularization to treat ischemic IMR over a four-year period. MethodsBetween January 2011 and December 2014, a total of 40 patients were identified to have a reduced left ventricular ejection fraction who underwent first-time mitral valve reduction annuloplasty concomitantly with coronary artery bypass grafting to treat moderate IMR. Variations in left ventricular end-systolic volume index (LVESVI), left ventricular ejection fraction (LVEF), functional class, and mitral regurgitation (MR) was followed up after surgery and retrospectively analyzed. ResultsIn our cohort, mitral reduction annuloplasty was successful in helping 33 (82%) patients to have no residual MR and to downgrade their MR from moderate (grade 3+) to trace (grade 1+) in 7 (18%) patients before leaving the operating room. A change from baseline value was observed secondary to correction of MR. At 3-months follow-up time; the mean MR grade that was 0.2 ± 0.1 by the intraoperative assessment post-bypass has increased significantly to be 1.8 ± 0.4 (p < 0.05). Similarly, at one year after surgery it increased to 1.9 ± 0.3, p < 0.05, compared to baseline value.Remarkably, our patients showed a significant increase in the mean LVEF (48 ± 1.1%, p < 0.05), at 3-month visit and 1-year visit post-surgery (47 ± 4.2%), %, p < 0.05) compared to the baseline values (39 ± 2.3%, p < 0.05 for both visits). While our patients showed gradually but non-significantly reduction in the mean LVESVI (57.6 ± 9.0 ml/m2, p > 0.05) at early follow-up time, mean LVESVI improved significantly to be 47.6 ± 11.0 ml/m2, p < 0.05 at the one year. This statistically significant increase in the LVEF% at 3-month visit, in addition to the reduction in the LVESVI after one year were capable to induce substantial clinical change in NYHA functional class, which was observed early (at 3-month visit) where 35 (88%) patients became in NYHA class I and II and later (at 1-year visit post-surgery) where 32 (80%) patients stayed in NYHA class I and II.No deaths were reported during the one-year follow-up resulting in 95% survival rate. During the one-year follow-up time, 7 (18%) were readmitted to the hospital due to non-cardiac indications.Early operative mortality (within 30 days after surgery) was 5%. One-year survival was 95%. The mean duration of follow-up was 1.1 ± 2.4 years (range, 1.0–3.5 years). ConclusionsMitral reduction annuloplasty concomitant to surgical myocardial revascularization may be sufficient to correct moderate IMR. It is associated with substantial improvement in early and intermediate-term survival rates, left ventricular functions, NYHA class and low incidence of recurrent MR.

Effects of Home Mechanical Ventilation on Left Ventricular Function in Sarcoglycanopathies (Limb Girdle Muscular Dystrophies)

Cardiac and respiratory function may be impaired in sarcoglycanopathies, a subgroup of muscular dystrophies due to sarcoglycan proteins (α, β, γ, and δ) genes mutations. Management of patients with restrictive respiratory failure mainly relies on home mechanical ventilation (HMV). Little is known about the cardiac effects of prolonged mechanical ventilation in patients with muscular dystrophy and restrictive respiratory insufficiency. We aimed to assess the effects of HMV on cardiac function in sarcoglycanopathies. We retrospectively included 10 genetically proven patients with sarcoglycanopathy followed at the HMV unit of the Raymond Poincare University Hospital (4 patients with α-sarcoglycanopathy and 6 patients with γ-sarcoglycanopathy). We collected cardiorespiratory clinical baseline data and left ventricular ejection fraction (LVEF) at baseline before initiation of HMV and at the end of follow-up. At baseline, median age was 30.5 years (27 to 39) and median pulmonary vital capacity was 27% of the predicted value (21 to 36). Forty percent of the patients had documented sleep apnea. Cardiomyopathy, defined as LVEF <50%, was found in 3 patients with γ-sarcoglycanopathy. After a median follow-up of 3 years (1.0 to 4.5), there was a significant increase in LVEF after initiation of HMV, that is, 62% (48 to 65) versus 53% (45.5 to 56.5) (p = 0.0039). In conclusion, HMV in sarcoglycanopathies is not harmful and may protect left ventricular function by its thoracic physiological effects.

