ERS/EBMT clinical practice guidelines on treatment of pulmonary chronic graft-versus-host disease in adults

Chronic graft-versus-host disease (cGvHD) is a common complication after allogeneic haematopoietic stem cell transplantation, characterised by a broad disease spectrum that can affect virtually any organ. Although pulmonary cGvHD is a less common manifestation, it is of great concern due to its severity and poor prognosis. Optimal management of patients with pulmonary cGvHD is complicated and no standardised approach is available. The purpose of this joint European Respiratory Society (ERS) and European Society for Blood and Marrow Transplantation task force was to develop evidence-based recommendations regarding the treatment of pulmonary cGvHD phenotype bronchiolitis obliterans syndrome in adults. A multidisciplinary group representing specialists in haematology, respiratory medicine and methodology, as well as patient advocates, formulated eight PICO (patient, intervention, comparison, outcome) and two narrative questions. Following the ERS standardised methodology, we conducted systematic reviews to address these questions and used the Grading of Recommendations Assessment, Development and Evaluation approach to develop recommendations. The resulting guideline addresses common therapeutic options (inhalation therapy, fluticasone-azithromycin-montelukast, imatinib, ibrutinib, ruxolitinib, belumosudil, extracorporeal photopheresis and lung transplantation), as well as other aspects of general management, such as lung functional and radiological follow-up and pulmonary rehabilitation, for adults with pulmonary cGvHD phenotype bronchiolitis obliterans syndrome. These recommendations include important advancements that could be incorporated in the management of adults with pulmonary cGvHD, primarily aimed at improving and standardising treatment and improving outcomes.

Associations between training characteristics and change in peak oxygen consumption following exercise training in patients with heart failure with preserved ejection fraction

Introduction

In heart failure with preserved ejection fraction (HFpEF), moderate continuous training (MCT) and high-intensity interval training (HIIT) are both effective in increasing peak oxygen uptake (peak V̇O2).

Purpose

The aim of this study was to investigate the association of training characteristics (i.e. average sessions/week, average duration/week, mean intensity) and change in peak V̇O2 following 3 months of MCT and HIIT in patients with HFpEF.

Methods

Among 120 patients who were randomized to MCT (5x40 min/week at 35–50% heart rate reserve [HRR]) or HIIT (3x38 min/week at 80–90% HRR), those who completed 3-month follow-up (N=107) were considered for this analysis. Training duration and heart rates [HR] were recorded with a smartphone application, evaluated with a customized software and manually checked for plausibility. If HR measurements were classified as invalid/unreliable (e.g. very strong fluctuations), patients were excluded from analysis. Intensities were calculated as average % HRR of total sessions in MCT and the average of the highest % HRR values of all intervals in HIIT. Associations between training characteristics and change in peak V̇O2 were evaluated using univariate and multivariate regression analyses. Individual HR-V̇O2 relationships were used to calculate and compare energy expenditure (MET-minutes) in MCT and HIIT.

Results

After excluding 16 patients due to invalid/unreliable HR data, 91 patients (67% female, 69±7 years) were included in this analysis. On average, MCT patients (N=45) performed 4.0±1.2 sessions/week (162±52 min/week) at 47.4±6.7% HRR, while HIIT patients (N=46) performed 2.4±0.8 sessions/week (96±40 min/week) at 81.8±11.8% HRR. Peak V̇O2 was improved by 1.70±2.35 ml/kg/min in MCT and 1.46±2.98 ml/kg/min in HIIT (difference: 0.24 [95% CI, −0.87 to 1.34], p=0.67). The associations between training characteristics and change in peak V̇O2 are shown in Fig.1. Mean % HRR was not significantly associated with the change in peak V̇O2 in the HIIT group, whereas in MCT, mean duration/week and mean intensity were of similar relative importance (standardized coefficients) and explained up to 26% of the variation in change in peak V̇O2 (Table 1). Average weekly MET-minutes above rest were 451±260 for MCT and 389±375 for HIIT (difference: 62 [95% CI, −71 to 195], p=0.36). After adjustment for MET-minutes, the difference in change in peak V̇O2 between groups diminished to 0.09 ml/kg/min (95% CI, −0.97 to 1.16; p=0.98).

