Advanced chronic heart failure: A position statement from the Study Group on Advanced Heart Failure of the Heart Failure Association of the European Society of Cardiology

Mechanisms of myocardial reverse remodelling and its clinical significance: A scientific statement of the ESC Working Group on Myocardial Function

Cardiovascular disease (CVD) is the leading cause of morbimortality in Europe and worldwide. CVD imposes a heterogeneous spectrum of cardiac remodelling, depending on the insult nature, that is, pressure or volume overload, ischaemia, arrhythmias, infection, pathogenic gene variant, or cardiotoxicity. Moreover, the progression of CVD-induced remodelling is influenced by sex, age, genetic background and comorbidities, impacting patients' outcomes and prognosis. Cardiac reverse remodelling (RR) is defined as any normative improvement in cardiac geometry and function, driven by therapeutic interventions and rarely occurring spontaneously. While RR is the outcome desired for most CVD treatments, they often only slow/halt its progression or modify risk factors, calling for novel and more timely RR approaches. Interventions triggering RR depend on the myocardial insult and include drugs (renin-angiotensin-aldosterone system inhibitors, beta-blockers, diuretics and sodium-glucose cotransporter 2 inhibitors), devices (cardiac resynchronization therapy, ventricular assist devices), surgeries (valve replacement, coronary artery bypass graft), or physiological responses (deconditioning, postpartum). Subsequently, cardiac RR is inferred from the degree of normalization of left ventricular mass, ejection fraction and end-diastolic/end-systolic volumes, whose extent often correlates with patients' prognosis. However, strategies aimed at achieving sustained cardiac improvement, predictive models assessing the extent of RR, or even clinical endpoints that allow for distinguishing complete from incomplete RR or adverse remodelling objectively, remain limited and controversial. This scientific statement aims to define RR, clarify its underlying (patho)physiologic mechanisms and address (non)pharmacological options and promising strategies to promote RR, focusing on the left heart. We highlight the predictors of the extent of RR and review the prognostic significance/impact of incomplete RR/adverse remodelling. Lastly, we present an overview of RR animal models and potential future strategies under pre-clinical evaluation.

Adverse Events in Total Artificial Heart for End-Stage Heart Failure: Insight From the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE)

Background and Objectives

Real-world clinical data, outside of clinical trials and expert centers, on adverse events related to the use of SyncCardia total artificial heart (TAH) remain limited. We aim to analyze adverse events related to the use of SynCardia TAH reported to the Food and Drug Administration (FDA)'s Manufacturers and User Defined Experience (MAUDE) database.

Methods

We reviewed the FDA's MAUDE database for any adverse events involving the use of SynCardia TAH from 1/01/2012 to 9/30/2020. All the events were independently reviewed by three physicians.

Results

A total of 1,512 adverse events were identified in 453 "injury and death" reports in the MAUDE database. The most common adverse events reported were infection (20.2%) and device malfunction (20.1%). These were followed by bleeding events (16.5%), respiratory failure (10.1%), cerebrovascular accident (CVA)/other neurological dysfunction (8.7%), renal dysfunction (7.5%), hepatic dysfunction (2.2%), thromboembolic events (1.8%), pericardial effusion (1.8%), and hemolysis (1%). Death was reported in 49.4% of all the reported cases (n=224/453). The most common cause of death was multiorgan failure (n=73, 32.6%), followed by CVA/other non-specific neurological dysfunction (n=44, 19.7%), sepsis (n=24, 10.7%), withdrawal of support (n=20, 8.9%), device malfunction (n=11, 4.9%), bleeding (n=7, 3.1%), respiratory failure (n=7, 3.1%), gastrointestinal disorder (n=6, 2.7%), and cardiomyopathy (n=3, 1.3%).

Conclusions

Infection was the most common adverse event following the implantation of TAH. Most of the deaths reported were due to multiorgan failure. Early recognition and management of any possible adverse events after the TAH implantation are essential to improve the procedural outcome and patient survival.

The Association between the Level of Ankle-Brachial Index and the Risk of Poor Physical Function in Patients with Cardiovascular Disease

AIMS

The progression of atherosclerosis and decline in physical function are poor prognostic factors in patients with cardiovascular disease (CVD). The ankle-brachial index (ABI) is a widely used indicator of the degree of progression of atherosclerosis, which may be used to identify patients with CVD who are at risk of poor physical function. This study examined the association between ABI and poor physical function in patients with CVD.

METHODS

We reviewed the data of patients with CVD who completed the ABI assessment and physical function tests (6-min walking distance, gait speed, quadriceps isometric strength, and short physical performance battery). Patients were divided into five categories according to the level of ABI, and the association between ABI and poor physical function was examined using multiple logistic regression analysis. Additionally, restricted cubic splines were used to examine the nonlinear association between ABI and physical function.

RESULTS

A total of 2982 patients (median [interquartile range] age: 71[62-78] years, 65.8% males) were included in this study. Using an ABI range of 1.11-1.20 as a reference, logistic regression analysis showed that ABI ≤ 1.10 was associated with poor physical function. The restricted cubic spline analysis showed that all physical functions increased with an increase in ABI level. The increase in physical function plateaued at an ABI level of approximately 1.1.

CONCLUSIONS

ABI may be used to identify patients with poor physical function. ABI levels below 1.1 are potentially associated with poor physical function in patients with CVD.

The role and application of current pharmacological management in patients with advanced heart failure

In the last decades, several classifications and definitions have been proposed for advanced heart failure (ADVHF) patients, including clinical, functional, hemodynamic, imaging, and electrocardiographic features. Despite different inclusion criteria, ADVHF is characterized by some common items, such as drug intolerance, low arterial pressure, multiple organ dysfunction, chronic kidney disease, and diuretic use dependency. Additional features include fatigue, hypotension, hyponatremia, and unintentional weight loss associated with a specific laboratory profile reflecting systemic multiorgan dysfunction. Notably, studies evaluating guideline-directed medical therapy recently endorsed by guidelines in stable HF, including the 4 drug classes all together (i.e., betablocker, mineral corticoid antagonist, renin angiotensin inhibitors/neprilysin inhibitors, and sodium glucose transporter inhibitors), remain scarcely analyzed in ADVHF and New York Heart Association (NYHA) Class IV. Additionally, due to the common conditions associated with advanced stages, the balance between drug tolerance and potential benefits of the contemporary use of all agents is questioned. Therefore, less hard endpoints, such as exercise tolerance, quality of life (QoL) and self-competency, are not clearly demonstrated. Specific analyses evaluating outcome and rehospitalization of each drug provided conflicting results and are often limited to subjects with stable conditions and less advanced NYHA class. Current European Society of Cardiology/American Heart Association (ESC/AHA) Guidelines do not indicate the type of treatment, dosage, and administration modalities, and they do not suggest specific indications for ADVHF patients. Due to these concerns, there is an impelling need to understand what drugs may be used as the first line, what management leads to the better outcome, and what is the best treatment algorithm in this setting. In this paper, we summarize the most common pitfalls and limitations for the use of the traditional agents, and we propose a personalized approach aiming at preserve drug tolerance and maintaining adverse event protection and satisfactory QoL.

Heart transplantation in patients from socioeconomically distressed communities

BACKGROUND

Studies examining heart transplantation disparities have focused on individual factors such as race or insurance status. We characterized the impact of a composite community socioeconomic disadvantage index on heart transplantation outcomes.

METHODS

From the Scientific Registry of Transplant Recipients (SRTR), we identified 49,340 primary, isolated adult heart transplant candidates and 32,494 recipients (2005-2020). Zip code-level socioeconomic disadvantage was characterized using the Distressed Community Index (DCI: 0-most prosperous, 100-most distressed) based on education, poverty, unemployment, housing vacancies, median income, and business growth. Patients from distressed communities (DCI ≥ 80) were compared to all others.

RESULTS

Patients from distressed communities were more often non-white, less educated, and had public insurance (all p < 0.01). Distressed patients were more likely to require ventricular assist devices at listing (29.4 vs 27.1%) and before transplant (44.8 vs 42.0%, both p < 0.001), and they underwent transplants at lower-volume centers (23 vs 26 cases/year, p < 0.01). Distressed patients had higher 1-year waitlist mortality or deterioration (12.3% [95% confidence interval (CI) 11.6-13.0] vs 10.9% [95% CI 10.5-11.3]) and inferior 5-year survival (75.3% [95% CI 74.0-76.5] vs 79.5% [95% CI 79.0-80.0]) (both p < 0.001). After adjustment, living in a distressed community was independently associated with an increased risk of waitlist mortality or deterioration hazard ratio (HR 1.10, 95% CI 1.02-1.18) and post-transplant mortality (HR 1.13, 95% CI 1.06-1.20).