Predictive value of cardiac magnetic resonance-derived parameters on the improvement of left ventricular function in patients with acute viral myocarditis

Objective: To evaluate the predictive value of cardiac magnetic resonance (CMR)-derived parameters on the improvement of left ventricular function in patients with acute viral myocarditis. Methods: Forty patients, who referred for acute viral myocarditis in our hospital from September 2011 to September 2015, were prospectively enrolled in this study.All patients were examined by CMR during hospitalization for acute viral myocarditis (baseline) and after 12 months.The CMR sequences include: two dimension steady state free precession, 2D SSFP; triple inversion recovery, triple IR; early gadolinium enhancement; phase sensitive inversion recovery turbo field echo, PSIR TFE. Results: Thirty out of 40 patients with susceptive acute viral myocarditis met the CMR criteria of acute viral myocarditis (Lake Louise Criteria) (LL+ ) and the other 10 patients did not meet the diagnostic criteria (LL-). Left ventricular ejection fraction (LVEF) values were significantly lower in LL+ group than in LL- group at baseline and at 12 months after discharge (P<0.01 or 0.05, respectively). The baseline left ventricular end-systolic volume index (LVESVI) was significantly higher in LL+ group than in LL- group (P<0.05) and was similar between the groups at 12 months follow up.Left ventricular end-diastolic volume index (LVEDVI )was similar between the two groups at baseline and at 12 months follow up.LVEF was significantly higher during 12 months follow up compared to baseline in LL+ group and remained unchanged in LL- group during the two time points.LVESVI and LVEDVI remained unchanged at baseline and during 12 months follow up both in LL+ and LL- groups (P>0.05). Results showed that LL+ , edema ratio (ER) positive and global relative enhancement (gRE) positive were associated with significant increase of LVEF at 12 months follow up.However, LL-, ER negative, gRE negative, late gadolinium enhancement(LGE) negative and LGE positive linked with unchanged LVEF at 12 months follow up (P>0.05). Patients were further divided into LVEF increase (ΔLVEF≥5%) group and non LVEF increase group (ΔLVEF<5%), the results of Chi-square test showed that LL+ and ER positive were related to the improvement of LVEF (P<0.05), while gRE and LGE were not associated with improvement of cardiac function (P>0.05). Multiple linear regression analysis, using ER, gRE and LGE as independent variables and LVEF as dependent variables, showed that the presence of myocardial edema was the strongest independent predictor of an increase in LVEF at follow up (full model: non-standardized coefficient 0.445, P=0.043; reduced model: non-standardized coefficient 0.442, P=0.12). Conclusion: Cardiac magnetic resonance imaging monitoring is valuable to observe the cardiac function and morphology changes in patients with acute viral myocarditis, and myocardial edema imaging is the most powerful parameter to predict the improvement of LVEF in this patient cohort.

Cardiovascular Effects of Continuous Positive Airway Pressure Treatment in Patients With Obstructive Sleep Apnea: A Meta-Analysis.

Continuous positive airway pressure (CPAP) is the first-line treatment of obstructive sleep apnea (OSA). Obstructive sleep apnea is a predictor of cardiovascular (CV) events. In this meta-analysis, we evaluated the effect of CPAP on left ventricular ejection fraction (LVEF), CV events, CV mortality, and all-cause mortality in patients with OSA. Nine articles (n = 9610 patients) were analyzed. Four different meta-analyses were performed: evaluation of LVEF, assessment of all-cause mortality, CV mortality, and CV events. Continuous positive airway pressure treatment was associated with a significant increase in LVEF (mean difference: 2.1%, 95% confidence interval [CI]: 0.8%-3.4%). There was a nonsignificant reduction in all-cause mortality (hazard ratio [HR]: 0.92, 95% CI: 0.73-1.15) but a significant reduction of 66% in the risk of CV mortality associated with the CPAP treatment (HR: 0.34, 95% CI: 0.17-0.68, P = .002). There was a nonsignificant reduction in the risk of CV events in the CPAP-treated patients (HR: 0.84, 95% CI: 0.60-1.18, P = .31). Our meta-analyses showed that CPAP treatment improves LVEF and could have a beneficial effect on CV mortality.