Conclusions

Weekly duration and mean % HRR had a similar predictive ability for the change in peak V̇O2 following MCT with, interestingly, lower change in peak V̇O2 with increasing intensity. In HIIT, mean % HRR was not significantly associated with the change in peak V̇O2. After adjusting for energy expenditure, the difference in change in peak V̇O2 between training modes diminished, suggesting that MCT and HIIT were similarly effective.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Commission, Framework Program 7

Gender differences with the use of percutaneous left ventricular assist device in cardiogenic shock patients – results from the Dresden Impella Registry

Background

Cardiogenic shock (CS) is a state of end-organ hypoperfusion due to cardiac output failure and is characterized by high mortality. Percutaneous left ventricular assist devices (pLVAD), like the Impella® system, support the left ventricular function and provide a sufficient oxygen supply to all tissues, which might improve outcome. In the current study, we investigated gender-specific differences in a large, propensity score matched cohort of patients receiving an Impella CP® in CS. Beside all-cause mortality, we focused on requirement of hemodialysis and surrogate parameters like development of systemic inflammatory response syndrome (SIRS), or sepsis, which is known to be associated with enhanced morbidity and mortality.

Methods

The Dresden Impella Registry is an ongoing registry including more than 650 patients since 2014. Among, a total of 95 female and 237 male patients received an Impella CP® in CS. Two groups of similar sample size (n=60) resulted after propensity score matching. A logistic regression model was used for adjustment of the baseline characteristics (nearest neighbor matching). Kaplan-Meier curves at 30, 180 and 365 days as well as clinical, laboratory and hemodynamic parameters were compared between male and female patients.

Results

The propensity score matched cohorts showed a well balancing without significant differences between baseline characteristics. At time of admission, female patients were 68.9±1.8 years old, male patients 67.2±1.5 years. A cardiopulmonary resuscitation (CPR) before pLVAD was performed in 53.3% in both groups. The comparison of mean arterial pressure, norepinephrine and dobutamine dosage showed no differences initially and in course. The left ventricular ejection fraction did not differ between both cohorts (♀ 28.6±2.3% vs. ♂ 26.7±1.7%, p=0.885). The duration of left ventricular unloading was 44.1±6.5 h among female patients and 56.0±7.3 h among male patients (p=0.119).

The all-cause mortality showed no difference at 30, 180, and 365 d (30 d: ♀ 61.7±6.3% vs. ♂ 56.7±6.4%, p=0.349; 180 d: ♀ 73.3±5.7% vs. ♂ 68.3±6.0%, p=0.312; 365 d: ♀ 76.7±5.5% vs. ♂ 70.0±5.9%, p=0.312).

However, hemodialysis was less frequently required in female patients (♀ 28.3% vs. ♂ 45.8%, p=0.049). The duration of hemodialysis did not differ between the groups (♀ 123.9±57.8 h vs. ♂ 108.1±56.3 h, p=0.744). Furthermore, occurrence of SIRS and sepsis were less frequently observed in female patients (SIRS ♀ 45.0% vs. ♂ 75.0%, p=0.042; sepsis ♀ 43.3% vs. ♂ 62.7%, p=0.034).

Conclusion

All-cause mortality showed no gender-specific differences in a well-balanced propensity score matched analysis of CS patients receiving LV-unloading with a pLVAD. However, females had a decreased requirement of hemodialysis and a less frequent occurrence of SIRS and sepsis. Further studies are needed to investigate whether these differences might improve outcome in larger cohorts.

Funding Acknowledgement

Type of funding sources: None.

Problem of implicit assumptions about left ventricular geometry in the calculation of myocardial mass by echocardiography – a validation study with cardiac magnetic resonance

Background/Introduction

Cardiac magnetic resonance imaging (CMR) is regarded as the reference method in assessing left ventricular (LV) myocardial mass. However, 2-dimensional echocardiography (Echo) is still used due to availability and practicability.

Purpose

We sought to assess measurements of LV myocardial mass from Echo exams and validate the results with CMR on a large cohort of patients.

Methods

We analyzed 357 patients who underwent clinically indicated CMR examinations and performed a standard Echo at the same day. In Echo, the commonly used Devereux formula (CUBE) was assessed for the calculation of LV mass: 0.8 × {1.04 × [([LV end-diastolic diameter + diastolic septum-thickness + posterior wall-thickness]3 − LV end-diastolic diameter3)]} + 0.6. Mass was indexed on body surface area (g/m2). Correlation (r), regression (R2) and Bland-Altman analysis were performed in order to assess bias between the two methods. Significance was defined as a 2-tailed P value <0.05.

Results

LV myocardial mass was measured in 345 patients with CMR and Echo. The median age was 61 years [19–79], 44% were female and CMR was performed due to coronary artery diseases (45%), suspected or florid myocarditis (31%) or further diagnosis of non-ischemic heart failure (24%). LV ejection fraction (EF) ranged between 13 and 71%. We found a significant relation of measurements for myocardial mass between Echo and CMR (R2=0.6, p<0.001) (Figure 1, left). However, there was a significant proportional bias (R2=0.47, p<0.001) depending in the amount of LV mass measured (Figure 1, right). As expected, the measurement bias correlated not only with the amount of mean wall-thickness (septum & posterior wall) from Echo, but also with LV end-diastolic diameter (r=−0.55 and −0.41, p<0.001 for all). Interestingly, the amount of LV EF correlated reversely with the proportional bias (r=0.34, p<0.001).