CONCLUSIONS

Patients from socioeconomically distressed communities have worse waitlist and post-transplant mortality. These findings should not be used to limit access to heart transplantation, but rather highlight the need for further studies to elucidate mechanisms underlying the impact of community-level socioeconomic disparity.

Therapeutic potential role of vitamin C in prevention and control of heart transplant rejection and cardiac allograft vasculopathy. A need for consideration

The burden of cardiovascular diseases is rising rapidly globally. Heart transplant is one of the most last resort medical option for patients with heart failure. Unfortunately, this surgical intervention is associated with several serious complications including heart transplant rejection (HTR) and Cardiac Allograft Vasculopathy (CAV) which can manifest just within few years' posttransplant. These complications affect significantly the prognosis and quality of life among postheart transplant patients. Several medications including immunosuppressant, antibiotics, antihypertensive, and statins have been used during posttransplant care so as to address such complications. Unfortunately, most of those drugs are expensive and pose a number of serious side effects to the patients enough to compromise patients' quality of life too. Several studies on Vitamin C are therapeutically suggestive that it can be used during postheart transplant care with more cost-effective benefits with less and minimized side effects compared to the current drugs in place. It should be considered pharmacologically that Vitamin C has a great potential role clinically in prevention and control of HTR and CAV development. On the light of such findings as described above, we recommend more studies especially clinical trials and molecular studies to determine whether Vitamin C can be repositioned to replace or to be used along the current drug regimens used in postheart transplant care for prevention and control of HTR and CAV.

Technology Usage, Physical Activity, and Motivation in Patients With Heart Failure and Heart Transplantation

The cross-sectional study enrolled 231 patients with heart failure (n = 115; 60.87% were men; mean age, 74.34 ± 12.70 years) and heart transplantation (n = 116; 72.41% were men; mean age, 56.85 ± 11.87 years) who self-reported their technology usage, physical activity, and source of motivation for exercise. Patients with heart failure were significantly older ( P = .0001) than patients with heart transplantation. Physical activity levels in patients with heart failure decreased as the New York Heart Association classification increased. Patients with heart failure reported significantly lower physical activity than patients with heart transplantation ( P = .0008). Smartphones were the most widely used electronic device to access the Internet in both groups. Patients with heart transplantation seemed to use more than one device to access the Internet. In both groups, patients reporting more technology usage also reported higher levels of physical activity. Patients who accessed the Internet daily reported lower levels of physical activity. Whereas patients with heart failure identified encouragement by family members as a source of motivation for exercise, patients with heart transplantation reported that they were likely to exercise if motivated by their healthcare provider. Patients with heart failure and heart transplantation have unique technological and motivational needs that need consideration for mobile health-driven interventions.

Pressure overload-induced systolic heart failure is associated with characteristic myocardial microRNA expression signature and post-transcriptional gene regulation in male rats

Although systolic function characteristically shows gradual impairment in pressure overload (PO)-evoked left ventricular (LV) hypertrophy (LVH), rapid progression to congestive heart failure (HF) occurs in distinct cases. The molecular mechanisms for the differences in maladaptation are unknown. Here, we examined microRNA (miRNA) expression and miRNA-driven posttranscriptional gene regulation in the two forms of PO-induced LVH (with/without systolic HF). PO was induced by aortic banding (AB) in male Sprague-Dawley rats. Sham-operated animals were controls. The majority of AB animals demonstrated concentric LVH and slightly decreased systolic function (termed as ABLVH). In contrast, in some AB rats severely reduced ejection fraction, LV dilatation and increased lung weight-to-tibial length ratio was noted (referred to as ABHF). Global LV miRNA sequencing revealed fifty differentially regulated miRNAs in ABHF compared to ABLVH. Network theoretical miRNA-target analysis predicted more than three thousand genes with miRNA-driven dysregulation between the two groups. Seventeen genes with high node strength value were selected for target validation, of which five (Fmr1, Zfpm2, Wasl, Ets1, Atg16l1) showed decreased mRNA expression in ABHF by PCR. PO-evoked systolic HF is associated with unique miRNA alterations, which negatively regulate the mRNA expression of Fmr1, Zfmp2, Wasl, Ets1 and Atg16l1.

Clinical Profile, Health Care Costs, and Outcomes of Patients Hospitalized for Heart Failure With Severely Reduced Ejection Fraction

Background Many patients with heart failure (HF) have severely reduced ejection fraction but do not meet threshold for consideration of advanced therapies (ie, stage D HF). The clinical profile and health care costs associated with these patients in US practice is not well described. Methods and Results We examined patients hospitalized for worsening chronic heart failure with reduced ejection fraction ≤40% from 2014 to 2019 in the GWTG-HF (Get With The Guidelines-Heart Failure) registry, who did not receive advanced HF therapies or have end-stage kidney disease. Patients with severely reduced EF defined as EF ≤30% were compared with those with EF 31% to 40% in terms of clinical profile and guideline-directed medical therapy. Among Medicare beneficiaries, postdischarge outcomes and health care expenditure were compared. Among 113 348 patients with EF ≤40%, 69% (78 589) had an EF ≤30%. Patients with severely reduced EF ≤30% tended to be younger and were more likely to be Black. Patients with EF ≤30% also tended to have fewer comorbidities and were more likely to be prescribed guideline-directed medical therapy ("triple therapy" 28.3% versus 18.2%, P<0.001). At 12-months postdischarge, patients with EF ≤30% had significantly higher risk of death (HR, 1.13 [95% CI, 1.08-1.18]) and HF hospitalization (HR, 1.14 [95% CI, 1.09-1.19]), with similar risk of all-cause hospitalizations. Health care expenditures were numerically higher for patients with EF ≤30% (median US$22 648 versus $21 392, P=0.11). Conclusions Among patients hospitalized for worsening chronic heart failure with reduced ejection fraction in US clinical practice, most patients have severely reduced EF ≤30%. Despite younger age and modestly higher use of guideline-directed medical therapy at discharge, patients with severely reduced EF face heightened postdischarge risk of death and HF hospitalization.

Subcutaneous implantable cardioverter-defibrillator noise following left ventricular assist device implantation

Background

The incidence and impact of noise in a subcutaneous implantable cardioverter defibrillator (S-ICD) after left ventricular assist device (LVAD) implantation is not well established.

Methods

We performed a retrospective study of patients implanted with LVAD and with a pre-existing S-ICD between January 2005 and December 2020 at the three Mayo Clinic centers (Minnesota, Arizona, and Florida).

Results

Of the 908 LVAD patients, a pre-existing S-ICD was present in 9 patients (mean age 49.1 ± 13.7 years, 66.7% males), 100% with Boston Scientific third-generation EMBLEM MRI S-ICD, 11% with HeartMate II (HM II), 44% with HeartMate 3 (HM 3), and 44% with HeartWare (HW) LVAD. The incidence of noise from LVAD-related electromagnetic interference (EMI) was 33% and was only seen with HM 3 LVAD. Multiple measures attempted to resolve noise, including using alternative S-ICD sensing vector, adjusting S-ICD time zone, and increasing LVAD pump speed, were unsuccessful, necessitating S-ICD device therapies to be turned off permanently.

Conclusions

The incidence of LVAD-related S-ICD noise is high in patients with concomitant LVAD and S-ICD with significant impact on device function. As conservative management failed to resolve the EMI, the S-ICDs had to be programmed off to avoid inappropriate shocks. This study highlights the importance of awareness of LVAD-SICD device interference and the need to improve S-ICD detection algorithms to eliminate noise.

Alpha-1-Antitrypsin Protects Vascular Grafts of Brain-Dead Rats Against Ischemia/Reperfusion Injury

INTRODUCTION

Endothelial dysfunction is a potential side effect of brain death (BD). Ischemia/reperfusion (IR) injury during heart transplantation may lead to further endothelial damage. Protective effects of alpha-1-antitrypsin (AAT), a human neutrophil serine protease inhibitor, have been demonstrated against IR injury. We hypothesized that AAT protects brain-dead rats' vascular grafts from IR injury.

METHODS

Donor rats were subjected to BD by inflation of a subdural balloon. After 5.5 h, aortic rings were immediately mounted in organ baths (BD, n = 6 rats) or preserved in saline, supplemented either with vehicle (BD-IR, n = 8 rats) or AAT (BD-IR + AAT, n = 14 rats) for 24 h. During organ bath experiment, rings from both IR groups were exposed to hypochlorite to simulate warm reperfusion-associated endothelial injury. Endothelial function was measured ex vivo. Immunohistochemical staining for caspases was carried out and DNA-strand breaks were evaluated using terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling. Data are presented as median (interquartile range).