Rational transplant timing and dose of mesenchymal stromal cells in patients with acute myocardial infarction: a meta-analysis of randomized controlled trials

BackgroundMesenchymal stromal cells (MSCs) are considered to have a modest benefit on left ventricular ejection fraction (LVEF) in patients with acute myocardial infarction (AMI). However, the optimal injection timing and dose needed to induce beneficial cardiac effects are unknown. The purpose of this meta-analysis was to identify an optimal MSC transplantation time and cell dose in the setting of AMI to achieve better clinical endpoints.MethodsThe authors conducted a systematic review of studies published up to June 2016 by searching PubMed, EMBASE, MEDLINE, and the Cochrane Library for relevant randomized controlled trials (RCTs).ResultsEight prospective RCTs with 449 participants were included. The pooled results revealed that patients in the MSC group had no significant increase in LVEF from baseline compared with that in the control group (1.47% increase, 95% confidence interval (CI) −4.5 to 7.45; I2 = 97%; P > 0.05). A subgroup analysis was conducted to explore the results according to differences in transplantation time and dose of MSCs injected. For transplantation timing, the LVEF of patients accepting a MSC infusion within 1 week was significantly increased by 3.22% (95% CI 1.31 to 5.14; I2 = 0; P < 0.05), but this increase was insignificant in the group that accepted an MSC infusion after 1 week (−0.35% in LVEF, 95% CI −10.22 to 9.52; I2 = 99%; P > 0.05). Furthermore, patients accepting a MSC dose of less than 107 cells exhibited an LVEF improvement of 2.25% compared with the control (95% CI 0.56 to 3.93; I2 = 9%; P < 0.05). Combining transplantation time and cell dose indicates that a significant improvement of LVEF of 3.32% was achieved in the group of patients injected with <107 MSCs within 1 week (95% CI 1.14 to 5.50; I2 = 0; P = 0.003).ConclusionsTransplantation time and injected cell dose are key factors that determine the therapeutic effect of stem cell therapy. The injection of no more than 107 MSCs within 1 week for AMI after percutaneous coronary intervention might improve left ventricular systolic function. Further studies on the mechanism and the effectiveness of MSCs for long-term therapy are warranted.

Meta-analyses and randomized trials investigating percutaneous coronary intervention of chronic total occlusions: what is left to explore?

The field of percutaneous coronary intervention of coronary chronic total occlusions (CTO PCI) is highly dynamic. This is mainly illustrated by the large number of technical advances that have propelled success rates of CTO PCI from 60–70% to as high as >90% in recent (selected) case series (1). However, the rationale for performing CTO PCI is currently largely based on observational data and untested hypotheses. Observational studies have suggested a reduction in the need for coronary artery bypass graft surgery (CABG), a reduced incidence of ventricular arrhythmias, and even reduced mortality after successful CTO PCI (2-6). Further hypothesis-generating research was recently published by our group in the form of a meta-analysis of observational studies investigating the evolution of left ventricular ejection fraction (LVEF) and left ventricular end diastolic volume (LVEDV) after CTO PCI (7). This study indicated a significant increase in LVEF of 4.44% [95% confidence interval (CI): 3.52–5.35%, P<0.01] after successful CTO PCI at a follow-up duration ranging from 1 to 36 months in 34 studies which included a total of 2,243 patients. Moreover, LVEDV was reduced by 6.14 mL/m2 in a meta-analysis of eight studies comprising 412 patients that evaluated LVEDV after successful CTO PCI.

Impact of age and sex on left ventricular function determined by coronary computed tomographic angiography: results from the prospective multicentre CONFIRM study.