Conclusion

The results provided by our study, highlight the problem of implicit assumptions of LV geometry in the calculation of LV myocardial mass by Echo (CUBE) compared to CMR. Furthermore, the strongly biased differences between these two measurement methods are not negligible and warrant further investigation.

Funding Acknowledgement

Type of funding sources: None.

The automatic identification of left ventricular chambers and quantification of ejection fraction using a novel artificial intelligence-based system – a validation against cardiac magnetic resonance

Background/Introduction

Cardiac magnetic resonance imaging (CMR) is regarded as the reference method in assessing left ventricular (LV) ejection fraction (EF). However, 2-dimensional echocardiography (2D-Echo) is the most frequently used technique due to availability and practicability. The interpretation of 2D-Echo examinations depends on the user's expertise and may vary between different operators. A novel vendor-independent software based on artificial intelligence (AI) performs both, automated evaluation of 2D-Echo exams and calculations of LV EF in one workflow.

Purpose

We sought to assess the ability of the AI to automatically identify appropriate LV 4- and 2-chamber views (4CV) (2CV) from 2D-Echo exams and validate the resulting EF with CMR.

Methods

We consecutively enrolled 128 patients who underwent clinically indicated CMR examinations and performed a standard 2D-Echo at the same day. The server-based AI solution recognized the optimal LV 4CV and 2CV from 2D-Echo according to quality and depth criteria and automatically performed calculation of biplane EF by endocardial borderline detection. LV EF from CMR and AI were supervised by independent cardiologists blinded to the mutual results. Pearson's correlation (R) and Bland-Altman analysis with limits of agreement (LOA) were performed in order to assess bias between the two methods. Significance was defined as a 2-tailed P value <0.05.

Results

CMR was performed and LV EF was measured in all 128 patients. The median age was 60 years [20–86], 65% were males and CMR was performed due to coronary artery diseases (33%), suspected/florid myocarditis (20%) or further diagnosis of non-ischemic heart failure (47%). Eleven cases (9%) did not pass AI's criteria due to impaired acoustic window or poor 2D-Echo images. The AI system detected either 4CV or 2CV (ratio 1.2) in 13 patients (10%), and both 4CV and 2CV in 104 patients (81% overall feasibility) with a correct classification of 100%. For these 104 patients, excellent correlation was found for AI's biplane LV EF and LV EF from CMR with r=0.91 (p<0.001) (Figure 1, left). However, the absolute mean bias between AI and CMR was 3.5% (p<0.001) and LOAs were −10.6 and +17.5% (Figure 1, right).

Conclusion

The results provided by the AI-based software showed good capabilities and a perfect classification rate to identify 4CV and 2CV. In addition, the LV EF results were excellent compared to CMR, especially since our study did not include “echocardiographically” pre-selected patients. However, differences between AI and CMR measurements are not negligible and warrant further investigation.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular ejection fraction – human vs artificial intelligence: quo vadis?

Background/Introduction

Two-dimensional echocardiography (Echo) is a feasible method for assessing left ventricular (LV) ejection fraction (EF) in daily practice. However, the interpretation of Echo exams depends on the user's expertise and may vary between different operators. A novel, vendor-neutral artificial intelligence (AI) performs both, automated evaluation of Echo exams and calculations of biplane LV EF in one workflow.

Purpose

We sought to assess the ability of the AI to automatically identify appropriate LV 4- and 2-chamber views (4CV) (2CV) from routine Echo examinations and compare the resulting biplane EF with conventional hand-tracing biplane Simpson method (Human).

Methods

We prospectively enrolled 311 patients who underwent clinically indicated Echo exams. Biplane LV EF was manually traced online on 4CV and 2CV by cardiologists (Human). After completion of the exam, the AI-based solution recognized the optimal LV 4CV and 2CV according to quality and depth criteria and automatically performed the calculation of biplane EF by endocardial borderline detection without Human's interaction. Spearman's correlation (R) and Bland-Altman analysis with limits of agreement (LOA) were assessed for bias between the two methods. In a subgroup of 20 patients, Echo exams were automatically reanalyzed by the AI, and conventional biplane Simpson of LV EF was performed by two cardiologists blinded to the previous results to determine intraclass correlation (ICC). Significance was defined as a 2-tailed p value <0.05.