RESULTS

AAT improved IR-induced decreased maximum endothelium-dependent vasorelaxation to acetylcholine in the BD-IR + AAT aortas compared to the BD-IR group (BD: 83 (9-28) % versus BD-IR: 49 (39-60) % versus BD-IR + AAT: 64 (24-42) %, P < 0.05). Additionally, an increase in the rings' sensitivity to acetylcholine was noted after AAT (pD₂-value: BD-IR + AAT: 7.35 (7.06-7.89) versus BD-IR: 6.96 (6.65-7.21), P < 0.05). Caspase-3, -8, -9, and -12 immunoreactivity and the number of terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling-positive cells were significantly decreased by AAT.

CONCLUSIONS

AAT alleviates endothelial dysfunction, prevents increased caspase-3, -8, -9, and -12 levels, and decreases apoptotic DNA breakage due to BD and IR injury. This suggests that AAT treatment may be therapeutically beneficial to reduce IR-induced vascular damage.

The Role of Preoperative Chronic Statin Therapy in Heart Transplant Receipts-A Retrospective Single-Center Cohort Study

BACKGROUND

Statin therapy has been proven to reduce the risk of cardiovascular events. The objective of our retrospective study was to investigate the relationship between preoperative chronic administration of statins to postoperative 2-month heart transplantation complications.

METHODS

A total number of 38 heart transplantation recipients from the Cardiovascular and Transplant Emergency Institute of Târgu Mureș between May 2014 and January 2021 were included in our study.

RESULTS

In logistic regression, we found a statistical significance between statin treatment and the presence of postoperative complications of any cause (OR: 0.06, 95% CI: 0.008-0.56; p = 0.0128), simultaneously presenting an elevated risk for early-postoperative acute kidney injury (AKI). From the statin group, atorvastatin therapy had a higher risk of type 2 diabetes mellitus (T2DM) development (OR: 29.73, 95% CI: 1.19-741.76; p = 0.0387) and AKI (OR: 29.73, 95% CI: 1.19-741.76; p = 0.0387). C-reactive protein (CRP), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-c) represented risk factors, atorvastatin administration being independently associated with lower CRP values.

CONCLUSIONS

Chronic previous administration of statins represented a protective factor to the development of 2-month postoperative complications of any cause in heart transplant receipts.

Early Cardiopulmonary Fitness after Heart Transplantation as a Determinant of Post-Transplant Survival

BACKGROUND

Decreased peak oxygen consumption during exercise (peak Vo₂) is a well-established prognostic marker for mortality in ambulatory heart failure. After heart transplantation, the utility of peak Vo₂ as a marker of post-transplant survival is not well established.

METHODS AND RESULTS

We performed a retrospective analysis of adult heart transplant recipients at the Hospital of the University of Pennsylvania who underwent cardiopulmonary exercise testing within a year of transplant between the years 2000 to 2011. Using time-to-event models, we analyzed the hazard of mortality over nearly two decades of follow-up as a function of post-transplant percent predicted peak Vo₂ (%Vo₂). A total of 235 patients met inclusion criteria. The median post-transplant %Vo₂ was 49% (IQR 42 to 60). Each standard deviation (±14%) increase in %Vo₂ was associated with a 32% decrease in mortality in adjusted models (HR 0.68, 95% CI 0.53 to 0.87, p = 0.002). A %Vo₂ below 29%, 64% and 88% predicted less than 80% survival at 5, 10, and 15 years, respectively.

CONCLUSIONS

Post-transplant peak Vo₂ is a highly significant prognostic marker for long-term post-transplant survival. It remains to be seen whether decreased peak Vo₂ post-transplant is modifiable as a target to improve post-transplant longevity.

[The biomarkers BNP and NT-proBNP]

The present review of the biomarkers BNP and NT-pro-BNP is published in the series "biomarkers" of the Zentralblatt für Arbeitsmedizin, Arbeitsschutz und Ergonomie, which deals with the increasing use of the determination of specific markers in so-called manager preventive and check-up examinations. In principle, BNP and NT-pro-BNP are fundamentally suitable as markers for diagnosing acute and chronic heart failure and for assessing the course. In this context these show a high sensitivity and specificity.

Utility of the Fatigue, Resistance, Ambulation, Illness, and Loss of weight Scale in Older Patients with Cardiovascular Disease

OBJECTIVES

To compare the Fried criteria for frailty diagnosis with the Frailty Screening Index (FSI) and the fatigue, resistance, ambulation, illness, and loss of weight (FRAIL) scale in older patients with cardiovascular disease (CVD).

DESIGN

We conducted a retrospective 1-year follow-up cohort study of adult inpatients who participated in a cardiac rehabilitation program between June 2016 and September 2018.

SETTING AND PARTICIPANTS

We included 1472 Japanese patients age 65 years and older with CVD. After excluding 765 patients with incomplete frailty measurements, 707 patients were included in the analysis.

METHODS

Frailty and physical function were measured before hospital discharge according to each of the 3 definitions. Outcomes were all-cause mortality and physical dysfunction.

RESULTS

The prevalence of frailty according to the Fried criteria, the FRAIL scale, and the FSI was 213 (30.1%), 181 (25.6%), and 186 (26.3%), respectively. The FSI and the FRAIL scale showed moderate agreement with the Fried criteria [vs FSI: K = 0.52, 95% confidence interval (CI): 0.45-0.59; vs FRAIL scale: K = 0.45, 95% CI: 0.37-0.52; all P < .001]. We found a significant correlation between all-cause mortality and frailty assessed by all of the definitions, even after multivariate adjustment [FSI: hazard ratio (HR): 2.43, 95% CI: 1.30-4.58, P = .006; FRAIL scale: HR: 2.32, 95% CI: 1.21-4.45, P = .011; Fried criteria: HR: 1.99, 95% CI: 1.04-3.82, P = .038). However, the prediction accuracy of the FRAIL scale was higher than that of the FSI and comparable to that of the Fried criteria for physical dysfunction.

CONCLUSIONS AND IMPLICATIONS

The FSI and the FRAIL scale showed moderate agreement with the Fried criteria regarding frailty diagnostic performance and had comparable prognostic value. However, only the FRAIL scale was as accurate as the Fried criteria in screening for physical dysfunction.

ECMO Support in Refractory Cardiogenic Shock: Risk Factors for Mortality

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (va-ECMO) is a specialized temporary support for patients with refractory cardiogenic shock. The true value of this potentially lifesaving modality is still a subject of debate. Therefore, we aimed to investigate the overall in-hospital mortality and identify potential risk factors for mortality.

METHODS

We retrospectively analyzed the data of 453 patients supported with va-ECMO over a period of 14 years who were admitted to intensive care units of a tertiary university center in Austria.

RESULTS

We observed in-hospital mortality of 40% for patients with refractory cardiogenic shock. Hemorrhage, ECMO initiation on weekends, higher SAPS III score, and sepsis were identified as significant risk factors for mortality. Hemorrhage was the most common adverse event (46%), with major bleeding events dominating in deceased patients. Thromboembolic events occurred in 25% of patients, followed by sepsis (18%).

CONCLUSIONS

Although the rates of complications are substantial, a well-selected proportion of patients with refractory cardiogenic shock can be rescued from probable death. The reported risk factors could be used to increase the awareness of clinicians towards the development of new therapeutic concepts that may reduce their incidence.

Prognostic impact of the updated 2018 HFA-ESC definition of advanced heart failure: results from the HELP-HF registry

AIMS

The Heart Failure Association of the European Society of Cardiology (HFA-ESC) proposed a definition of advanced heart failure (HF) that has not been validated, yet. We assessed its prognostic impact in a consecutive series of patients with high-risk HF.

METHODS AND RESULTS

The HELP-HF registry enrolled consecutive patients with HF and at least one high-risk 'I NEED HELP' marker, evaluated at four Italian centres between 1^st January 2020 and 30^th November 2021. Patients meeting the HFA-ESC advanced HF definition were compared to patients not meeting this definition. The primary endpoint was the composite of all-cause mortality or first HF hospitalization. Out of 4753 patients with HF screened, 1149 (24.3%) patients with at least one high-risk 'I NEED HELP' marker were included (mean age 75.1 ± 11.5 years, 67.3% male, median left ventricular ejection fraction [LVEF] 35% [interquartile range 25%-50%]). Among them, 193 (16.8%) patients met the HFA-ESC advanced HF definition. As compared to others, these patients were younger, had lower LVEF, higher natriuretic peptides and a worse clinical profile. The 1-year rate of the primary endpoint was 69.3% in patients with advanced HF according to the HFA-ESC definition versus 41.8% in the others (hazard ratio [HR] 2.23, 95% confidence interval [CI] 1.82-2.74, p < 0.001). The prognostic impact of the HFA-ESC advanced HF definition was confirmed after multivariable adjustment for relevant covariates (adjusted HR 1.98, 95% CI 1.57-2.50, p < 0.001).

CONCLUSIONS

The HFA-ESC advanced HF definition had a strong prognostic impact in a contemporary, real-world, multicentre high-risk cohort of patients with HF.