Left ventricular (LV) volumetric and functional parameters measured with cardiac computed tomography (cardiac CT) augment risk prediction and discrimination for future mortality. Gender- and age-specific standard values for LV dimensions and systolic function obtained by 64-slice cardiac CT are lacking. 1155 patients from the Coronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter registry (54.5% males, mean age 53.1 ± 12.4 years, range: 18-92 years) without known coronary artery disease (CAD), structural heart disease, diabetes, or hypertension who underwent cardiac CT for various indications were categorized according to age and sex. A cardiac CT data acquisition protocol was used that allowed volumetric measuring of LV function. Image interpretation was performed at each site. Patients with significant CAD (>50% stenosis) on cardiac CT were excluded from the analysis. Overall, mean left ventricular ejection fraction (LVEF) was higher in women when compared with men (66.6 ± 7.7% vs. 64.6 ± 8.1%, P < 0.001). This gender-difference in overall LVEF was caused by a significantly higher LVEF in women ≥70 years when compared with men ≥70 years (69.95 ± 8.89% vs. 65.50 ± 9.42%, P = 0.004). Accordingly, a significant increase in LVEF was observed with age (P = 0.005 for males and P < 0.001 for females), which was more pronounced in females (5.21%) than in males (2.6%). LV end-diastolic volume decreased in females from 122.48 ± 27.87 (<40 years) to 95.56 ± 23.17 (>70 years; P < 0.001) and in males from 155.22 ± 35.07 (<40 years) to 130.26 ± 27.18 (>70 years; P < 0.001). Our findings indicate that the LV undergoes a lifelong remodelling and highlight the need for age and gender adjusted reference values.

Effect of stimulating the auricular branch of the vagus nerve on the heart rate in patients with severe chronic heart failure

A study was made to evaluate the prospects of improving the cardiac function by electrical stimulation of the auricular branch of the vagus nerve in patients with severe chronic heart failure (CHF). Sympathetic hyperactivity and the cardiac function were evaluated by 24-hour ECG monitoring, echocardiography, and a 6-min walk test. At the time of enrollment into the study, patients had a heart rate (HR) of more than 60 bpm, a left ventricular (LV) ejection fraction (EF) of less than 40%, and CHF NYHA functional class (FC) III or IV even with well tolerated medications. Control-group patients (n = 7) did not show significant changes in the functional state of the heart after sham treatment. In the test group (n = 44), a significant increase in LV EF and a decrease in end-systolic volume were induced by electrical pulse stimulation of the auricular branch. A decrease in HR was documented in 34 patients; CHF FC decreased by one or two grades in 40 patients. The changes were assumed to reflect new balance achieved in the autonomic regulation of the heart to contribute to sustaining competence of the myocardium. Electrical pulse stimulation of the auricular branch of the vagus nerve was concluded to provide a safe and efficacious addition to drug therapy in patients with severe CHF.

The Effect of Cardiac Rehabilitation Exercise Training on Cardiopulmonary Function in Ischemic Cardiomyopathy With Reduced Left Ventricular Ejection Fraction.

ObjectiveTo observe the effect and safety of cardiac rehabilitation (CR) exercise in ischemic cardiomyopathy and to compare the results between patients with preserved left ventricular ejection fraction (LVEF) and reduced LVEF.MethodsPatients with ischemic cardiomyopathy with LVEF <50% were included as subjects. The patients were classified into the preserved LVEF (pLVEF; LVEF 41%–49%) group and the reduced LVEF (rLVEF; LVEF ≤40%) group. Patients underwent hourly aerobic exercise training sessions with an intensity of 60%–85% of heart rate reserve, three times a week for 6 weeks. Graded exercise test and transthoracic echocardiogram were performed in all study patients before and after completion of the CR exercise program.ResultsAfter completion of the CR exercise program, both groups (pLVEF, n=30; rLVEF, n=18) showed significant increases in LVEF and VO2max. In the pLVEF group, LVEF and VO2max increased from 45.1%±4.8% to 52.5%±9.6% (p<0.001) and from 24.1±6.3 to 28.1±8.8 mL/kg/min (p=0.002), respectively. In the rLVEF group, LVEF and VO2max increased from 29.7%±7.7% to 37.6%±10.3% (p<0.001) and from 17.6±4.7 to 21.2±5.1 mL/kg/min (p<0.001), respectively. Both groups completed their exercise program safely.ConclusionIn both groups, patients with ischemic cardiomyopathy who completed a 6-week supervised CR exercise program demonstrated remarkable improvements in cardiopulmonary function. This result implies that neither of the two groups showed higher efficacy in comparison to each other, but we can conclude that CR exercise in the rLVEF group was as effective and safe as that in the pLVEF group.

Late deterioration of left ventricular function after right ventricular pacemaker implantation.