Results

311 patients (median age 72 years [19–97]; 40% female) received an Echo for valvular heart disease, ischemic and non-ischemic heart failure or other indications (39, 31, 19 and 11%). 16 cases (5%) did not pass AI's criteria due to poor Echo imaging or impaired acoustic window of patients. In 53 patients (17%) either 4CV or 2CV were recognized, but the AI system successfully identified both 4CV and 2CV in 242 patients (overall feasibility 78%). For these 242 patients, correlation between AI and Human biplane LV EF was r=0.83 (p<0.001) (Figure 1 left). The absolute mean bias between methods was 5.2% (p<0.001) and absolute LOA ranged from −9.0 to +19.4% (Figure 1 right). ICC of LV EF by Human was 0.77 (p<0.001). The AI's ability to correctly re-/classify 4CV and 2CV was 100% with an ICC of 1 for fully automated LV EF measurements.

Conclusion

The results provided by the AI-based software showed very good capability to identify 4CV and 2CV and good LV EF result compared to Human manual tracings, especially since patients were not pre-selected. However, differences between AI and Human measurements are not negligible and warrant further investigations.

Funding Acknowledgement

Type of funding sources: None.

Reduced LVEDD following a 12 week exercise training program in patients with symptomatic chronic heart failure is associated with reduction in serum levels of Troponin I

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Norwegian University of Science and Technology Danish Research Council

Background

Exercise training (ET) exerts many beneficial effects on the cardiovascular system, and longitudinal observational data from epidemiological studies suggest that higher physical activity is associated with lower concentrations of cardiac troponins. We have previously shown that ET can reduce Left Ventricle End-diastolic diameter (LVEDD), and improve exercise capacity.

Purpose

Our aim was to explore the relationship between changes in LVEDD and changes in high-sensitive plasma troponin I (hs-TnI) levels in patients with symptomatic heart failure undergoing a 12 week structured exercise training program in the randomized multicenter SMARTEX trial.

Methods

This was a post hoc analysis in 199 patients with symptomatic HF with LVEF <35% and NYHA II-III that were randomly assigned to High Intensity Interval Training (HIIT, n = 73), Moderate Continuous Training (MCT, n = 59) or Recommendation of Regular Exercise, (RRT, n = 67) for 12 weeks. Log-transformed Hs-TnI measurements and clinical data acquired before (BL) and after a 12 week exercise training intervention (12 weeks) and at 1 year follow-up (1 year) were analysed using a linear mixed model. For Troponin analysis the STAT Troponin-I from Abbott Diagnostics was used.

Nakagawa’s marginal R2 and conditional R2 were used to evaluate variance explained by fixed effects only and by fixed and random effects together, respectively.

Changes of LVEDD between baseline and 12 weeks and baseline and 52 weeks were evaluated using linear mixed model. The outcome variable were measures of LVEDD, while age, sex, visit and training group and their interaction [visit × training group]  were included as fixed effects. Patient id and training center were random effects. Covariance structure was compound symmetry.

Linear association between log-transformed TnI and LVEDD baseline was evaluated using Pearson correlation coefficient (R).

Results

Serum was available for hs-TnI analyses in 199 patients. In the HIIT group there was a sustained significant reduction in LVEDD at both 12 and 52 weeks.

In the MCT group this reduction was statistically significant at 52 weeks only.

Mixed model analysis predicts that each 1 mm decrease in LVEDD is associated with 1.2% decrease in TnI levels (95% CI: 0.6 – 1.9%, p <0.001). Neither time nor training group were associated with changes of TnI (overall test p = 0.739 and p = 0.987, respectively).

Dynamics of TnI is highly patient-specific with Intraclass correlation coefficient (ICC) = 0.86. Mixed model explains 87% variation of the data (conditional R2), however, only 7% is attributed to the fixed effects (marginal R2).

At baseline, TnI and LVEDD have modest but statistically significant correlation (R = 0.2, p= 0.004).

Conclusions

A reduction of LVEDD following a 12-week exercise-training program is associated with a reduction in plasma troponin levels, in patients with mild to moderate chronic heart failure. Abstract Figure.

Increased VO2 peak after a structured exercise-training program is associated with reduced levels of cardiac myosin binding protein C in patients with symptomatic chronic heart failure

Background

Cardiac myosin-binding protein C (cMyC), a cardiac contractile protein, is a novel biomarker of myocardial injury, rising earlier and disappearing faster than cardiac troponins. It is a promising biomarker for use in triage of patients with chest pain presenting in the emergency department. It also has prognostic significance in patients with heart failure. However, the effects of systematic exercise training on plasma levels of cMyC has previously not been evaluated.

Purpose

The aim of this study was to assess the effect of a 12-week exercise training program on changes in plasma levels of cMyC in patients with chronic symptomatic heart failure with reduced ejection fraction (HFrEF). The changes in plasma levels of cMyC in an intervention group, performing structured exercise programs, were compared to those in a control group, instructed to perform regular recommended exercise (RRE) according to current guidelines.

