Symptoms Of Congestive Heart Failure Research Articles

Endocardial Fibroelastosis: A Comprehensive Review.

Endocardial fibroelastosis emerged as a challenging clinical phenomenon in the 1940s. It is characterized by an atypical proliferation of fibrous and elastic tissue within the heart and is primarily observed in childhood, occasionally displaying familial inheritance. While the precise cause remains elusive, various factors, including genetic, infectious, metabolic, autoimmune, oncologic, and medication-related influences, appear to play a role in its pathogenesis. The coexistence of endocardial fibroelastosis with multiple cardiac structural abnormalities manifests in symptoms of congestive heart failure and rhythm abnormalities. Despite its challenging diagnosis, various findings from ECG and imaging have proven beneficial in further evaluation of this condition. Finally, the treatment approach to endocardial fibroelastosis became complex due to addressing its concurrent cardiac abnormalities. Strategies for managing and preventing this condition are still under investigation. In this review, we intend to highlight the existing knowledge and illuminate future considerations regarding the etiology, diagnosis, and management of this disease.

Bridging Bronchus – An Unsuspected Airway Anomaly Associated with Congenital Heart Disease: A Case Report with Review of Literature

Abstract Background: The association of airway anomalies with congenital heart disease (CHD) is common, but often remains undetected, due to a lack of awareness. We describe the unfortunate demise of an infant with CHD due to delayed diagnosis of a bridging bronchus (BB) with multifocal bronchial stenosis. Clinical Description: An 18-month-old boy, who was a known case of ventricular septal defect (VSD), was hospitalized for the third time with symptoms of pneumonia and congestive heart failure. He also had intermittent stridor and wheeze similar to his earlier illnesses. Management and Outcome: After stabilization with bubble continuous positive airway pressure, antibiotics, and diuretics, he underwent surgery for the VSD and got extubated successfully on day 3. Subsequently, however, he failed to get weaned off further from respiratory support and started having recurrent episodes of stridor along with suprasternal retractions and wheeze. Computerized tomography (CT) showed BB with multifocal stenosis of the airway and sequestration of the left lower lobe of the lung. He developed pneumonia and succumbed to the illness before he could be considered for surgical correction of the airway anomalies. Conclusion: Awareness about associated airway anomalies and their preoperative detection may alter prognostication, parental counseling, surgical approach, and final outcome.

Heyde Syndrome as Cause of New-onset Heart Failure in the Setting of Bioprosthetic Aortic Valve: A Case Report

This report describes the case of a 70-year-old female with a history of bioprosthetic aortic valve replacement. She presented to the emergency department with significant shortness of breath and bilateral lower extremity edema, which was found to be secondary to new-onset acute symptomatic congestive heart failure in the setting of Heyde syndrome.

Diagnosis and Management of Congenital Coronary Artery Fistulas in Infants and Children.

Coronary artery fistulas (CAFs) are rare coronary anomalies that most often occur as congenital malformations in children. Although most children with CAFs are asymptomatic at the time of diagnosis, some present with symptoms of congestive heart failure in the setting of large left-to-right shunts. Others may develop additional complications including coronary artery ectasia and coronary thrombosis. Surgical and transcatheter closure techniques have been previously described. This review presents the classifications of CAFs in children and the short and long-term outcomes of CAF closure in children in the reported literature. We also summarize previously-reported angiographic findings and post-treatment remodeling characteristics in pediatric patients. With advancements in cross-sectional imaging technologies, anatomic delineation of CAFs via these modalities has become crucial in procedural planning. Recent reports of surgical and transcatheter closure of CAFs in children have reported good procedural success and low rates of short-term morbidity and mortality. Distal-type CAFs have elevated risk for long-term sequelae post-closure compared to proximal-type CAFs. A recent report of a multi-institutional cohort also describes post-closure remodeling classifications which may predict long-term outcomes in these patients as well as guide individualized anticoagulation management. Invasive closure of significant CAFs via surgical or transcatheter techniques is feasible and safe in most children with good short and intermediate-term outcomes. However, close clinical and imaging follow-up is required to monitor for late complications even after successful closure. Antiplatelet and anticoagulation regimens remain important aspects of post-closure management, but the necessary intensity and duration of such therapy remains unknown.