Objectives:Right ventricular (RV) pacing induces a left bundle branch block pattern on ECG and may promote heart failure. Patients with dual chamber pacemakers (DCPs) who present with progressive reduction in left ventricular ejection fraction (LVEF) secondary to RV pacing are candidates for cardiac resynchronization therapy (CRT). This study analyzes whether upgrading DCP to CRT with the additional implantation of a left ventricular (LV) lead improves LV function in patients with reduced LVEF following DCP implantation.Methods:Twenty-two patients (13 males) implanted with DCPs and a high RV pacing percentage (>90%) were evaluated in term of new-onset heart failure symptoms. The patients were enrolled in this retrospective single-center study after obvious causes for a reduced LVEF were excluded with echocardiography and coronary angiography. In all patients, DCPs were then upgraded to biventricular devices. LVEF was analyzed with a two-sided t-test. QRS duration and brain natriuretic peptide (BNP) levels were analyzed with the unpaired t-test.Results:LVEF declined after DCP implantation from 54±10% to 31±7%, and the mean QRS duration was 161±20 ms during RV pacing. NT-pro BNP levels were elevated (3365±11436 pmol/L). After upgrading to a biventricular device, a biventricular pacing percentage of 98.1±2% was achieved. QRS duration decreased to 108±16 ms and 106±20 ms after 1 and 6 months, respectively. There was a significant increase in LVEF to 38±8% and 41±11% and a decrease in NT-pro BNP levels to 3088±2326 pmol/L and 1860±1838 pmol/L at 1 and 6 months, respectively.Conclusion:Upgrading to CRT may be beneficial in patients with DCPs and heart failure induced by a high RV pacing percentage.

Long-Term Recovery of Reduced Left Ventricular Ejection Fraction after Aortic Valve Replacement in Patients with Bicuspid Aortic Valve Disease

Background Long-term prognosis of patients with bicuspid aortic valve (BAV) disease and poor left ventricular ejection fraction (LVEF) who underwent aortic valve replacement (AVR) is unknown. We aimed to analyze the recovery of LVEF and incidence of adverse events after AVR in patients with BAV and poor LVEF. Materials and Methods A total of 90 consecutive BAV patients (mean age 57 ± 10 years, 89% male) with baseline LVEF ≤40% underwent an isolated AVR between January 1, 1995, and June 30, 2008, and served as our study population. Follow-up data (800 patient-years) were obtained for all 90 hospital survivors. A subgroup of patients who underwent AVR for BAV stenosis (Group aortic stenosis [AS], n = 70) was compared with those who underwent AVR for BAV regurgitation (Group aortic regurgitation [AR], n = 20). Primary end point was the recovery of LVEF in AS Group versus AR Group. Secondary end points were survival and freedom from adverse cardiac events (i.e., cardiac-related death and need for reinterventions due to persisting heart failure). Results There was a significant increase in LVEF (mean follow-up 9.0 ± 5 years) in AS versus AR Group (i.e., 32 ± 7% [baseline] and 53 ± 9% [follow-up], p < 0.001 in AS Group vs. 33 ± 7% [baseline] and 38 ± 13% [follow-up], p = 0.07 in AR Group). Recovery rate of LVEF was significantly higher in AS Group versus AR Group (i.e., 2.8 percentage points (pp)/year vs. 0.7 pp/year, respectively). In Group AS, 86% of patients were responders, whereas in Group AR, only 30% (p < 0.001). The subjects in Group AR did not show a difference between baseline and follow-up left ventricular end-diastolic diameter (LVEDD) (baseline 61 ± 12 vs. follow-up 58 ± 8, p = 0.813), whereas in Group AS, there was a significant difference of LVEDD (baseline 56 ± 7 vs. follow-up 54 ± 6 mm, p = 0.019). Ten-year survival was 76 ± 6.5% in AS Group versus 78 ± 11% in AR Group (p = 0.3). Prevalence of late adverse cardiac events was 7% in AS Group versus 40% in AR Group (p = 0.03). Conclusion The recovery of reduced LVEF after AVR surgery is significantly impaired in patients with BAV regurgitation as compared with BAV stenosis.

Autonomic modulation for the management of patients with chronic heart failure.