Validation of R-hf risk score for risk stratification in ischemic heart failure patients: A prospective cohort study

Background

The aim of this study was to validate R-heart failure (R-hf) risk score in ischemic heart failure patients.

Methods

We prospectively recruited a cohort of 179 ischemic and 107 non-ischemic heart failure patients. This study mainly focused on ischemic heart failure patients. Non-ischemic heart failure patients were included for the purpose of validation of the risk score in various heart failure groups. Patients were stratified in high risk, moderate risk and low risk groups according to R-hf risk score.

Results

A total of 179 participants with ischemic heart failure were included. Based on R-hf risk score, 82 had high risk, 50 had moderate risk and 47 had low risk heart failure scores. More than half of the patients having R-hf score of <5 had renal failure (n = 91, 50.8%) and anemia (n = 99, 55.3%). Notably, HFrEF was more prevalent in patients with high risk score (74, 90.2%). Patients with high risk score had significantly higher creatinine (2.63 ± 1.96, p < 0.001), Troponin-T HS (59.9 ± 38.0, p < 0.001) and PRO BNP (17842 ± 6684, p < 0.001) when compared to patients with low and moderate risk score. Patients with low risk score had significantly higher Hb (13.2 ± 1.85, p < 0.001), Albumin (3.69 ± 0.42, p < 0.001) and GFR (90.0 ± 8.04, p < 0.001). A R-hf score of <5 was a significant predictor of mortality in ischemic (OR = 50.34; 95% CI [16.94–194.00, p < 0.001) and non-ischemic (OR = 46.34; 95% CI [12.97–225.39], p < 0.001) heart failure patients.

Conclusions

Lower R-hf risk score is a significant predictor of mortality in ischemic and non-ischemic heart failure patients. Risk score can be accessed at https://www.hfriskcalc.in.

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R-hf risk score is a robust tool (a derivative of e-GFR, EF, Hb, and NT proBNP) to predict heart failure mortality.

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Lower R-hf risk score is a significant predictor of mortality.

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Rajan's-hf risk score calculator will be available at https://www.hfriskcalc.in/.

Effectiveness and cost-efficacy of diuretics home administration via peripherally inserted central venous catheter in patients with end-stage heart failure

BACKGROUND

End-stage heart failure (ESHF) is characterized by severe cardiac dysfunction with persistent disabling symptoms and recurrent acute decompensated heart failure (ADHF), despite guideline-directed medical therapy. The aim of this study was to evaluate the efficacy and safety of intravenous diuretics administration at home through a peripherally inserted central venous catheter (PICC) in ESHF patients.

METHODS AND RESULTS

Forty-one ESHF patients received PICC implantation for intravenous diuretic administration at home. The primary efficacy endpoint was the patient-level number of HF hospitalizations in the short (1-3 months), medium (six months), and long term (1 year), before and after PICC implantation. Pre- and post-PICC ADHF-free days were also evaluated as co-primary endpoint. Secondary endpoints comprised changes in clinical, laboratory and echocardiographic parameters, and device safety. A cost-effectiveness analysis was performed to estimate the economic impact of using PICC. For each time frame analyzed, a significant reduction in the number of hospitalizations due to ADHF was observed, resulting in a significant increase in ADHF-free days (71 ± 44 vs. 163 ± 136, p = 0.003). In matched patients' analysis, significant decrease in body weight (68 ± 16 kg vs. 63 ± 10 kg, p = 0.041) and mitral regurgitation grade 3/4 (55% vs. 18%, p < 0.001) were also observed. Freedom from PICC-related complications was observed in 61% of patients. A significant reduction in overall ADHF-hospitalizations cost was observed.

CONCLUSIONS

This proof-of-concept study demonstrates the effectiveness and safety of home administration of intravenous diuretic therapy via PICC in ESHF patients. This palliative cost-effective strategy can be taken in consideration for selected end-stage patients no longer responsive to conventional therapies.

Feasibility of inpatient cardiac rehabilitation after percutaneous mitral valve reconstruction using clipping procedures: a retrospective analysis

Background

To date, no studies on the feasibility or outcomes of cardiac rehabilitation (CR) after percutaneous mitral valve reconstruction using clipping procedures have been published. The aim of this study was to report on our first experiences with this special target group.

Methods

Monocentric retrospective analysis of 27 patients (72 ± 12 years old, 52% female) who underwent multimodal inpatient CR in the first 2 month after MitraClip™ implantation. A six-minute-walking-test, a handgrip-strength-test and the Berg-Balance-Scale was conducted at the beginning and end of CR. Echocardiography was performed to rule out device-related complications.

Results

Adapted inpatient CR started 16 ± 13 days after clipping intervention and lasted 22 ± 4 days. In 4 patients (15%) CR had to be interrupted or aborted prematurely due to cardiac decompensations. All other patients (85%) completed CR period without complications. Six-minute-walking-distance improved from 272 ± 97 to 304 ± 111 m (p < .05) and dependence on rollator walker or walking aids was significantly reduced (p < .05). Results of handgrip-strength-test and Berg-Balance-Scale increased (p < .05). Overall, social-medical and psychological consultations were well received by the patients and no device-related complications occurred during rehabilitation treatments.

Conclusions

The results indicate that an adapted inpatient CR in selected patients after MitraClip™ implantation is feasible. Patients benefited from treatments both at functional and social-medical level and no device-related complications occurred. Larger controlled studies are needed.

Left Ventricular Assist Devices: A Primer for the Non-Mechanical Circulatory Support Provider

Survival after implant of a left ventricular assist device (LVAD) continues to improve for patients with end-stage heart failure. Meanwhile, more patients are implanted with a destination therapy, rather than bridge-to-transplant, indication, meaning the population of patients living long-term on LVADs will continue to grow. Non-LVAD healthcare providers will encounter such patients in their scope of practice, and familiarity and comfort with the physiology and operation of these devices and common problems is essential. This review article describes the history, development, and operation of the modern LVAD. Common LVAD-related complications such as bleeding, infection, stroke, and right heart failure are reviewed and an approach to the patient with an LVAD is suggested. Nominal operating parameters and device response to various physiologic conditions, including hypo- and hypervolemia, hypertension, and device failure, are reviewed.

Optimal cutoff values for physical function tests in elderly patients with heart failure

Six-minute walk distance (6MWD) of 300 and 400 m are important targets of functional capacity. The present study was performed to determine cutoff values of physical function associated with 6MWD < 300 m and < 400 m in elderly patients with heart failure (HF). 6MWD, handgrip strength, quadriceps isometric strength (QIS), one-leg standing time (OLST), and 5-times sit-to-stand (5STS) before hospital discharge were evaluated in 1001 patients > 65 years (median age, 75: interquartile range, 71-80, 607 men) with HF. 6MWD < 300 and < 400 m were seen in 323 patients (32.3%) and 658 patients (65.7%), respectively. Handgrip strength, QIS, OLST, and 5STS were associated with 6MWD < 300 and < 400 m, respectively (P < 0.001). The cutoff values of handgrip strength, QIS, OLST, and 5STS were 18.9 kg, 35.0% body mass (BM), 9.1 s, and 9.5 s for 6MWD < 300 m, and 21.9 kg, 40.0% BM, 12.0 s, and 8.8 s for < 400 m, respectively. The cutoff values of physical function could be used to set cardiac rehabilitation goals and limiting determinants of reduced functional capacity in a clinical setting in elderly patients with HF.

Rationale, Design, and Baseline Characteristics of the CURRENT AS Registry-2

BACKGROUND

There is scarce data evaluating the current practice pattern and clinical outcomes for patients with severe aortic stenosis (AS), including both those who underwent surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) and those who were managed conservatively in the TAVI era.Methods and Results: The Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis (CURRENT AS) Registry-2 is a prospective, physician-initiated, multicenter registry enrolling consecutive patients who were diagnosed with severe AS between April 2018 and December 2020 among 21 centers in Japan. The rationale for the prospective enrollment was to standardize the assessment of symptomatic status, echocardiographic evaluation, and other recommended diagnostic examinations such as computed tomography and measurement of B-type natriuretic peptide. Moreover, the schedule of clinical and echocardiographic follow up was prospectively defined and strongly recommended for patients who were managed conservatively. The entire study population consisted of 3,394 patients (mean age: 81.6 years and women: 60%). Etiology of AS was degenerative in 90% of patients. AS-related symptoms were present in 60% of patients; these were most often heart failure symptoms. The prevalence of high- and low-gradient AS was 58% and 42%, respectively, with classical and paradoxical low-flow low-gradient AS in 4.5% and 6.7%, respectively.

CONCLUSIONS

The CURRENT AS Registry-2 might be large and meticulous enough to determine the appropriate timing of intervention for patients with severe AS in contemporary clinical practice.