Human in vitro disease modeling of ATTR cardiac amyloidosis

Abstract Background Amyloidosis is a systemic protein-folding disorder characterized by extracellular misfolded fibrillar protein aggregates that are insoluble and resistant to proteolysis, leading to progressive and vital organ damage [1]. Transthyretin amyloidosis (ATTR) is one of the primary amyloidosis types that affect the heart. Based on the TTR gene sequence, ATTR is further classified into wild-type ATTR (ATTRwt) and hereditary ATTR (ATTRv). Advanced stage TTR amyloid infiltration of the myocardium results in progressive thickening and stiffening of the ventricle wall, and symptoms of restrictive cardiomyopathy and congestive heart failure. Due to the lack of specificity of cardiac amyloidosis symptoms, misdiagnosis and delays in diagnosis are common, resulting in worsening symptoms, organ damage, and increased mortality [2]. Despite the development of several disease-modifying agents [3], current experimental cell and animal models do not adequately represent the human situation, thereby limiting disease understanding and therapeutic discovery. Purpose This project aims to develop an in vitro ATTR disease model, which is critical to define early disease stages and disease progression, map human disease-specific pathways, and screen for novel drugs or validating cutting-edge therapeutic strategies. Methods Recombinant WT-TTR and V122I mutated TTR (V122I) were prepared using E.coli protein production system. TTR purification and acid-mediated TTR-fibril were characterized by SDS-PAGE, Thioflavin T fluorescence measurement, and transmission electron microscope (EM). iPSC-derived cardiomyocytes (iPS-CMs) were differentiated using GiWi protocol as described [4,5]. iPS-CMs or HUVECs were seeded on TTR or TTR-fibril, and we measured beating rate, cell viability (AlamarBlue and LiveDead), and cell/fibril morphology using immunofluorescence. Results Purified recombinant WT and V122I TTR was successfully generated (Figure 1A). Fluorescence increase (Thioflavin T) and EM revealed the presence of TTR-fibril (Figure 1B). iPS-CMs seeded on TTR-fibril resulted in a dose- and time-dependent increase in cell death. Confocal microscopy revealed the attachment of TTR-fibril on iPS-CMs, leading to sarcomere disarray, loss of cell-to-cell coupling, resulting in irregular beating (Figure 2A). Additionally, we found drastically affected viability of HUVECs upon TTR-fibril exposure (Figure 2B). Conclusion Here, we demonstrate an established method to generate purified TTR and TTR-fibril. TTR-fibril attached to the surface of iPS-CMs decreased cell viability and functionality. Similar reduction in HUVEC viability were observed as well. These findings reflect the cytotoxicity of TTR-fibril in a human in vitro model.TTR and TTR-fibril characterizationCell viability up TTR-fibril exposure

Abstract 17455: Heart in Crisis: Graves’ Thyrotoxicosis-Induced Cardiomyopathy

Background: We present a case of a young healthy male who presented with signs and symptoms of congestive heart failure and was subsequently diagnosed with dilated cardiomyopathy secondary to an unknown history of Graves’ disease. Case Presentation: A 40-year-old male with no medical history presented to the hospital with scrotal and bilateral lower leg edema for 4 days with associated shortness of breath. Physical examination was significant for an irregularly irregular heart rhythm. Electrocardiogram showed atrial fibrillation with a rapid ventricular response (Image B). Initial laboratory findings were elevated NT-proBNP of 1,240 pg/mL (<125 pg/mL). Chest x-ray revealed significant cardiomegaly (Image A). Echocardiogram demonstrated an ejection fraction of 20% with a severely dilated bilateral atrium, left ventricle with severe diffuse hypokinesis of the left ventricle, and severe mitral regurgitation (Images C and D). Endocrine was consulted for abnormal thyroid function tests with TSH of <0.010 mU/L (0.27-4.2 mU/L), free T4 of 6.06 ng/dL (.93-1.70 ng/dL), T3 of 258 ng/dL (80-200 ng/dL), thyroid-stimulating immunoglobulin of 9.51 IU/L (0.00-.55 IU/L) and TSH receptor antibody 14.00 IU/L (0.00-1.75 IU/L). The patient was started on methimazole and metoprolol with close follow-up with cardiology and endocrinology. Discussion: Severe Cardiomyopathy in adult patients with hyperthyroidism is rare occurring in approximately 6% of patients with less than 1% developing dilated cardiomyopathy with impaired left ventricular systolic function. Although the mechanism of dilated cardiomyopathy is still being researched it has been suggested that prolonged uncontrolled hyperthyroidism and autoimmunity as the potential causes. Further studies are needed to develop optimal management studies as it has been shown that the management of thyrotoxicosis can reverse cardiovascular manifestations and prevent irreversible cardiomyopathy.

Salsolinol improves angiotensin II‑induced myocardial fibrosis invitro via inhibition of LSD1 through regulation of the STAT3/Notch‑1 signaling pathway.

The clinical incidence of congestive heart failure (CHF) is very high and it poses a significant threat to the health of patients. The traditional Chinese medicine monomer salsolinol is widely used to treat similar symptoms of CHF. However, there have been no reports on the effect of salsolinol for the management of CHF and its effects on myocardial fibrosis. In the present study, salsolinol was used to treat angiotensin II (AngII)-induced human cardiac fibroblasts (HCFs) and cell proliferation and migration were assessed using a CCK-8, EdU staining assay and wound healing assay. Subsequently, immunofluorescence, western blotting and other techniques were used to detect indicators associated with cell fibrosis and relevant kits were used to detect markers of cellular inflammation and reactive oxygen species (ROS) production. Molecular docking analysis was used to predict the relationship between salsolinol and lysine-specific histone demethylase 1A (LSD1). Subsequently, the expression of LSD1 in the serum of CHF patients was detected by reverse transcription-quantitative PCR. Finally, LSD1 was overexpressed in cells to explore the regulatory mechanism of salsolinol in AngII-induced HFCs. Salsolinol reduced the proliferation and migration. Salsolinol reduced the expression of fibrosis marker proteins α-smooth muscle actin, Collagen I and Collagen III in a concentration-dependent manner, thereby reducing cell fibrosis. In addition, salsolinol reduced the levels of TNF-α and IL-6 in the cell supernatant and ROS production following AngII induction. Salsolinol inhibited LSD1 expression and regulated the STAT3/Notch-1 signaling pathway. Upregulation of LSD1 reversed the effects of salsolinol on AngII-induced HCFs. Salsolinol inhibited LSD1 via regulation of the STAT3/Notch-1 signaling pathway to improve Ang II-induced myocardial fibrosis in vitro.