Dysregulation of the autonomic nervous system in heart failure (HF) has received considerable attention during the past 3 decades, largely because of the well-recognized association between increased sympathetic activity and the elaboration of biologically active molecules, collectively referred to as neurohormones, that help to maintain cardiovascular homeostasis through increased volume expansion, peripheral arterial vasoconstriction, and increased myocardial contractility. However, high and sustained levels of these biologically active molecules (eg, norepinephrine, angiotensin II, aldosterone) are overtly toxic to the heart and circulation.1 These and other insights have led to the clinical use of neurohormonal antagonists, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone antagonists, and β-blockers to treat patients with HF with a reduced left ventricular ejection fraction (LVEF).1 The effectiveness of these pharmacological agents is predominantly because of their ability to directly antagonize the deleterious effects of excessive sympathetic and renin–angiotensin activation. However, the current guideline-directed medical therapy (GDMT) in patients with HF fails to completely restore normal autonomic balance disrupted as a part of HF pathophysiology. During the last decade, a novel approach has generated widespread interest: modulation of the autonomic nervous system as a result of either a one-time intervention (eg, denervation) or of ongoing active therapy (eg, electric stimulation) as a means of further diminishing the sympathovagal imbalance that develops in HF.2,3 Of note, therapeutic neuromodulation with device-based therapies, either with spinal cord stimulation (SCS) or vagal stimulation (VS), has been used safely in patients with chronic pain, epilepsy, and depression, since the 1980s. As noted above, HF with a reduced LVEF is associated with sustained activation of the sympathetic nervous system that is accompanied by a withdrawal of parasympathetic tone. Impaired arterial baroreflexes have been proposed as an important mechanism that contributes to the sympathovagal imbalance present in HF4 …

Impact of transcatheter aortic valve implantation in patients with reduced ejection fraction.

Aortic stenosis increases with age. According to guidelines, left ventricular systolic dysfunction is an indication for aortic valve replacement, even in asymptomatic patients. There is no clear data on the application of transcatheter aortic valve implantation (TAVI), which is a method showing continuous improvement in recent years, in patients with reduced ejection fraction (REF) having a poor prognosis for surgical aortic valve replacement. We therefore aimed to investigate the effect of TAVI on left ventricular ejection fraction (LVEF) and also its efficacy and safety in patients with REF. The study included 104 patients who underwent transfemoral TAVI in our clinic. The patients were divided into two groups: LVEF ≤ 45% (REF group, n = 28) and LVEF > 45% (preserved ejection fraction [PEF] group, n = 76). Follow-up measurements were performed at baseline, discharge, 1st, 6th and 12th months. No statistical difference was found between the groups with respect to complications and mortality rates. A statistically significant difference was detected in LVEF after TAVI, either in all patients (53.9 ± 14.6, 57.0 ± 11.4, 59.4 ± 8.4, 60.4 ± 6.8, 63.2 ± 3.9, respectively, at baseline, discharge, 1st, 6th and 12th months, p < 0.001) or in the groups separately. A statistically significant increase in LVEF (p < 0.001) was determined at discharge, 1st, 6th and 12th months, whereas LVEF increased in all follow-ups of the PEF group, however this elevation reached a statistical significance only at the 1st month (p = 0.04). Our study has shown the positive effect of TAVI on LVEF and its effective and safe applicability in patients with REF.

Regional myocardial contractile reserve assessed by strain echocardiography and the response to cardiac resynchronization therapy

Overall response rate to cardiac resynchronization therapy (CRT) is still not optimal. The aim of the study was to evaluate the influence of the regional myocardial contractile reserve during dobutamine infusion in the area of left ventricular (LV) electrode on the response rate and reverse remodeling LV in patients receiving CRT. Biventricular pacemaker was implanted in 41 consecutive patients (33 men, mean age 62 ± 10 years) with LV ejection fraction (LVEF) ≤ 35%, New York Heart Association class III and QRS duration ≥ 120 ms. Myocardial contractile reserve was assessed by LV strain during dobutamine infusion (20 μg/kg/min) using speckle tracking echocardiography. Patients were classified as responders if an increase in LVEF ≥ 5% or decrease in end-systolic volume ≥ 15% was observed after 6 months of CRT. Twenty-four patients were responders and 17 were non-responders. During dobutamine infusion at a rate of 20 μg/kg/min, responders showed significant increase in regional deformation (Δ strain) when compared to non-responders (2.14 ± 2.9 vs. - 0.94 ± 1.74, p = 0.042). Patients with increased deformation in the LV lead area during dobutamine stimulation were more likely to be responders to CRT compared to patients without increased deformation in this area (81% vs. 20%, p = 0.0002). They exhibited significant increase in LVEF (8.8% ± 10.3% vs. 0.3% ± 6.4%, p = 0.01). LV electrode localization in viable myocardium was a good predictor of response to CRT (AUC 0.852, p < 0.0001). Regional contractile reserve assessed by strain rate echocardiography during dobutamine infusion predicts the response to CRT.