Advanced heart failure: guideline-directed medical therapy, diuretics, inotropes, and palliative care

Heart failure (HF) is a major cause of mortality, hospitalizations, and reduced quality of life and a major burden for the healthcare system. The number of patients that progress to an advanced stage of HF is growing. Only a limited proportion of these patients can undergo heart transplantation or mechanical circulatory support. The purpose of this review is to summarize medical management of patients with advanced HF. First, evidence-based oral treatment must be implemented although it is often not tolerated. New therapeutic options may soon become possible for these patients. The second goal is to lessen the symptomatic burden through both decongestion and haemodynamic improvement. Some new treatments acting on cardiac function may fulfil both these needs. Inotropic agents acting through an increase in intracellular calcium have often increased risk of death. However, in the recent Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC-HF) trial, omecamtiv mecarbil was safe and effective in the reduction of the primary outcome of cardiovascular death or HF event compared with placebo (hazard ratio, 0.92; 95% confidence interval, 0.86-0.99; P = 0.03) and its effects were larger in those patients with more severe left ventricular dysfunction. Patients with severe HF who received omecamtiv mecarbil experienced a significant treatment benefit, whereas patients without severe HF did not (P = 0.005 for interaction). Lastly, clinicians should take care of the end of life with an appropriate multidisciplinary approach. Medical treatment of advanced HF therefore remains a major challenge and a wide open area for further research.

Delayed Improvement of Left Ventricular Function in Newly Diagnosed Heart Failure Depends on Etiology—A PROLONG-II Substudy

In patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF), three months of optimal therapy are recommended before considering a primary preventive implantable cardioverter-defibrillator (ICD). It is unclear which patients benefit from a prolonged waiting period under protection of the wearable cardioverter-defibrillator (WCD) to avoid unnecessary ICD implantations. This study included all patients receiving a WCD for newly diagnosed HFrEF (n = 353) at our center between 2012 and 2017. Median follow-up was 2.7 years. From baseline until three months, LVEF improved in patients with all peripartum cardiomyopathy (PPCM), myocarditis, dilated cardiomyopathy (DCM), or ischemic cardiomyopathy (ICM). Beyond this time, LVEF improved in PPCM and DCM only (10 ± 8% and 10 ± 12%, respectively), whereas patients with ICM showed no further improvement. The patients with newly diagnosed HFrEF were compared to 29 patients with a distinct WCD indication, which is an explantation of an infected ICD. This latter group had a higher incidence of WCD shocks and poorer overall survival. All-cause mortality should be considered when deciding on WCD prescription. In patients with newly diagnosed HFrEF, the potential for delayed LVEF recovery should be considered when timing ICD implantation, especially in patients with PPCM and DCM.

Reduction of Hospitalization and Mortality by Echocardiography-Guided Treatment in Advanced Heart Failure

In advanced heart failure (AHF) clinical evaluation fails to detect subclinical HF deterioration in outpatient settings. The aim of the study was to determine whether the strategy of intensive outpatient echocardiographic monitoring, followed by treatment modification, reduces mortality and re-hospitalizations at 12 months. Methods: 214 patients with ejection fraction < 30% and >1 hospitalization during the last year underwent clinical evaluation and echocardiography at discharge and were divided into intensive (IMG; N = 143) or standard monitoring group (SMG; N = 71). In IMG, volemic status and left ventricular filling pressure were assessed 14, 30, 90, 180 and 365 days after discharge. HF treatment, particularly diuretic therapy, was temporarily intensified when HF deterioration signs and E/e’ > 15 were detected. In SMG, standard outpatient monitoring without obligatory echocardiography at outpatient visits was performed. Results: We observed lower hospitalization (absolute risk reduction [ARR]-0.343, CI-95%: 0.287−0.434, p < 0.05; number needed to treat [NNT]-2.91) and mortality (ARR-0.159, CI 95%: 0.127−0.224, p < 0.05; NNT-6.29) in IMG at 12 months. One-year survival was 88.8% in IMG and 71.8% in SMG (p < 0.05). Conclusion: In AHF, outpatient monitoring of volemic status and intracardiac filling pressures to individualize treatment may potentially reduce hospitalizations and mortality at 12 months follow-up. Echocardiography-guided outpatient therapy is feasible and clinically beneficial, providing evidence for the larger application of this approach.

Contemporary Drug Treatment of Advanced Heart Failure with Reduced Ejection Fraction

The introduction of multiple new pharmacological agents over the past three decades in the field of heart failure with reduced ejection fraction (HFrEF) has led to reduced rates of mortality and hospitalizations, and consequently the prevalence of HFrEF has increased, and up to 10% of patients progress to more advanced stages, characterized by high rates of mortality, hospitalizations, and poor quality of life. Advanced HFrEF patients often show persistent or progressive signs of severe HF symptoms corresponding to New York Heart Association class III or IV despite being on optimal medical, surgical, and device therapies. However, a subpopulation of patients with advanced HF, those with the most advanced stages of disease, were often insufficiently represented in the major trials demonstrating efficacy and tolerability of the drugs used in HFrEF due to exclusion criteria such as low BP and kidney dysfunction. Consequently, the results of many landmark trials cannot necessarily be transferred to patients with the most advanced stages of HFrEF. Thus, the efficacy and tolerability of guideline-directed medical therapies in patients with the most advanced stages of HFrEF often remain unsettled, and this knowledge is of crucial importance in the planning and timing of consideration for referral for advanced therapies. This review discusses the evidence regarding the use of contemporary drugs in the advanced HFrEF population, covering components such as guideline HFrEF drugs, diuretics, inotropes, and the use of HFrEF drugs in LVAD recipients, and provides suggestions on how to manage guideline-directed therapy in this patient group.

A Preliminary Case-Control Study: Peritoneal Approach in Congestive Heart Failure Treatment

BACKGROUND

Congestive heart failure (CHF) associated with worsening renal function is a very common disorder, and, as well known, the goal of the treatment is reducing venous congestion and maintaining a targeted extracellular volume. The objective of the study is to evaluate regular peritoneal ultrafiltration treatment compared to a standard conservative approach in NYHA III-IV CHF patients. In particular, the primary endpoints of the study were the major event-free survival and the total days of medical care per month (which consist of the days of hospitalization and the number of outpatient visits).

MATERIAL AND METHODS

This is a retrospective case-control study. Twenty-four patients were included in the present study. Twelve consecutive patients were treated with peritoneal treatment (group A) and 12 matched for age, gender, and severity of disease with a standard approach. Patients were observed over a maximum period of 18 months. Information on events, hospitalizations, and number of visits was collected during follow-up.

RESULTS

During the follow-up, we observed a major event in 4 patients in group A (33.3%) and in 8 patients in group B (66.7%). In group B, we observed 7 deaths and 1 ICD shock, while in group A, 3 deaths and 1 ICD shock. The number of visits per month was significantly lower in patients treated with the peritoneal method (1.2 [0.4-4.1] vs. 2.5 [2.0-3.1]; p = 0.03). The total days of medical care was significantly lower in group A (2.0 [1.1-5.5] vs. 4.4 [3.0-8.7]; p = 0.034). A multiple event analysis according to the Andersen-Gill model showed a significant event-free survival for group A. During the follow-up, we did not observe any episode of peritonitis in the treated group.

CONCLUSIONS

Our study shows that the peritoneal technique is a good therapeutic tool in well-selected patients with CHF. In accordance with prior experience, this intervention has not only an important and significant clinical impact but also potential economic and social consequences.

Efficacy and safety of intermittent repeated levosimendan infusions in advanced heart failure patients: the LAICA study

Aims

The aim of the LAICA study was to evaluate the long‐term effectiveness and safety of intermittent levosimendan infusion in patients with advanced heart failure (AdHF).

Methods and results

This was a multicentre, randomized, double‐blind, placebo‐controlled clinical trial of intermittent levosimendan 0.1 μg/kg/min as a continuous 24‐h intravenous infusion administered once monthly for 1 year in patients with AdHF. The primary endpoint [incidence of rehospitalization (admission to the emergency department or hospital ward for >12 h) for acute decompensated HF or clinical deterioration of the underlying HF] occurred in 23/70 (33%) of the levosimendan group (Group I) and 12/27 (44%) of the placebo group (Group II) (P = 0.286). The incidence of hospital readmissions for acute decompensated HF (Group I vs. Group II) at 1, 3, 6, and 12 months was 4.2% vs. 18.2% (P = 0.036); 12.8% vs. 33.3% (P = 0.02); 25.7% vs. 40.7% (P = 0.147); 32.8% vs. 44.4% (P = 0.28), respectively. In a secondary pre‐specified time‐to‐event analysis no differences were observed in admission for acute decompensated HF between patients treated with levosimendan compared with placebo (hazard ratio 0.66; 95% CI, 0.32–1.32; P = 0.24). Cumulative incidence for the aggregated endpoint of acute decompensation of HF and/or death at 1 and 3 months were significatively lower in the levosimendan group than in placebo group [5.7% vs. 25.9% (P = 0.004) and 17.1% vs. 48.1% (P = 0.001), respectively], but not at 6 and 12 months [34.2% vs. 59.2% (P = 0.025); 41.4% vs. 66.6% (P = 0.022), respectively]. Survival probability was significantly higher in patients who received levosimendan compared with those who received placebo (log rank: 4.06; P = 0.044). There were no clinically relevant differences in tolerability between levosimendan and placebo and no new safety signals were observed.