The CINCH-FMR postmarket registry: Real-world long-term outcomes with percutaneous mitral valve repair with the Carillon Mitral Contour System®

BackgroundThe Carillon® Mitral Contour System® has been studied in 4 prospective controlled studies in the treatment of functional mitral regurgitation (FMR) where it has been found to reduce mitral regurgitation, reduce left ventricular and atrial volumes, and be associated with improvements in clinical parameters. AimsThe CINCH post-market registry is designed to evaluate immediate, mid-term and long-term outcomes from a post-approval study of the Carillon® device evaluated in real-world practice. MethodsThe CINCH post-market registry is a single-arm study of percutaneous mitral annuloplasty with the Carillon device in patients with functional (secondary) mitral regurgitation and symptomatic congestive heart failure when utilized in real-world conditions. Patient selection, echocardiographic hemodynamic measurements, and patient follow-up requirements were performed per standard of care at each institution. ResultsA total of 101 patients treated with the Carillon device at 13 sites in Germany were enrolled in the CINCH registry. The mean age was 75 ± 9 years, 57 % were male, and patient presentation included primarily NYHA class III (69 %) with MR grade 3 (68 %). Over 5 years of follow-up, all-cause mortality was 40.1 %, the incidence of HFH was 53.9 %, and the composite outcome of HFH or death was 66.4 %. At each follow-up interval through 5 years, statistically significant reductions in NYHA class (p < 0.05) and MR grade (p < 0.01) were reported. ConclusionsIn this “real world” registry of the Carillon Mitral Contour System, procedural safety and medium-term follow-up outcomes is similar to the outcomes seen in the prospective, controlled clinical trials, despite being used in populations of patients that extend outside of those studied in the trials. The use of this therapy in patients with atrial functional mitral regurgitation, and heart failure with preserved ejection fraction, was notable, since these types of patients were excluded from the prospective, controlled trials. This supports possible additional patient populations who might benefit from this type of mechanical therapy. The safety profile of this therapy in this registry and in the earlier trials may support a potential role in earlier forms of secondary mitral regurgitation.

#3160 IMPACT OF HEART FUNCTION ON ELDERLY INCIDENT HEMODIALYSIS PATIENTS

Abstract Background and Aims Cardiovascular disease (CVD) is the most common cause of death in patients on hemodialysis (HD). Indeed, left ventricular (LV) dysfunction, symptomatic congestive heart failure and arrhythmia are independent predictors of poor survival and hospitalization in these patients. Among the patients who initiated HD, the proportions of the elderly patients aged &amp;gt;65 years are increasing worldwide. According to the Korean Renal Data System, the percentage of incident HD patients aged&amp;gt;65 years increased from 11% in 1990 to 53% in 2022. In addition, the prevalence of CVD increases with age. Therefore following these trends, investigating the impact of heart function on prognosis in elderly patients on HD is important for predicting prognosis and making appropriate treatment plans. This study aims to investigate the all-cause mortality in elderly incident HD patients according to heart function and presence of arrhythmia. Method 1,002 incident HD patients aged &amp;gt;70 years were recruited from a retrospective cohort of the Korean Society of Geriatric Nephrology. The primary outcome is all-cause mortality (6 months, overall) according to the LV function and presence of arrhythmia. To analyze, patients were divided into 6 groups according to the LV function (LV ejection fraction [LVEF]≥50%, 40≤LVEF&amp;lt;50%, LVEF&amp;lt;40%) and the presence of arrhythmia. The secondary outcome is all-cause mortality (6 months, overall) according to the LV function or presence of arrhythmia. To analyze, patients were divided into 3 groups according to the LV function and separately divided into 2 groups according to the presence of arrhythmia. Cox regression univariate and multivariate analyses was used. Results 1,002 patients were divided into 6 groups (LVEF≥50% without arrhythmia [N = 707, 70.6%], 40≤LVEF&amp;lt;50% without arrhythmia [N = 71, 7.1%], LVEF&amp;lt;40% without arrhythmia [N = 66, 6.6%], LVEF≥50% with arrhythmia [N = 124, 12.4%], 40≤LVEF&amp;lt;50% with arrhythmia [N = 15, 1.5%], LVEF&amp;lt;40% with arrhythmia [N = 19, 1.8%]). There were no differences of 6-month all-cause mortality among the groups. Compared with LVEF≥50% without arrhythmia group, 40≤LVEF&amp;lt;50% without arrhythmia (hazard ratio [HR], 1.59; 95% confidence interval [95% CI], 1.21-2.09; P = 0.001), LVEF≥50% with arrhythmia (HR, 1.39; 95% CI, 1.12-1.74, P = 0.003) and LVEF&amp;lt;40% with arrhythmia groups (HR, 1.95; 95% CI, 1.19-3.17, P = 0.007) showed higher all-cause mortality of overall period. According to the LVEF groups, there were no differences of 6-month all-cause mortality among the groups. Compared with LVEF≥50% group, 40≤LVEF&amp;lt;50% group showed higher all-cause mortality of overall period (HR, 1.51; 95% CI, 1.18-1.94, P = 0.001). According to the arrhythmia groups, there were no differences of 6-month all-cause mortality between the groups. The presence of arrhythmia was associated with higher all-cause mortality of overall period (HR, 1.39; 95% CI, 1.15-1.69, P = 0.001). Conclusion Decreased heart function and presence of arrhythmia have negative impact on all-cause mortality of overall period, but not on 6-month all-cause mortality in elderly patients on incident HD. Therefore, evaluation of the heart function and detection of arrhythmia in elderly patients who start HD and providing the appropriate treatment to these patients would be helpful for improving the prognosis.