Methods

This was a post hoc analysis of the SMARTEX-HF trial in 215 patients with symptomatic HF with Left Ventricular Ejection Fraction (LVEF) <35% and NYHA II-III. The patients were randomly assigned to High Intensity Interval Training (HIIT, n=77), Moderate Continuous Training (MCT, n=65) or RRE, (n=73) for 12 weeks. HIIT and MCT groups constituted the intervention group (IG). Measurements and clinical data were acquired before and after the 12-week intervention.

Statistical analysis

We divided the patients in two groups with Δ VO2Peak above and below the median of the sample. The absolute changes of cMyC were then compared between the two groups.

Mann-Whitney U test was used to compare continuous variables between the groups. Chi-squared test and Fisher exact test were used to compare categorical variables, as appropriate. A two-tailed p<0.05 was considered significant.

Results

There were no differences in changes of cMyC plasma levels, measured at baseline and after the intervention, between patients in the IG and RRE-group (p=0.580).

When dividing the entire study population according to Δ VO2Peak higher or lower than median value 0.48 ml/kg/min, we found a statistically significant greater reduction of cMyC values after 12 weeks of exercise training for those with higher than median Delta VO2Peak values compared to those with lower values (p=0.012). This finding was even stronger for the percentage change in cMyC levels (p=0.004 between groups).

Conclusion

In patients with symptomatic chronic HFrEF performing a structured 12-week exercise training program, a greater increase in Δ VO2Peak is significantly associated with a reduction in cMyC, suggesting cMyC may provide a dynamic measure of cardiorespiratory state.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Central Norwegian Health authority,Norwegian University of Science and Technology Baseline characteristicsBoxplot cMyC vs peak VO2

Frailty is associated with chronic inflammation and pro-inflammatory monocyte subpopulations

Introduction

Patients with frailty represent an increasing patient group in the intensive care medicine. A connection between frailty and inflammation has been suggested. An increased mortality rate in patients with high grade aortic valve stenosis (AS) and frailty, who underwent Transcatheter Aortic Valve Implantation (TAVI) has been observed. A systemic inflammatory reaction in the intensive care unit in the first days after TAVI is a positive predictive factor for an unfavorable outcome. Exact mechanisms are still not fully explained. Monocyte subpopulations are associated with both cardiovascular diseases and a high APACHE II score in critically ill patients.

Purpose

This study investigates the correlation between frailty and cellular and systemic inflammatory mechanisms and mortality after TAVI.

Methods

We examined 120 patients with symptomatic AS who underwent TAVI. Before the implantation, frailty status has been assessed. In all patients a flow cytometry analysis has been performed. Monocyte subpopulations were defined as follows: Mon1 (CD14++CD16–), Mon2 (CD14++CD16+) and Mon3 (CD14+CD16++). Expression of CD11b has been measured as a marker for monocyte activation. Pro-inflammatory cytokines such as interleukin IL-8, as well as CRP have been measured with Cytometric Bead Array or standard laboratory methods.

Results

After 3 months 15 of 120 patients died, primarily without relevant dysfunction of the implanted aortic valve. In 8 of 15 (53%) of the deceased patients and 20 of 100 (19%) of the surviving patients, frailty could be diagnozed before TAVI (p=0.003). Patients with frailty showed prior to TAVI signs of chronic inflammation: elevated CRP (3.7 vs. 5.9 mg/l, p=0.001) and elevated levels of considered as pro-inflammatory Mon2 monocytes (37 vs. 53, p=0.001). Expression of CD11b and IL-8 showed an increasing trend in patients with frailty. Frailty, the monocyte markers, IL-8 and CRP prior to TAVI correlated with increased early mortality after TAVI.

Conclusion

A considerable number of elderly patients with high grade aortic valve stenosis can be described as frail. This syndrome is associated with increased mortality and with signs of chronic systemic inflammation and pro-inflammatory monocytes.

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Heart Center Dresden

Plasma levels of troponin I is reduced after a 12 week exercise training program in patients with uncomplicated heart failure. A substudy of the SMARTEX-HF study

Background

Low-level elevation of cardiac troponins has been associated with adverse outcome, and concentrations even within the normal range provide independent information concerning risk in heart failure (HF). Exercise training exerts many beneficial effects on the cardiovascular system, and longitudinal observational data from epidemiological studies suggest that higher physical activity (PA) is associated with lower concentrations of cardiac troponins.

Purpose

Our aim was to compare changes in plasma troponin I (TnI) levels (Abbott Diagnostics) in patients with symptomatic heart failure undergoing a 12 week structured exercise training program (Intervention group, IG) with changes in controls on a recommendation of regular exercise (RRE); control group, (CG) in a randomized clinical trial.