Addendum to 'Intraoperative CD133+ cell transplantation during coronary artery bypass grafting in ischemic cardiomyopathy'

In a recent article [1], we reported on a combination therapy of CABG, laser treatment and CD133+ cell transplantation, to treat chronic cardiac ischaemia, which has been examined for safety and feasibility in the multicentre INSTEM trial. In our previous publication, we have shown exemplary 2D echocardiographyderived left ventricular ejection fraction (LVEF) data from patients who had been included in the study early on in this trial. While this subset of patients presented an increase in LVEF from 25% preoperatively to 40% after 6 months, the final analysis after completion of the study, including all patients from all centres, resulted in an echocardiographic improvement from 27.7 ± 0.9% preoperatively to 37.6 ± 1.4% after 6 months (P < 0.001). While the endpoint-relevant evaluation assessed by magnetic resonance imaging (MRI) among all patients included in this trial did not reach the level of functional improvement as previously assessed by echocardiography in a smaller cohort, a significant increase in LVEF was confirmed (29.7 ± 1.9% after 6 months vs 24.6 ± 1.5% preoperatively; P = 0.004). The difference between the data in our previous publication and the final trial analysis can be explained by the different functional readout methods as well as by the larger number of patients finally included upon completion of the study. Since MRI is the gold standard for global and regional functional evaluation of ischaemic myocardium, we regard the data obtained by MRI as crucial to objectively assess the overall results in addition to the previous 2D echocardiography analysis.

Effects of Lipophilic Statins for Heart Failure: A Meta-analysis of 13 Randomised Controlled Trials

The effects of lipophilic statins in heart failure (HF) were controversial. The goal of the present study was to systematically review all randomised controlled trials evaluating the effects of lipophilic statins in patients with HF. We performed a comprehensive literature search to identify eligible trials that prospectively randomised patients with HF to lipophilic statins or control. Primary end points were all-cause mortality, cardiovascular mortality, hospitalisation for worsening HF, left ventricular ejection fraction (LVEF), and low-density lipoprotein cholesterol. Risk ratios (RRs) and Weighted mean differences (WMDs) were calculated using fixed-effects models or random-effects models. A total of 13 randomised trials with 1,532 subjects were included in this analysis. Ten trials randomised patients to atorvastatin, two to simvastatin, and one to pitavastatin. Overall, lipophilic statins significantly decreased all-cause mortality (RR 0.53, P<0.001), cardiovascular mortality (RR 0.66, P=0.04), and hospitalisation for worsening HF (RR 0.60, P<0.001). Subgroup analyses showed that the effects of lipophilic statins in HF were not modified by age, baseline LVEF, and cause of HF. In addition, patients randomised to lipophilic statins had a significant increase in LVEF (WMD 3.91%, P<0.001) and decrease in low-density lipoprotein cholesterol (WMD 0.90 mmol/L, P<0.001). It appears that further studies are needed to determine if lipophilic statins are beneficial for HF patients.

Frequency and Predictors of Normalization of Left Ventricular Ejection Fraction in Recent-Onset Nonischemic Cardiomyopathy