Thoracoscopic Radiofrequency Fragmentation of the Left Atrium as a Bridge to Decision Before Heart Transplant.

Atrial fibrillation and congestive heart failure can provoke and aggravate each other. Often the boundaries between those diseases are ambiguous, and successful diagnosis is initially elusive. However, the last stage of congestive heart failure can lead the patient to heart transplant. We suggested that restoration and stabilization of sinus rhythm could be used as a differential diagnostic criterion to distinguish dilated cardiomyopathy from atrial fibrillation. We investigated the possibility that thoracoscopic radiofrequency fragmentation of the left atrium could be a valid a bridge to decision before heart transplant in patients with the combination of atrial fibrillation and congestive heart failure with reduced left ventricular ejection fraction. The pilot study included 3 men who consecutively received thoracoscopic radiofrequency fragmentation of the left atrium from November 2021 to May 2022. All 3 patients had a combination of atrial fibrillation and congestive heart failure with a reduced ejection fraction and left ventricle dilatation (echocardiography, Simpson method: 31%, 33%, and 30%, respectively) despite receiving as highly as possible drug therapy and normalization of heart rate. The patients were 42, 38, and 55 years old, with rates of N-terminal pro-B-type natriuretic peptide of 3047, 2548, and 2542 pg/mL, respectively. The follow-up examination was performed every month. The total durations of the follow-up were 12, 9, and 7 months, respectively. By month 3 after the surgery, the left ventricular ejection fraction began to increase. By month 6 of follow-up, the left ventricular ejection fraction reached its maximum value and stabilized. All patients reported cessation of congestive heart failure symptoms. Thoracoscopic radiofrequency fragmentation of the left atrium can be considered a bridge to decision before heart transplant in patients with a combination of atrial fibrillation and congestive heart failure with reduced left ventricular ejection fraction.

Transcarotid Artery Revascularization Is the Safest Carotid Artery Revascularization Option for Patients With Symptomatic Congestive Heart Failure