Conclusions

In our study, intermittent levosimendan in patients with AdHF produced a statistically non‐significant reduction in the incidence of hospital readmissions for acute decompensated HF, a significantly lower cumulative incidence of acute decompensation of HF and/or death at 1 and 3 month of treatment and a significant improvement in survival during 12 months of treatment.

Assessment of Omecamtiv Mecarbil for the Treatment of Patients With Severe Heart Failure: A Post Hoc Analysis of Data From the GALACTIC-HF Randomized Clinical Trial

Importance

Heart failure with reduced ejection fraction is a progressive clinical syndrome, and many patients' condition worsen over time despite treatment. Patients with more severe disease are often intolerant of available medical therapies.

Objective

To evaluate the efficacy and safety of omecamtiv mecarbil for the treatment of patients with severe heart failure (HF) enrolled in the Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC-HF) randomized clinical trial.

Design, Setting, and Participants

The GALACTIC-HF study was a global double-blind, placebo-controlled phase 3 randomized clinical trial that was conducted at multiple centers between January 2017 and August 2020. A total of 8232 patients with symptomatic HF (defined as New York Heart Association symptom class II-IV) and left ventricular ejection fraction of 35% or less were randomized to receive omecamtiv mecarbil or placebo and followed up for a median of 21.8 months (range, 15.4-28.6 months). The current post hoc analysis evaluated the efficacy and safety of omecamtiv mecarbil therapy among patients classified as having severe HF compared with patients without severe HF. Severe HF was defined as the presence of all of the following criteria: New York Heart Association symptom class III to IV, left ventricular ejection fraction of 30% or less, and hospitalization for HF within the previous 6 months.

Interventions

Participants were randomized at a 1:1 ratio to receive either omecamtiv mecarbil or placebo.

Main Outcomes and Measures

The primary end point was time to first HF event or cardiovascular (CV) death. Secondary end points included time to CV death and safety and tolerability.

Results

Among 8232 patients enrolled in the GALACTIC-HF clinical trial, 2258 patients (27.4%; mean [SD] age, 64.5 [11.6] years; 1781 men [78.9%]) met the specified criteria for severe HF. Of those, 1106 patients were randomized to the omecamtiv mecarbil group and 1152 to the placebo group. Patients with severe HF who received omecamtiv mecarbil experienced a significant treatment benefit for the primary end point (hazard ratio [HR], 0.80; 95% CI, 0.71-0.90), whereas patients without severe HF had no significant treatment benefit (HR, 0.99; 95% CI, 0.91-1.08; P = .005 for interaction). For CV death, the results were similar (HR for patients with vs without severe HF: 0.88 [95% CI, 0.75-1.03] vs 1.10 [95% CI, 0.97-1.25]; P = .03 for interaction). Omecamtiv mecarbil therapy was well tolerated in patients with severe HF, with no significant changes in blood pressure, kidney function, or potassium level compared with placebo.

Conclusions and Relevance

In this post hoc analysis of data from the GALACTIC-HF clinical trial, omecamtiv mecarbil therapy may have provided a clinically meaningful reduction in the composite end point of time to first HF event or CV death among patients with severe HF. These data support a potential role of omecamtiv mecarbil therapy among patients for whom current treatment options are limited.

Trial Registration

ClinicalTrials.gov Identifier: NCT02929329.

Advanced Heart Failure: Definition, Epidemiology, and Clinical Course

Advanced heart failure (HF) is characterized by a progressive worsening of symptoms disabling for daily life, refractory to all therapies, and with high mortality. These patients may be candidates for life-prolonging therapies, such as heart transplantation (HT) or long-term (LT) mechanical circulatory support (MCS) or must just require palliative therapies. The 1-year survival after HT and/or LT-MCS is approaching 80% to 90%, being patient selection and timely referral to advanced HF centers critical for optimal outcomes. There is no single symptom, sign, or test that can identify these patients and different classifications are complementary and helpful for clinical decision-making.

Usefulness of physical function sub-item of SF-36 survey to predict exercise intolerance in patients with heart failure

Background

Exercise intolerance is widely known to be a major cardinal symptom in patients with heart failure (HF), but due to the recent coronavirus disease 2019 epidemic, it is still difficult to directly measure exercise tolerance in many hospitals and facilities. The 36-Item Short-Form Health Survey physical functioning (SF-36PF) pertain to lower extremity functioning and walking. The purpose of this study was to investigate whether SF-36PF is a useful predictor of exercise intolerance and to provide its optimal cut-off value for patients with HF.

Methods and results

SF-36PF and 6-min walking distance (6MWD) were evaluated in 372 consecutive patients with HF. Exercise intolerance was defined at 6MWD cut-offs of 200, 300, and 400 m. The addition of SF-36PF to the pre-existing determinants of exercise tolerance significantly improved the area under the curve scores (0.85 vs. 0.89, P = 0.011 for 6MWD <200 m; 0.90 vs. 0.93, P = 0.001 for 6MWD <300 m; 0.88 vs. 0.90, P = 0.021 for 6MWD <400 m) for the predictive effect on exercise intolerance. The cut-off values of SF-36PF for predicting exercise intolerance defined by 6MWD <200, 300, and 400 m were 45, 50, and 70, respectively.

Conclusions

SF-36PF is a useful tool as an alternative index to predict exercise intolerance in patients with HF.

Medical malpractice in heart transplantation from 1994 to 2019

BACKGROUND

Heart transplantation is a unique clinical intervention because it involves two separate parties, the donor and the recipient. This increases the potential for the legal liability of heart teams involved with heart transplantation, but there is no research that exists to date that analyzes the etiology of medical malpractice litigations relating to heart transplantation.

METHODS

The Westlaw legal database was queried for all medical malpractice litigations concerning heart transplantation from 1994 to 2019 in the United States. Individual litigations were reviewed for inclusion, resulting in 41 included cases, and then analyzed for legal and clinical data. Statistical analyses were performed with the Fisher exact test and Mann-Whitney U tests.

RESULTS

The mean age of patients involved in these litigations was 38.88 years, with female patients being younger on average. Female patients received a significantly larger average award than male counterparts (p = .03). Alleged failure to diagnose was significantly associated with settlements (p = .047). An alleged failure to obtain informed consent as presented by the plaintiff was significantly associated with defendant verdicts (p = .03). Incidence of stroke and infection were each significantly associated with nondefendant verdicts (p = .02 and p = .02).

CONCLUSIONS

There should be an emphasis on documenting informed consent from all involved parties in heart transplantation to limit litigations filed against clinicians. As technologies and growing donor pools increase the prevalence of heart transplantation, clinicians would be well-served to be aware of legally tenable practices that will allow them to adopt a higher transplant volume without simultaneously adopting added legal exposure.

Identification of novel circulating microRNAs in advanced heart failure by next-generation sequencing

Aims

Risk stratification in patients with advanced chronic heart failure (HF) is an unmet need. Circulating microRNA (miRNA) levels have been proposed as diagnostic and prognostic biomarkers in several diseases including HF. The aims of the present study were to characterize HF‐specific miRNA expression profiles and to identify miRNAs with prognostic value in HF patients.

Methods and results

We performed a global miRNome analysis using next‐generation sequencing in the plasma of 30 advanced chronic HF patients and of matched healthy controls. A small subset of miRNAs was validated by real‐time PCR (P < 0.0008). Pearson's correlation analysis was computed between miRNA expression levels and common HF markers. Multivariate prediction models were exploited to evaluate miRNA profiles' prognostic role. Thirty‐two miRNAs were found to be dysregulated between the two groups. Six miRNAs (miR‐210‐3p, miR‐22‐5p, miR‐22‐3p, miR‐21‐3p, miR‐339‐3p, and miR‐125a‐5p) significantly correlated with HF biomarkers, among which N‐terminal prohormone of brain natriuretic peptide. Inside the cohort of advanced HF population, we identified three miRNAs (miR‐125a‐5p, miR‐10b‐5p, and miR‐9‐5p) altered in HF patients experiencing the primary endpoint of cardiac death, heart transplantation, or mechanical circulatory support implantation when compared with those without clinical events. The three miRNAs added substantial prognostic power to Barcelona Bio‐HF score, a multiparametric and validated risk stratification tool for HF (from area under the curve = 0.72 to area under the curve = 0.82).