Methods

This was a post hoc analysis of the SMARTEX-HF trial in 199 patients with symptomatic HF with LVEF <35% and NYHA II-III. The patients were randomly assigned to High Intensity Interval Training (HIIT, n=73), Moderate Continuous Training (MCT, n=59) or RRE, (n=67) for 12 weeks. HIIT and MCT groups constituted the intervention group (IG). Measurements and clinical data acquired before and after the 12-week exercise training intervention were analysed.

Statistical analysis

Changes of TnI levels from baseline to 12 weeks are presented as medians and interquartile ranges. One-sample Wilcoxon sign rank test was used to determine if for a specific group of patients, the median change of troponin levels was equal to zero. In addition, Mann-Whitney U test was used to compare reductions of TnI between two groups.

Results

After 12 weeks plasma levels of TnI were reduced for all patients (median 11.9 to 11.4 ng/L, p=0.032) and there was no difference between the study groups (p=0.072). However, when the groups were studied separately, reduction of plasma levels of TnI was statistically significant in the IG only (12.5 to 11.7 ng/L, p=0.011), (CG 11.4 to 10.7 ng/L, p=0.955).

For the study cohort restricted to patients without additional complicating factors (i.e. no atrial fibrillation, no history of hypertension, diabetes or chronic obstructive pulmonary disease, n=77), difference in changes of plasma levels of TnI between IG (n=54) and CG (n=23) was found to be statistically significant (p=0.004). IG changed from 11.3 to 9.5 ng/L (p=0.002), (CG 12.6 to 12.7 ng/L, p=0.467).

Conclusions

A 12 weeks exercise-training program was associated with a reduction of plasma TnI levels in patients with mild to moderate HFrEF without additional complicating factors.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Western Norway Regional; Health Authority [Grant Number 911 715]. St. Olavs Hospital; Faculty of Medicine, Norwegian University of Science and Technology; Norwegian Health Association

CD11b expression on monocytes and data of inflammatory parameters after Transcatheter Aortic Valve Implantation in dependence of early mortality

An inflammatory systemic reaction is common after Transcatheter Aortic Valve Implantation (TAVI). We recently reported about an involvement of Mon2-monocytes, the CD11b expression on monocytes and parameters of systemic inflammation before TAVI correlating with early mortality after TAVI. Here, we provide data of monocyte subpopulations, CD11b expression and parameters of a systemic inflammation in dependence of three-month mortality after TAVI. With this, we provide further insights into inflammatory mechanism after TAVI. The data were collected by flow-cytometric quantification analyses of peripheral blood in 120 consecutive patients who underwent TAVI (on day 1 and 7 after TAVI). Monocyte-subsets were identified by their CD14 and CD16 expression and monocyte-platelet-aggregates (MPA) by CD14/CD41 co-expression. The extent of monocyte activation was determined by quantification of CD11b-expression (activate epitope). Additionally, pro-inflammatory cytokines such as interleukin (IL)-6, IL-8, C-reactive protein, procalcitonin were measured using the cytometric bead array method or standard laboratory tests. Additionally, we report procedural outcomes in dependence of three-month mortality. Furthermore, correlations of CD11b-expression on monocytes with parameters of platelet activation or further inflammatory parameters are presented. For further interpretation of the presented data, please see the research article “Mon2-Monocytes and Increased CD-11b Expression Before Transcatheter Aortic Valve Implantation are Associated with Earlier Death” by Pfluecke et al.[1]

P1854Clinical implications of physical function and resilience in patients undergoing transcatheter aortic valve implantation

Background

Gait speed, as a measure of physical function and marker of frailty, is now routinely screened when evaluating patients with aortic stenosis (AS) for transcatheter aortic valve implantation (TAVI). Assessment of physical function is important to identify patients for whom TAVI may be futile and to assign patients to a procedural risk category. After TAVI, patients may exhibit physical resilience (improvement in physical function) or vulnerability (worsening). Characterizing the trajectory and clinical consequences of physical function after TAVI represent knowledge gaps in the field.

Purpose

Evaluate associations between physical resilience (improved gait speed) vs vulnerability (decline) after TAVI and subsequent death/hospitalization.

Methods

The REPRISE III trial compared a mechanically-expanded vs a self-expanding valve in 912 high/extreme risk patients with symptomatic AS. Patients (n=587) who underwent valve implantation and who had a gait speed recorded both pre- and 1-year post-TAVI were analyzed. Gait speed is based on the 5m walk test (slow: 5m in >6s, <0.83m/s; normal: ≥0.83m/s). Trajectory of physical function after TAVI was characterized in 2 ways. Model 1 examined 4 groups based on slow or normal gait speeds at baseline and 1-year post-TAVI. Model 2 examined gait speed change pre-TAVI to 1 year (adjusted for baseline gait speed). Using a landmark approach, the relationships between baseline and 1-year gait speed were evaluated in multivariable Cox PH models of outcomes between 1 and 2 years post-TAVI.