Congestive heart failure (CHF) is a high-risk comorbidity for patients undergoing carotid revascularization. For patients with CHF with ejection fraction ≤30%, carotid artery stenting is preferred over carotid endarterectomy (CEA). However, there is a paucity of data regarding the best carotid revascularization method specifically for these patients. Thus, we aimed to determine the safest carotid revascularization method in patients with symptomatic CHF (sCHF). This retrospective study analyzed the Vascular Quality Initiative database for patients with sCHF with carotid stenosis undergoing CEA, transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) between December 2016 and May 2022. sCHF refers to patients with cardiac disease and physical activity limitations (New York Heart Association class II-IV). The primary outcome was in-hospital rates of stroke, death, and myocardial infarction (MI). The secondary outcomes included 30-day mortality, in-hospital stroke/death, and in-hospital stroke/death/MI. The logistic regression model was used for multivariate analysis. The study included 3909 (54.1%) CEA, 1369 (19.0%) TFCAS, and 1947 (27.0%) TCAR cases, all performed in patients with sCHF. TFCAS was associated with increased risk of 30-day mortality (adjusted odds ratio [aOR]: 2.14, 95% confidence interval [CI]: 1.41-3.24; P < .001), stroke/death (aOR: 2.57, 95% CI: 1.42-4.63); P = .002), and stroke/death/MI (aOR: 2.05, 95% CI: 1.22-3.45; P = .007) compared with CEA. However, patients with sCHF had similar outcomes with TCAR compared with CEA. Moreover, TCAR was associated with decreased odds of 30-day mortality (aOR: 0.38, 95% CI: 0.21-0.73; P = .003), stroke/death (aOR: 0.41, 95% CI: 0.20-0.85; P = .017), and stroke/death/MI (aOR: 0.45, 95% CI: 0.24-0.85; P = .014) compared with TFCAS in patients with sCHF (Table I). The subanalysis based on the symptomatic status of carotid stenosis showed persistent results only for the symptomatic cohort. In addition, TFCAS in symptomatic patients was associated with an almost threefold increase in the risk of MI (aOR: 2.73, 95% CI: 1.04-7.19; P = .041) compared with CEA, but TCAR was not. TCAR was associated with a 72% reduction in the risk of MI (aOR: 0.28, 95% CI: 0.08-0.98; P = .046) compared with TFCAS (Table II). CHF is considered a high-risk criterion for CEA and an indication for stenting. However, in this large national study, we have shown that TFCAS is associated with worse perioperative mortality, stroke/death, and stroke/death/MI compared with CEA in these patients. TCAR had similar outcomes to CEA and was superior to TFCAS in terms of 30-day mortality, stroke, stroke/death, and stroke/death/MI. The advantages of TCAR become more pronounced in symptomatic patients. Our findings suggest TCAR as the best minimally invasive method of carotid revascularization in patients with sCHF. Further research is needed to confirm our findings.Table IMultivariate analysis of all patients with symptomatic CHF stratified by carotid revascularization typeOutcomesaTFCAS vs CEATCAR vs CEATCAR vs TFCASaOR (95% CI)P valueaOR (95% CI)P valueaOR (95% CI)P value30-day mortality2.14 (1.41-3.24)<.0011.23 (0.74-2.02).4240.38 (0.21-0.73).003Stroke1.18 (0.74-1.85).4880.66 (0.41-1.08).0980.53 (0.29-0.97).039MI1.15 (0.52-2.52).7240.58 (0.33-1.00).0520.85 (0.48-1.53).594Stroke/death2.57 (1.42-4.63).0021.10 (0.63-1.92).7540.41 (0.20-0.85).017Stroke/death/MI2.05 (1.22-3.45).0070.91 (0.63-1.31).6130.45 (0.24-0.85).014ACEI, Angiotensin-converting enzyme inhibitor; aOR, adjusted odds ratio; CAD, coronary artery disease; CEA, carotid endarterectomy; CI, confidence interval; CKD, chronic kidney injury; COPD, chronic obstructive pulmonary disease; HTN, hypertension; MI, myocardial infarction; RAAS, renin-angiotensin-aldosterone system; TCAR, transcarotid artery revascularization; TFCAS, transfemoral carotid artery stenting.aAdjusting for age, sex, race, ethnicity, insurance, CAD, CKD, COPD, HTN, diabetes, smoking status, obesity, anemia, prior procedures, preoperative conditions, urgency, symptomatic status, preoperative aspirin, ACEI, P2Y12-receptor antagonist, β-blocker, anticoagulant, and RAAS inhibitor intake. Open table in a new tab Table IIMultivariate analysis of patients with symptomatic CHF with symptomatic and asymptomatic carotid stenosis stratified by carotid revascularization typeOutcomesaTFCAS vs CEATCAR vs CEATCAR vs TFCASaOR (95% CI)P valueaOR (95% CI)P valueaOR (95% CI)P valueSymptomatic carotid stenosis 30-day mortality2.26 (1.22-4.20).0101.33 (0.71-2.51).3750.32 (0.14- 0.75).008 Stroke1.47 (0.74-2.95).2740.73 (0.36-1.49).3930.44 (0.19 -1.01).054 MI2.73 (1.04- 7.19).04127 (0.08-0.97).0450.28 (0.08-0.98).046 Stroke/death3.67 (1.68-8.00).0011.10 (0.56 -2.14).7840.28 (0.13- 0.61).001 Stroke/death/MI3.63 (1.83-7.22)<.0010.90 (0.51-1.60).7270.24 (0.12-0.48)<.001Asymptomatic carotid stenosis 30-day mortality2.11 (1.16-3.84).0141.18 (0.57-2.42).6610.47 (0.21-1.07).074 Stroke1.00 (0.50-2.00).9940.64 (0.34-1.20).1660.60 (0.26-1.38).232 MI0.54 (0.19-1.52).2440.70 (0.37-1.33).2741.45 (0.65-3.22).361 Stroke/death1.93 (0.86-4.33).1231.16 (0.51-2.61).7240.58 (0.21-1.62).301 Stroke/death/MI1.23 (0.64-2.36).5340.95 (0.60-1.48).8070.88 (0.38-2.04).757ACEI, Angiotensin-converting enzyme inhibitor; aOR, adjusted odds ratio; CAD, coronary artery disease; CEA, carotid endarterectomy; CI, confidence interval; CKD, chronic kidney injury; COPD, chronic obstructive pulmonary disease; HTN, hypertension; MI, myocardial infarction; RAAS, renin-angiotensin-aldosterone system; TCAR, transcarotid artery revascularization; TFCAS, transfemoral carotid artery stenting.aAdjusting for age, sex, race, ethnicity, insurance, CAD, CKD, COPD, HTN, diabetes, smoking status, obesity, anemia, prior procedures, preoperative conditions, urgency, symptomatic status, preoperative aspirin, ACEI, P2Y12-receptor antagonist, β-blocker, anticoagulant, and RAAS inhibitor intake. 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PO-05-027 INCIDENCE OF PACING-INDUCED CARDIOMYOPATHY AND NEED FOR CARDIAC RESYNCHRONIZATION THERAPY UPGRADE IN PATIENTS WITH LEADLESS PACEMAKER: LONG TERM FOLLOW-UP OF 75 PATIENTS