Conclusions

This discovery study has characterized, for the first time, the advanced chronic HF‐specific miRNA expression pattern. We identified a few miRNAs able to improve the prognostic stratification of HF patients based on common clinical and laboratory values. Further studies are needed to validate our results in larger populations.

Clinical Significance of Variants in the TTN Gene in a Large Cohort of Patients With Sporadic Dilated Cardiomyopathy

Background: Mutations in the TTN gene are the most common causes of dilated cardiomyopathy (DCM). The clinical significance of TTN gene variants remains inadequately understood.

Methods: Whole-exome sequencing and phenotypic characterisation were performed, and patients were followed up for a median of 44 months.

Results: We analyzed the association of the TTN variants with the clinical outcomes in a prospective study of 1,041 patients with sporadic DCM. TTN truncating variants (tTTN) were detected in 120 (11.5%) patients as compared with 2.4/10,000 East Asian populations in the Genome Aggregation Database (GnomAD; p < 0.0001). Pathogenic TTN missense variants were also enriched in DCM as compared with the GnomAD populations (27.6 vs. 5.9%, p < 0.0001). DCM patients with tTTN had a lower left ventricular ejection fraction (28.89 ± 8.72 vs. 31.81 ± 9.97, p = 0.002) and a lower frequency of the left bundle branch block (3.3 vs. 11.3%, p = 0.011) than those without or with mutations in other known causal genes (OCG). However, tTTN were not associated with the composite primary endpoint of cardiac death and heart transplantation during the follow-up period [adjusted hazard ratio (HR): 0.912; 95% confidence interval: 0.464–1.793; p = 0.790]. There was also no sex-dependent effect. Concomitant tTTN and pathogenic variants in OCG were present in only eight DCM patients and did not affect the outcome.

Conclusion: The phenotype of DCM caused by tTTN, major causes of sporadic DCM, is not distinctly different from those caused by other causal genes for DCM.

MicroRNAs as theranostic markers in cardiac allograft transplantation: from murine models to clinical practice

Congestive heart failure affects about 23 million people worldwide, and cardiac allograft transplantation remains one of the last options for patients with terminal refractory heart failure. Besides the infectious or oncological complications, the prognosis of patients after heart transplantation is affected by acute cellular or antibody-mediated rejection and allograft vasculopathy development. Current monitoring of both conditions requires the performance of invasive procedures (endomyocardial biopsy sampling and coronary angiography or optical coherence tomography, respectively) that are costly, time-demanding, and non-comfortable for the patient. Within this narrative review, we focus on the potential pathophysiological and clinical roles of microRNAs (miRNAs, miRs) in the field of cardiac allograft transplantation. Firstly, we provide a general introduction about the status of cardiac allograft function monitoring and the discovery of miRNAs as post-transcriptional regulators of gene expression and clinically relevant biomarkers found in the extracellular fluid. After this general introduction, information from animal and human studies are summarized to underline the importance of miRNAs both in the pathophysiology of the rejection process, the possibility of its modulation by altering miRNAs levels, and last but not least, about the use of miRNAs in the clinical practice to diagnose or predict the rejection occurrence.

Overview of Options for Mechanical Circulatory Support

Mechanical circulatory support is used widely in acute setting of myocardial infarction, myocarditis, and cardiogenic shock as well as in chronic scenarios with advanced end-stage heart failure. Different algorithmic approaches can help the clinician decide the type of support required in a high morbidity and mortality setting. It is paramount to emphasize the need for a multidisciplinary approach to make steadfast decisions in the acute settings of cardiogenic shock.

3-Dimensional Versus 2-Dimensional STE for Right Ventricular Myocardial Fibrosis in Patients With End-Stage Heart Failure

BACKGROUND

Longitudinal strain of the right ventricular (RV) free wall (RVFWLS) assessed by 2-dimensional (2D) speckle-tracking echocardiography (STE) has been recently demonstrated to correlate with the extent of RV myocardial fibrosis (MF). However, the value of 3-dimensional (3D) STE-derived strain parameters in predicting RV MF has not been investigated in patients with end-stage heart failure (HF).

OBJECTIVES

This study aimed to determine which RV strain parameter assessed by 2D-STE and 3D-STE was the most reliable parameter for predicting RV MF in patients with end-stage HF against histological confirmation of MF.

METHODS

A total of 105 consecutive patients with end-stage HF undergoing heart transplantation were enrolled in our study. The conventional RV function parameters, 2D-RVFWLS, and 3D-RVFWLS were obtained in these patients. The degree of MF was quantified by Masson trichrome staining in RV myocardial samples. The study population was divided into 3 groups according to the degree of MF on histology.

RESULTS

Patients with severe MF had lower 3D-RVFWLS, 2D-RVFWLS, and conventional parameters of RV function compared with those with mild and moderate MF. RV MF strongly correlated with 3D-RVFWLS (r = -0.72; p < 0.001), modestly with 2D-RVFWLS (r = -0.53; p < 0.001), and weakly with conventional RV function parameters (r = -0.21 to -0.49; p < 0.01). 3D-RVFWLS correlated best with the degree of MF (r = -0.72 vs. -0.21 to -0.53; p < 0.05) compared with 2D-RVFWLS and conventional RV function parameters. 3D-RVFWLS had the highest accuracy for detecting severe MF (area under the receiver-operating characteristic curve: 0.90 vs. 0.24-0.80; p < 0.05) compared with 2D-RVFWLS and conventional RV parameters. The model with 3D-RVFWLS (R² = 0.63; p < 0.001) was better in predicting the degree of RV MF than that with 2D-RVFWLS (R² = 0.54; p < 0.001).

CONCLUSIONS

3D-RVFWLS may be the most robust echocardiographic measure for predicting the extent of RV MF in patients with end-stage HF.

Local administration of porcine immunomodulatory, chemotactic and angiogenic extracellular vesicles using engineered cardiac scaffolds for myocardial infarction

The administration of extracellular vesicles (EV) from mesenchymal stromal cells (MSC) is a promising cell-free nanotherapy for tissue repair after myocardial infarction (MI). However, the optimal EV delivery strategy remains undetermined. Here, we designed a novel MSC-EV delivery, using 3D scaffolds engineered from decellularised cardiac tissue as a cell-free product for cardiac repair. EV from porcine cardiac adipose tissue-derived MSC (cATMSC) were purified by size exclusion chromatography (SEC), functionally analysed and loaded to scaffolds. cATMSC-EV markedly reduced polyclonal proliferation and pro-inflammatory cytokines production (IFNγ, TNFα, IL12p40) of allogeneic PBMC. Moreover, cATMSC-EV recruited outgrowth endothelial cells (OEC) and allogeneic MSC, and promoted angiogenesis. Fluorescently labelled cATMSC-EV were mixed with peptide hydrogel, and were successfully retained in decellularised scaffolds. Then, cATMSC-EV-embedded pericardial scaffolds were administered in vivo over the ischemic myocardium in a pig model of MI. Six days from implantation, the engineered scaffold efficiently integrated into the post-infarcted myocardium. cATMSC-EV were detected within the construct and MI core, and promoted an increase in vascular density and reduction in macrophage and T cell infiltration within the damaged myocardium. The confined administration of multifunctional MSC-EV within an engineered pericardial scaffold ensures local EV dosage and release, and generates a vascularised bioactive niche for cell recruitment, engraftment and modulation of short-term post-ischemic inflammation.

Mesenchymal stem cell-derived conditioned medium protects vascular grafts of brain-dead rats against in vitro ischemia/reperfusion injury

BACKGROUND

Brain death (BD) has been suggested to induce coronary endothelial dysfunction. Ischemia/reperfusion (IR) injury during heart transplantation may lead to further damage of the endothelium. Previous studies have shown protective effects of conditioned medium (CM) from bone marrow-derived mesenchymal stem cells (MSCs) against IR injury. We hypothesized that physiological saline-supplemented CM protects BD rats' vascular grafts from IR injury.

METHODS

The CM from rat MSCs, used for conservation purposes, indicates the presence of 23 factors involved in apoptosis, inflammation, and oxidative stress. BD was induced by an intracranial-balloon. Controls were subjected to a sham operation. After 5.5 h, arterial pressures were measured in vivo. Aortic rings from BD rats were harvested and immediately mounted in organ bath chambers (BD group, n = 7) or preserved for 24 h in 4 °C saline-supplemented either with a vehicle (BD-IR group, n = 8) or CM (BD-IR+CM group, n = 8), prior to mounting. Vascular function was measured in vitro. Furthermore, immunohistochemistry and quantitative real-time polymerase chain reaction (qRT-PCR) have been performed.