Results

A clinically-meaningful improvement (≥0.1m/s), no change (±0.1m/s), or decline (≥0.1/ms) in gait speed 1 year after TAVI was observed in 39%, 36%, and 26% of patients, respectively. Among the 4 groups defined by pre- and 1-year post-TAVI gait speeds, 1 to 2 year mortality or hospitalization rates were: 6.6% (normal/normal), 20.9% (normal/slow), 8.0% (slow/normal), and 21.5% (slow/slow). Adjusted hazard ratios of the 2 models are shown (Table).

Table. Outcome by Change in Gait Speed Death/Hospitalization P-value Death P-value Hospitalization P-value Adjusted HR [95% CI] Adjusted HR [95% CI] Adjusted HR [95% CI] Model 1: Baseline/1 year Gait Speed   (Normal/Normal (n=150) [referent])   Normal/Slow (n=59) 3.82 [1.61, 9.08] <0.01 2.75 [0.96, 7.86] 0.06 7.31 [1.94, 27.58] <0.01   Slow/Normal (n=114) 1.39 [0.53, 3.59] 0.50 1.44 [0.50, 4.12] 0.50 1.69 [0.38, 7.60] 0.49   Slow/Slow (n=253) 3.88 [1.91, 7.91] <0.01 2.36 [1.02, 5.46] 0.045 3.89 [1.14, 13.27] 0.03 Model 2: Gait speed change   Baseline to 1 year per 0.1m/s increase 0.83 [0.74, 0.92] <0.01 0.92 [0.80, 1.04] 0.19 0.75 [0.64, 0.88] <0.01

Conclusion

These data reveal there is marked heterogeneity in the trajectory of physical function after TAVI and that this trajectory–more so than baseline physical function–is clinically consequential. Identifying and optimizing factors associated with physical resilience after TAVI may improve outcomes.

Acknowledgement/Funding

Boston Scientific

4314Cardiac involvement of Wilsons disease

Background

Wilson's disease (WD) is an inherited autosomal recessive disorder resulting from abnormal copper metabolism. Relatively little is known about the effects of copper accumulation on the heart.

Objective

We aimed to determine if patients with Wilson's disease show signs of cardiac involvement and structural heart disease.

Methods

In this prospective trial, we studied 61 patients with Wilson's disease and compared them to 61 age- and gender-matched healthy controls.

Results

While left ventricular function assessed by global longitudinal and global radial strain did not differ significantly between the groups, Wilson's disease patients had significantly reduced global radial strain (table 1).

Wilson's disease patients demonstrated significantly more late gadolinium enhancement than the control patients (4.9±1.4 vs. 1.1±0.2% p<0.001).

The severity of Wilson's disease, based on the Unified Wilson's Disease Rating Scale, was significantly correlated with the extent of late gadolinium enhancement (r=0.53, P=0.001), cardiac troponin (r=0.56, P=0.001), the number of premature ventricular contraction (r=0.66, P=0.001).

Table 1. Myocardial strain and CMR characteristics of patients and controls Parameter Patients (n=61) Controls (n=61) p value Left ventricular parameters   GLS, % −22.8 (4.8) −21.8 (5.1) 0.124   GRS, % 43.2 (13.2) 51.6 (13.8) 0.002   GCS, % −29.2 (5.2) −28.6 (4.7) 0.534 Late gadolinium enhancement   LGE, %* 4.9 (1.4) 1.1 (0.2) 0.003   LGE at RVIP, n (%) 58 (95) 3 (5) <0.001   Midwall LGE, n (%) 11 (18) 0 <0.001 Right ventricular parameters   GLS, % −23.6 (4.9) −26.1 (5) 0.01 Data are presented as mean (SD), median (IQR)*, or n (%) unless otherwise stated. GLS, global longitudinal strain; GRS, global radial strain; GCS, global circular strain; LGE: late gadolinium enhancement; RIVP, right ventricular insertion point.

Conclusion

Our data demonstrate that cardiac involvement in Wilson's disease is possible and those patients who are severely affected by the disease carry a higher risk of developing structural heart disease.

P3700Left trial appendage thrombosis in patients with severe aortic stenosis treated by transfemoral transcatheter aortic valve implantation

Introduction

Data about the impact of left atrial appendage thrombosis (LAAT) on early safety and midterm mortality in patients undergoing transfemoral (TF) transcatheter aortic valve implantation (TAVI) are scarce.

Purpose

To investigate the incidence and predictors of LAAT as well as the outcome associated with this condition in a large cohort of patients treated by TF-TAVI.