Excessive right ventricular (RV) pacing with traditional pacemaker has been associated with a 17-25% risk of pacing-induced cardiomyopathy (PICM), defined as a decrease of left ventricular ejection fraction by 10% or more. The risk of PICM with more septally placed leadless pacemaker is unknown. We aimed to report the incidence of PICM in patients with leadless pacemaker and the need for cardiac resynchronization therapy (CRT) upgrade. We performed a single-center analysis of patients who underwent leadless pacemaker implantation between January 1, 2014 and April 1, 2022. Patient echocardiogram result pre and post implantation were collected. The outcomes of this study included the incidence of PICM in leadless pacemaker implant patient, the rate of CRT upgrade, RV pacing percentage, total RV pacing time and follow up duration. The definition of total RV pacing time was the duration from pacemaker to last follow up multiplied by RV pacing percentage. A total 75 patients underwent leadless-pacemaker implantation were included in this study. The mean age was 80 ± 8.5 year-old. Indications for single chamber leadless implantation include sick sinus syndrome and bradycardia. Mean duration of follow up was 14.6 months. The RV pacing percentage was 64.4 ± 38.58 %.The mean RV pacing time was 9.2 ± 1.4 months, PICM was found in 32 patients (44%), 10 patients (13.5%) required CRT upgrade due to congestive heart failure symptoms. The mean duration between implantation of leadless pacemaker to upgrade CRT was 372 ± 489.8 days. The incidence of PICM in leadless pacemaker patients was 44% and 13.5 % of patients required CRT upgrade within 2 years after the leadless pacemaker implant in the majority of the patients. Further studies are necessary to confirm these findings.

Pulmonary Artery Banding -Original, Current, and New Indications for Pulmonary Artery Banding-

First performed in the early 1950s in children with a large left-to-right shunt or single ventricle and excessive pulmonary blood flow, pulmonary artery banding (PAB) is a palliative surgery designed to relieve symptoms. After advances in cardiopulmonary bypass techniques in the 1980s allowed surgeons to perform corrective surgery even in infants, PAB has continued to play a palliative role in balancing the pulmonary to systemic blood flow ratio in critical situations. PAB is also used to retrain the left ventricle in patients with transposition of the great arteries to prepare them for the arterial switch procedure, either following late presentation or following prior atrial repair. Another role played by PAB is to train the left ventricle in patients with congenitally corrected transposition of the great arteries, not only for the purpose of retraining the sub-pulmonary left ventricle but also as an early prophylactic approach in newborns to avoid the severe tricuspid regurgitation sometimes associated with a morphologic right ventricle in the systemic position. Currently, PAB has two indications: 1. to reduce the pulmonary blood flow and relieve the symptoms of congestive heart failure, and 2. to train the sub-pulmonary ventricle for future corrective surgery. Recently, PAB has been successfully employed to treat children with dilated cardiomyopathy (DCM), a disease that has shown considerably increased morbidity and mortality rates and indications for heart transplantation; some of the patients thus treated have shown improved left ventricular function, allowing them to be taken off the waiting list for heart transplantation. In this paper, we review the original and current indications for PAB and explain the surgical technique and strategy. We also present a literature review of the new indications for PAB in patients with pediatric DCM, and compare outcomes in Japan with those in other countries.

Cardiac Safety and Efficacy of SB3 Trastuzumab Biosimilar for ERBB2-Positive Early Breast Cancer