RESULTS

BD in donors was associated with significantly impaired hemodynamic parameters and higher immunoreactivity of aortic myeloperoxidase (MPO), nitrotyrosine, caspase-3, caspase-8, caspase-9, and caspase-12 compared to sham-operated rats. In organ bath experiments, impaired endothelium-dependent vasorelaxation to acetylcholine in the BD-IR group compared to BD rats was significantly improved by CM (maximum relaxation to acetylcholine: BD 81 ± 2% vs. BD-IR 50 ± 3% vs. BD-IR + CM 72 ± 2%, p < 0.05). Additionally, the preservation of BD-IR aortic rings with CM significantly lowered MPO, caspase-3, caspase-8, and caspase-9 immunoreactivity compared with the BD-IR group. Furthermore, increased mRNA expression of vascular cell adhesion molecule (VCAM)-1 and intercellular adhesion molecule (ICAM)-1 in the aortas from the BD-IR rats compared to BD group were significantly decreased by CM.

CONCLUSIONS

The preservation of BD rats' vascular grafts with CM alleviates endothelial dysfunction following IR injury, in part, by reducing levels of inflammatory response and caspase-mediated apoptosis.

BET bromodomain inhibition attenuates cardiac phenotype in myocyte-specific lamin A/C-deficient mice

Mutation in the LMNA gene, encoding lamin A/C, causes a diverse group of diseases called laminopathies. Cardiac involvement is the major cause of death and manifests as dilated cardiomyopathy, heart failure, arrhythmias, and sudden death. There is no specific therapy for LMNA-associated cardiomyopathy. We report that deletion of Lmna in cardiomyocytes in mice leads to severe cardiac dysfunction, conduction defect, ventricular arrhythmias, fibrosis, apoptosis, and premature death within 4 weeks. The phenotype is similar to LMNA-associated cardiomyopathy in humans. RNA sequencing, performed before the onset of cardiac dysfunction, led to identification of 2338 differentially expressed genes (DEGs) in Lmna-deleted cardiomyocytes. DEGs predicted activation of bromodomain-containing protein 4 (BRD4), a regulator of chromatin-associated proteins and transcription factors, which was confirmed by complementary approaches, including chromatin immunoprecipitation sequencing. Daily injection of JQ1, a specific BET bromodomain inhibitor, partially reversed the DEGs, including those encoding secretome; improved cardiac function; abrogated cardiac arrhythmias, fibrosis, and apoptosis; and prolonged the median survival time 2-fold in the myocyte-specific Lmna-deleted mice. The findings highlight the important role of LMNA in cardiomyocytes and identify BET bromodomain inhibition as a potential therapeutic target in LMNA-associated cardiomyopathy, for which there is no specific effective therapy.

Hybrid transcatheter left ventricular reconstruction for the treatment of ischemic cardiomyopathy

Left ventricular (LV) enlargement is a mechanical adaptation to accommodate LV systolic inefficiency following an acute damage or a progressive functional deterioration, which fails to correct the decline of stroke volume in the long term, leading to progressive heart failure (HF). Surgical ventricular reconstruction (SVR) is a treatment for patients with severe ischemic HF aiming to restore LV efficiency by volume reduction and LV re-shaping. Recently, a new minimally-invasive hybrid technique for ventricular reconstruction has been developed by means of the Revivent™ system (BioVentrix Inc., San Ramon, CA, USA). The device for ventricular reconstruction consists of anchor pairs that enable plication of the anterior and free wall LV scar against the right ventricular (RV) septal scar of anteroseptal infarctions to decrease cardiac volume without ventriculotomy in a beating-heart minimally-invasive procedure, consisting of a transjugular and left thoracotomy approach. Patients with severe (Grade 4) functional mitral regurgitation (FMR) or with previous cardiac surgery procedures were excluded. Outcome of the reconstruction procedure: from 2012 until 2019, it has been applied to 203 patients, with 5 (2.5%) in-hospital deaths. LV volume reduction varied according to experience gained along years: LV end-systolic volume index decreased from baseline 43% (post-market registry) vs. 27% (CE-mark study); left ventricular ejection fraction (LVEF) increased from baseline 25% (post-market registry) vs. 16% (CE-mark study). Clinical status (NYHA class, HF questionnaire, 6-minute walking test) improved significantly compared to baseline, and re-hospitalization rate was only 13% at 6-month follow-up (60% of patients in NYHA =3). FMR grade decreased at follow-up in 63%, while it was unchanged in 37% of patients. The hybrid ventricular reconstruction (HVR) seems a promising treatment for HF patients who may benefit from LV volume reduction, with reasonable mortality and good results at follow-up. A baseline less severe clinical profile was not associated to better outcome at follow-up, which makes the procedure feasible in patients with very large ventricles and depressed ejection fraction (EF). LV reshaping has no detrimental effect on FMR, that may, on the contrary, benefit owing to less papillary muscle displacement, partial recovery of torsion dynamics and of myofibers re-orientation. A controlled study on top of optimal medical treatment is warranted to confirm its role in the management of HF patients.

Hemodynamic effects of ivabradine use in combination with intravenous inotropic therapy in advanced heart failure

Intravenous inotropic therapy can be used in patients with advanced heart failure, as palliative therapy or as a bridge to cardiac transplantation or mechanical circulatory support, as well as in cardiogenic shock. Their use is limited to increasing cardiac output in low cardiac output states and reducing ventricular filling pressures to alleviate patient symptoms and improve functional class. Many advanced heart failure patients have sinus tachycardia as a compensatory mechanism to maintain cardiac output. However, excessive sinus tachycardia caused by intravenous inotropes can increase myocardial oxygen consumption, decrease coronary perfusion, and at extreme heart rates decrease ventricular filling and stroke volume. The limited available hemodynamic studies support the hypothesis that adding ivabradine, a rate control agent without negative inotropic effect, may blunt inotrope-induced tachycardia and its associated deleterious effects, while optimizing cardiac output by increasing stroke volume. This review analyzes the intriguing pathophysiology of combined intravenous inotropes and ivabradine to optimize the hemodynamic profile of patients in advanced heart failure. Graphical abstract Illustration of the beneficial and deleterious hemodynamic effects of intravenous inotropes in advanced heart failure, and the positive effects of adding ivabradine.

Long-term milrinone therapy as a bridge to heart transplantation: Safety, efficacy, and predictors of failure

BACKGROUND

Studies of long-term inotrope use in advanced HF have previously provided limited and conflicting results. This study aimed to evaluate the safety and efficacy of long-term milrinone use and identify predictors of failure to bridge to orthotropic heart transplant (OHT) in a cohort of end-stage heart failure (HF) patients listed for heart transplantation and receiving inotrope therapy.

METHODS

The study included 150 adults listed for OHT at a single center from 2001 to 2017 who received milrinone therapy for ≥30 days. Multivariate Cox proportional hazards models were used to identify factors associated with "failure" (left ventricular assist device, intra-aortic balloon pump, status downgrade due to instability, death) vs. "success" (OHT, recovery) during bridging to OHT.

RESULTS

"Failure" occurred in 33 (22%) patients. Factors independently associated with failure included male sex (HR = 7.6; p = 0.004), no implantable cardioverter-defibrillator (HR = 3.8; p = 0.009), and lack of guideline-directed medical therapy (GDMT) with a beta-blocker (HR = 7.8; p = 0.002) or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (HR = 6.3; p < 0.001). Patients who received fewer guideline-directed medications had a higher cumulative probability of failure. Adverse events included central line-associated bloodstream infection (2.55 per 1000 line-days) and arrhythmia (1.59 per 1000 treatment-days).

CONCLUSIONS

Our findings suggest that long-term milrinone therapy in selected patients is associated with a high rate of successful bridging to OHT and a low rate of adverse events. Patients intolerant of GDMT are more likely to fail to bridge to OHT without mechanical support. Sex differences in outcomes associated with milrinone therapy should be explored.

A review of the management of patients with advanced heart failure in the intensive care unit

Despite progress in the medical and device therapy for heart failure (HF), the prognosis for those with advanced HF remains poor. Acute heart failure (AcHF) is the rapid development of, or worsening of symptoms and signs of HF typically leading to hospitalization. Whilst many HF decompensations are managed at a ward-based level, a proportion of patients require higher acuity care in the intensive care unit (ICU). Admission to ICU is associated with a higher risk of in-hospital mortality, and in those who fail to respond to standard supportive and medical therapy, a proportion maybe suitable for mechanical circulatory support (MCS). The optimal pre-operative management of advanced HF patients awaiting durable MCS or cardiac transplantation (CTx) is vital in improving both short and longer-term outcomes. This review will summarize the clinical assessment, hemodynamic profiling and management of the patient with AcHF in the ICU. The general principles of pre-surgical optimization encompassing individual systems (the kidneys, the liver, blood and glycemic control) will be discussed. Other factors impacting upon post-operative outcomes including nutrition and sarcopenia and pre-surgical skin decolonization have been included. Issues specific to durable MCS including the assessment of the right ventricle and strategies for optimization will also be discussed.