Methods

Patients receiving TF-TAVI for native aortic valve stenosis or failed aortic bioprostheses were stratified according to the presence of LAAT diagnosed by transoesophageal echocardiography. Early safety at 30-days according to Valve Academic Research Consortium-2 (VARC-2) and 2-year all-cause mortality were the primary outcome measures.

Results

From 02/2006 to 06/2016, 2.527 patients (88.5%) out of 2.854 patients treated by TF-TAVI had an available transesophageal echocardiography (TEE) at baseline and formed the analysis cohort. LAAT was found in 7.6% of the whole cohort and in 16.6% in those patients with known pre-existing atrial fibrillation (AF cohort). Patients with LAAT appeared to be sicker compared to controls indicated by a higher STS-Score and burden of comorbidities. Neither VARC-2 defined early safety at 30-days nor the rate of stroke was different between LAAT and controls in both the whole (early safety: 24.2% vs. 29.2%, p=0.123; stroke: 4.7% vs. 5.9%, p=0.495) and AF cohort (early safety: 22.9% vs. 29.1%, p=0.072; stroke: 3.3% vs. 5.6%, p=0.142). Evaluating the whole cohort in a univariate analysis, the 2-year mortality was significantly higher in LAAT compared to controls (HR 1.41 [95% CI 1.07–1.86], p=0.014). However, a multivariate analysis of the whole cohort and a separate examination of the AF cohort revealed no association between LAAT and 2-year mortality.

Conclusion

LAAT was frequent in patients undergoing TF-TAVI, in particular in patients with a history of AF, but it was not associated with an increase in periprocedural complications. The fact that LAAT was no independent predictor of mortality indicates that it should be interpreted as a marker of an advanced disease stage rather than a prognostic factor.

P6357Left ventricular unloading leads to heart rhythm stabilization in cardiogenic shock - Results from the Dresden Impella Registry

Background

Cardiogenic shock (CS) is often associated with severe heart rhythm disturbances (SHRD). Percutaneous left ventricular assist devices (pLVAD) can actively unload the left ventricle (LV) using a micro-axial pump and resulting in a decreased end-diastolic pressure and wall tension. These parameters are suspected to induce and maintain rhythmological instability.

Purpose

In the current study, we firstly describe the termination of SHRD immediately (less than 5 minutes) after LV-unloading in CS patients with previous unsuccessful antiarrhythmic treatment.

Methods

The Dresden Impella Registry is an ongoing single center registry. Since 2014, a total of 97 patients were included. Each of whom had received a micro-axial heart pump in refractory CS supplying a circulatory support of 3.5 l/min. We investigated the subgroup of patients which initially exhibited SHRD like ventricular tachycardia or ventricular fibrillation, and showed an immediately stabilization of heart rhythm directly after insertion of pLVAD (HRS). This subgroup was compared with the other patients of the registry (NHRS). Therefore, clinical laboratory and hemodynamic parameters were measured and analyzed.

Results

In 19 patients of the registry a HRS was observed. Among these patients, a CPR before pLVAD was performed in 89.5% with a mean duration of 30.7min, whereby 52.6% sustained an in-hospital cardiac arrest and 36.9% an out-of-hospital cardiac arrest respectively. In the NHRS subgroup (n=78), a CPR was performed less frequently (39.7%; p<0.001) with shorter mean duration (19.5min; p=0.016) and a lower out-of-hospital ratio (12.8%; p=0.014). The comparison of hemodynamic parameters between the HRS and NHRS cohort showed no difference in mean arterial pressure, heart rate, left ventricular ejection fraction (LVEF), and serum lactate.

The mortality showed no differences between the HRS and NHRS cohort at 30 days (68.4% vs. 58.1%; p=0.413) and 90 days (78.9% vs. 66.7%; p=0.306), despite a more frequent and longer CPR with a higher ratio of out-of-hospital cardiac arrests among the HRS patients. There was also no difference in mortality between patients, who received an in-hospital CPR. However, HRS patients with in-hospital CPR showed a significantly lower serum lactate and NA dosage compared to the NHRS cohort (Figure A & B). Furthermore, NA recovery, defined as 50% decrease as compared to the initial NA dosage, occurred more frequently in the HRS group (HRS 42.9% vs. NHRS 7.1%; p=0.049). The LVEF nearly double in the HRS subgroup after LV-unloading, whereas it did not change in the NHRS subgroup (relative LVEF increase: HRS 95% vs. NHRS 15%).

Figure A & B

Conclusion

The termination of SHRD due to LV-unloading occurred in around 20% of CS patients in Dresden Impella Registry and was associated with a lower serum lactate and NA dosage as well as an improved LVEF among patients with in-hospital CPR.

Acknowledgement/Funding

None