Trastuzumab has been the standard of care for the treatment of patients with ERBB2-positive breast cancer; however, cardiac events have been reported. This long-term follow-up study provides clinical evidence supporting the similarity of a trastuzumab biosimilar (SB3) to reference trastuzumab (TRZ). To compare cardiac safety and efficacy between SB3 and TRZ for patients with ERBB2-positive early or locally advanced breast cancer after up to 6 years of follow-up. This prespecified secondary analysis of a randomized clinical trial, conducted from April 2016 to January 2021, included patients with ERBB2-positive early or locally advanced breast cancer from a multicenter double-blind, parallel-group, equivalence phase 3 randomized clinical trial of SB3 vs TRZ with concomitant neoadjuvant chemotherapy who completed neoadjuvant and adjuvant treatment. In the original trial, patients were randomized to either SB3 or TRZ with concomitant neoadjuvant chemotherapy for 8 cycles (4 cycles of docetaxel followed by 4 cycles of fluorouracil, epirubicin, and cyclophosphamide). After surgery, patients continued SB3 or TRZ monotherapy for 10 cycles of adjuvant treatment per previous treatment allocation. Following neoadjuvant and adjuvant treatment, patients were monitored for up to 5 years. The primary outcomes were the incidence of symptomatic congestive heart failure and asymptomatic, significant decrease in left ventricular ejection fraction (LVEF). The secondary outcomes were event-free survival (EFS) and overall survival (OS). A total of 538 female patients were included (median age, 51 years [range, 22-65 years]). Baseline characteristics were comparable between the SB3 and TRZ groups. Cardiac safety was monitored for 367 patients (SB3, n = 186; TRZ, n = 181). Median follow-up was 68 months (range, 8.5-78.1 months). Asymptomatic, clinically significant LVEF decreases were rarely reported (SB3, 1 patient [0.4%]; TRZ, 2 [0.7%]). No patient experienced symptomatic cardiac failure or death due to a cardiovascular event. Survival was evaluated for the 367 patients in the cardiac safety cohort and an additional 171 patients enrolled after a protocol amendment (538 patients [SB3, n = 267; TRZ, n = 271]). No difference was observed in EFS or OS between treatment groups (EFS: hazard ratio [HR], 0.84; 95% CI, 0.58-1.20; P = .34; OS: HR, 0.61; 95% CI, 0.36-1.05; P = .07). Five-year EFS rates were 79.8% (95% CI, 74.8%-84.9%) in the SB3 group and 75.0% (95% CI, 69.7%-80.3%) in the TRZ group, and OS rates were 92.5% (95% CI, 89.2%-95.7%) in the SB3 group and 85.4% (95% CI, 81.0%-89.7%) in the TRZ group. In this secondary analysis of a randomized clinical trial, SB3 demonstrated cardiac safety and survival comparable to those of TRZ after up to 6 years of follow-up in patients with ERBB2-positive early or locally advanced breast cancer. ClinicalTrials.gov Identifier: NCT02771795.

A Case of Stress Cardiomyopathy With Nab-Paclitaxel Infusion.

Stress cardiomyopathy is a transient left ventricular dysfunction caused by physiologic or pathologic stressors. Anaphylaxis is a hypersensitivity disorder that can lead to a rapid life-threatening respiratory collapse. It happens due to exposure to allergens including medications. During anaphylaxis, there is a compensatory release of catecholamines that can lead to stress cardiomyopathy. In this case, nab-paclitaxel infusion led to anaphylaxis with respiratory failure. Echocardiogram showed features of diffuse hypokinesis with preserved basal segment contractility, and cardiac catheterization did not show any evidence of obstructive coronary artery disease. The overall clinical picture suggested stress cardiomyopathy. The patient was treated with guideline-directed medical therapy which resulted in normalization of the ejection fraction with no symptoms of congestive heart failure at any point. The patient was thereafter resumed on a reduced dose of nab-paclitaxel. This case report adds to the spectrum of infusion-related reactions associated with paclitaxel and demonstrates the course of events in the management of anaphylaxis and stress cardiomyopathy in this scenario.

Cholecystalgia: An Atypical Presentation of Congestive Heart Failure in a New Diagnosis of Alcohol-Induced Cardiomyopathy

Right upper quadrant (RUQ) pain is a frequent presenting symptom in the emergency department, and gallstone-induced acute cholecystitis is one of the main causes; in addition, RUQ pain can be a consequence of several other conditions. Although rare, it may also indicate cholecystalgia from gallbladder edema, which is usually related to other conditions, such as congestive heart failure (CHF), alcoholic and nonalcoholic liver cirrhosis, acute viral or drug-induced hepatitis, renal failure, and hypoproteinemia. We present a case of cholecystalgia resulting from gallbladder edema in a patient with a newly diagnosed alcohol-induced cardiomyopathy without the common CHF signs and symptoms.

169: SITOSTEROLEMIA PRESENTING WITH SEVERE HYPERTENSION AND CONGESTIVE HEART FAILURE IN A CHILD

Introduction: Sitosterolemia is an autosomal recessive condition caused by pathogenic variants in the ABCG5/ABCG8 genes that prohibit the body from excreting plant sterols, causing build-up in the soft tissues and systemic vasculature. Pediatric vasculopathy secondary to sitosterolemia is poorly described, and there is no clear guidance on the management of complications, including cardiac dysfunction. This case report describes the diagnosis and acute management of a child with severe systemic hypertension, multiple levels of arterial stenosis, and cardiomyopathy presenting in congestive heart failure and ultimately diagnosed with sitosterolemia. Description: An 8-year-old Amish male with no past medical history presented to the emergency department with emesis and associated fatigue and abdominal pain. Vital signs were significant for severe systemic hypertension (BP 220/110), a gallop rhythm, hepatomegaly, cardiomegaly, and mid-aortic narrowing on CT angiogram. Exam was also notable for bilateral knee xanthomas. Laboratory data after admission to the pediatric cardiac ICU showed elevated BNP (peak 4418 pg/mL) and total cholesterol (317 mg/dL) levels. Echocardiogram showed severe mitral and tricuspid valve regurgitation, severely dilated and concentrically hypertrophied and dysfunctional left ventricle, ejection fraction of 30%, and pulmonary hypertension. Consultations included genetics, cardiology, nephrology, and vascular surgery. Initial management included a continuous Milrinone infusion and loop diuretics with improved BP and congestive heart failure symptoms. Cardiac catheterization including coronary and renal angiograms demonstrated severe proximal right coronary artery stenosis and bilateral renal artery stenosis. Right coronary artery and left renal artery angioplasties were performed with good results, and showed significant improvement in parameters of ventricular function and pulmonary arterial hypertension. Genetic testing and positive serum plant sterols confirmed the diagnosis of sitosterolemia. Discussion: Sitosterolemia is a rare genetic disorder and a rare cause of pediatric arteriopathy. Early recognition can prevent the development of life-threatening systemic hypertension, arterial stenosis including coronary artery disease, and cardiomyopathy.