Emerging evidence has shown the potential of marked improvement in left ventricular ejection fraction (LVEF) in patients with recent-onset cardiomyopathy (ROCM) on medical therapy. This study was designed to determine the frequency and to identify predictors of normalization of LVEF in a cohort of Chinese patients with ROCM receiving contemporary medication. A consecutive series of patients admitted from October 2008 to November 2012 with the clinical diagnosis of ROCM and LVEF ≤ 40% by echocardiography at presentation were followed up at least 12 months to identify those with normalization of LVEF, defined as an increase in LVEF to a final level of ≥ 50%. An array of clinical and echocardiographic variables regarded as potentially relevant to normalization was evaluated to identify predictors using logistic regression analysis. After a mean follow-up of 31 ± 13 months, 48% of 128 patients had normalized their LVEF, showing a significant increase in LVEF from 32 ± 6% to 58 ± 5%, of which 68% occurred within 1 year after initial diagnosis. Multivariate analysis demonstrated that normalization of LVEF was associated with a history of hypertension, higher systolic blood pressure at presentation, shorter electrocardiographic QRS duration, smaller left ventricular end-diastolic diameter, and higher LVEF by echocardiography at baseline. In conclusion, nearly 1/2 of a relatively large number of Chinese patients with ROCM have shown normalization of LVEF on current medical therapy after a medium-term follow-up, which was associated with some clinical and echocardiographic parameters.

Meta-Analysis of Effects of Optimization of Cardiac Resynchronization Therapy on Left Ventricular Function, Exercise Capacity, and Quality of Life in Patients With Heart Failure

The contribution of postimplant optimization of device settings to the beneficial effect of cardiac resynchronization therapy (CRT) in heart failure is uncertain. We performed a meta-analysis to investigate the impact of CRT optimization on the improvement of left ventricular function, exercise capacity, and quality of life. We undertook a systemic review of the evidence from a search of relevant controlled clinical studies in the MEDLINE and EMBASE databases. Changes in left ventricular ejection fraction (LVEF), 6-minute walk distance, and Minnesota Living with Heart Failure score at follow-up were assessed; the primary outcome was ejection fraction. A random-effects model was used to combine weighted mean difference (WMD) and 95% confidence intervals (CIs). A metaregression was undertaken to assess the impact of potential covariates. Data were collated from 13 studies enrolling 1,431 patients (919 optimized and 669 controls). Pooled analysis demonstrated that the optimization procedure resulted in a significant increase in LVEF (WMD 2.6%, 95% CI 0.8 to 4.4, p = 0.001) as compared with a nonoptimized CRT. No improvements with the optimization of CRT were seen in 6-minute walk distance and quality of life (WMD 12 m, 95% CI 23 to 48, p = 0.49, and 3.6, 95% CI 2.2 to 9.5, p = 0.22, respectively); however, this part of the analysis was performed using limited data. Thus, these collated data suggest that the optimization of CRT leads to a significant but small improvement in LVEF in patients with heart failure. Additional, adequately powered studies are needed to evaluate the effects of this procedure on exercise tolerance and quality of life.

Age‐ and Gender‐Dependent Left Ventricular Remodeling

The effect of age and gender on left ventricular (LV) size, muscle mass, and systolic function as determined by two-dimensional echocardiography has not yet been investigated in a large population. Normal transthoracic two-dimensional echocardiography studies of 5307 subjects (47% males) performed between March 1990 and December 2011 were analyzed. LV end-diastolic volume index (LVEDVI), LV muscle mass index (LVMMI), LV ejection fraction (LVEF), and LV fractional shortening (LVFS) were compared in different age groups. LVMMI increased in females from 66.4±1.3g/m(2) (7-20years) to 76.3±0.9g/m(2) (60-80years; P<0.0001) and in males from 81.9±1.7g/m(2) (7-20years) to 94.6±1.3g/m(2) (60-80years; P<0.0001). LVEDVI decreased in females from 49.8±0.9mL/m(2) (7-20years) to 42.8±0.6mL/m(2) (60-80years; P<0.0001) and in males from 56.6±0.8mL/m(2) (7-20years) to 49.0±0.7mL/m(2) (60-80years; P<0.0001). A significant increase in LVEF was observed with age (P<0.0001 for both genders), but it was more pronounced in females (62±0.5% [age 7-20years] vs. 65±0.3% [age 60-80years]) than in males (62±0.5% [age 7-20years] vs. 64±0.3% [age 60-80years]). Similarly, LVFS increased in females from 37.7±0.5% (7-20years) to 42.4±0.4% (60-80years; P<0.001) and in males from 37.3±0.5% (7-20years) to 39.4±0.5% (60-80years; P<0.001). LVEF, LVFS, and LVMMI increase with advancing age, in particular in females. In contrast, LVEDVI decreases with age. These findings indicate that the LV undergoes a lifelong remodeling.