A Unique High-Output Cardiac Hypertrophy Phenotype Arising From Low Systemic Vascular Resistance in Cantu Syndrome.

Background Cardiomegaly caused by left ventricular hypertrophy is a risk factor for development of congestive heart failure, classically associated with decreased systolic and/or diastolic ventricular function. Less attention has been given to the phenotype of left ventricular hypertrophy with enhanced ventricular function and increased cardiac output, which is potentially associated with high-output heart failure. Lack of recognition may pose diagnostic ambiguity and management complexities. Methods and Results We sought to systematically characterize high-output cardiac hypertrophy in subjects with Cantu syndrome (CS), caused by gain-of-function variants in ABCC9, which encodes cardiovascular KATP (ATP-sensitive potassium) channel subunits. We studied the cardiovascular phenotype longitudinally in 31 subjects with CS with confirmed ABCC9 variants (median [interquartile range] age 8 years [3-32 years], body mass index 19.9 [16.5-22.9], 16 male subjects). Subjects with CS presented with significant left ventricular hypertrophy (left ventricular mass index 86.7 [57.7-103.0] g/m2 in CS, n=30; 26.6 [24.1-32.8] g/m2 in controls, n=17; P<0.0001) and low blood pressure (systolic 94.5 [90-103] mm Hg in CS, n=17; 109 [98-115] mm Hg in controls, n=17; P=0.0301; diastolic 60 [56-66] mm Hg in CS, n=17; 69 [65-72] mm Hg in control, n=17; P=0.0063). Most (21/31) subjects with CS exhibited eccentric hypertrophy with normal left ventricular wall thickness. Congestive heart failure symptoms were evident in 4 of the 5 subjects with CS aged >40 years on long-term follow-up. Conclusions The data define the natural history of high-output cardiac hypertrophy resulting from decreased systemic vascular resistance in subjects with CS, a defining population for long-term consequences of high-output hypertrophy caused by low systemic vascular resistance, and the potential for progression to high-output heart failure.

Abstract 12413: Type 2 Diabetes Mellitus and Congestive Heart Failure in Women Are Mutually Independent Predictors of Non-alcoholic Fatty Liver Disease

Introduction: Non-alcoholic fatty liver disease (NAFLD) is associated with both type 2 diabetes mellitus (T2DM) and congestive heart failure (CHF), and T2DM is highly prevalent in CHF patients, in particular among women. However, the single and joint associations of T2DM and CHF with NAFLD in women have not been investigated yet. Hypothesis: We hypothesize that congestive heart failure and T2DM are independent predictors of NAFLD in women. Methods: We investigated 76 female patients with CHF and 321 female controls who did not have signs or symptoms of CHF and in whom significant coronary artery disease was ruled out angiographically. The presence of NAFLD was determined using the validated fatty liver index (FLI). Results: The prevalence of T2DM was 39.5% in women with CHF and 22.1% in controls (p=0.002). FLI values and prevalence rates of NAFLD (FLI≥60) in non-CHF women without T2DM were 43±28 and 31.6%, respectively. They were significantly higher in non-CHF, but T2DM patients (65±28, p&lt;0.001 and 64.8%, p&lt;0.001, respectively), in CHF patients without T2DM (67±25, p&lt;0.001 and 63.0%, p=0.002, respectively) and in CHF patients with T2DM (66±31, p&lt;0.001 and 66.7%, p&lt;0.001, respectively). In multivariate analysis of covariance, T2DM and CHF proved to be mutually independent predictors of FLI after adjustment for age, sex, BMI, LDL-C, history of smoking and hypertension and use of statins (F=7.25; p=0.007 and F=46.89; p&lt;0.001, respectively); concordantly, T2DM and CHF independently predicted the presence of NAFLD in logistic regression analyses, with adjusted odds ratios of 3.22 [1.38-7.50]; p=0.007 and 21.71 [6.58-71.59]; p&lt;0.001, respectively. Conclusions: We conclude that CHF and T2DM are mutually independent predictors of NAFLD in women.

International abstracts

Iliac arteriovenous (AV) fistula after lumbar disc surgery are uncommon entities with limited reported cases. This report describes a 44-year-old man with history of L4-L5 spinal discectomy who complained of congestive heart failure symptoms four years later. Computed tomography angiography (CTA) revealed an AV fistula connecting the right common iliac artery and vein. AV closure with lateral suturing of common iliac artery and vein was performed through transperitoneal aorto-iliac approach. Postoperatively, the patient's symptoms of orthopnea resolved. Follow-up at six years was uneventful.