The prognostic impact of a concentric left ventricular structure evaluated by transthoracic echocardiography in patients with acute decompensated heart failure: A retrospective study

The role of body composition in left ventricular remodeling, reverse remodeling, and clinical outcomes for heart failure with mildly reduced ejection fraction: more knowledge to the "obesity paradox"

BACKGROUND

Although the "obesity paradox" is comprehensively elucidated in heart failure (HF) with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF), the role of body composition in left ventricular (LV) remodeling, LV reverse remodeling (LVRR), and clinical outcomes is still unclear for HF with mildly reduced ejection fraction (HFmrEF).

METHODS

Our study is a single-centre, prospective, and echocardiography-based study. Consecutive HFmrEF patients, defined as HF patients with a left ventricular ejection fraction (LVEF) between 40 and 49%, between January 2016 to December 2021 were included. Echocardiography was re-examined at 3-, 6-, and 12-month follow-up to assess the LVRR dynamically. Body mass index (BMI), fat mass, fat-free mass, percent body fat (PBF), CUN-BAE index, and lean mass index (LMI) were adopted as anthropometric parameters in our study to assess body composition. The primary outcome was LVRR, defined as: (1) a reduction higher than 10% in LV end-diastolic diameter index (LVEDDI), or a LVEDDI < 33 mm/m2, (2) an absolute increase of LVEF higher than 10 points compared with baseline echocardiogram, or a follow-up LVEF ≥50%. The secondary outcome was a composite of re-hospitalization for HF or cardiovascular death.

RESULTS

A total of 240 HFmrEF patients were enrolled in our formal analysis. After 1-year follow-up based on echocardiography, 113 (47.1%) patients developed LVRR. Patients with LVRR had higher fat mass (21.7 kg vs. 19.3 kg, P = 0.034) and PBF (28.7% vs. 26.6%, P = 0.047) compared with those without. The negative correlation between anthropometric parameters and baseline LVEDDI was significant (all P < 0.05). HFmrEF patients with higher BMI, fat mass, PBF, CUN-BAE index, and LMI had more pronounced and persistent increase of LVEF and decline in LV mass index (LVMI). Univariable Cox regression analysis revealed that higher BMI (HR 1.042, 95% CI 1.002-1.083, P = 0.037) and fat mass (HR 1.019, 95% CI 1.002-1.036, P = 0.026) were each significantly associated with higher cumulative incidence of LVRR for HFmrEF patients, while this relationship vanished in the adjusted model. Mediation analysis indicated that the association between BMI and fat mass with LVRR was fully mediated by baseline LV dilation. Furthermore, higher fat mass (aHR 0.957, 95% CI 0.917-0.999, P = 0.049) and PBF (aHR 0.963, 95% CI 0.924-0.976, P = 0.043) was independently associated with lower risk of adverse clinical events.

CONCLUSIONS

Body composition played an important role in the LVRR and clinical outcomes for HFmrEF. For HFmrEF patients, BMI and fat mass was positively associated with the cumulative incidence of LVRR, while higher fat mass and PBF predicted lower risk of adverse clinical events but not LMI.

Risk Factors for All-Cause Mortality in Patients Diagnosed with Advanced Heart Failure: A Scoping Review

Introduction: Identifying the evolving needs of patients with advanced heart failure (AdHF) and triaging those at high risk of death can facilitate timely referrals to palliative care and advance patient-centered individualized care. There are limited models specific for patients with end-stage HF. We aim to identify risk factors associated with up to three-year all-cause mortality (ACM) and describe prognostic models developed or validated in AdHF populations. Methods: Frameworks proposed by Arksey, O'Malley, and Levac were adopted for this scoping review. We searched the Medline, EMBASE, PubMed, CINAHL, Cochrane library, Web of Science and gray literature databases for articles published between January 2010 and September 2020. Primary studies that included adults aged ≥ 18 years, diagnosed with AdHF defined as New York Heart Association class III/IV, American Heart Association/American College of Cardiology Stage D, end-stage HF, and assessed for risk factors associated with up to three-year ACM using multivariate analysis were included. Studies were appraised using the Quality of Prognostic Studies tool. Data were analyzed using a narrative synthesis approach. Results: We reviewed 167 risk factors that were associated with up to three-year ACM and prognostic models specific to AdHF patients across 65 articles with low-to-moderate bias. Studies were mostly based in Western and/or European cohorts (n = 60), in the acute care setting (n = 56), and derived from clinical trials (n = 40). Risk factors were grouped into six domains. Variables related to cardiovascular and overall health were frequently assessed. Ten prognostic models developed/validated on AdHF patients displayed acceptable model performance [area under the curve (AUC) range: 0.71-0.81]. Among the ten models, the model for end-stage-liver disease (MELD-XI) and acute decompensated HF with N-terminal pro b-type natriuretic peptide (ADHF/proBNP) model attained the highest discriminatory performance against short-term ACM (AUC: 0.81). Conclusions: To enable timely referrals to palliative care interventions, further research is required to develop or validate prognostic models that consider the evolving landscape of AdHF management.

Predictive value for mortality of left ventricular wall thickness in dilated cardiomyopathy

AIMS

The purpose of this study was to explore the predictive value of wall thickness measured by cardiac magnetic resonance (CMR) for all-cause mortality in dilated cardiomyopathy (DCM) patients.

METHODS AND RESULTS

DCM patients who underwent CMR and completed the regular follow-up were included in this study. The left ventricular end-diastolic diameter (LVDd), left ventricular end-diastolic volume (LVEDV), left ventricular posterior wall thickness (PWT), interventricular septum thickness (IVST), left ventricular ejection fraction, and left ventricular mass (LVM) were measured by CMR. The presence and extent of late gadolinium enhancement (LGE) were also assessed. The relative posterior wall thickness (RWTPW ) and relative interventricular septum wall thickness (RWTIVS ) were defined by the following equations: RWTPW  = (2 × PWT)/LVDd, and RWTIVS  = (2 × IVST)/LVDd. All patients received regular telephone and outpatient follow-up. The primary endpoint was all-cause mortality. A total of 161 patients were enrolled in this study, including 126 (78.3%) males. The mean age was 52.3 ± 13.6 years. During the median follow-up of 47 months (interquartile range 32-57 months), 41 (24.8%) patients died. Compared with the non-death group, LVDd (75.2 ± 11.9 vs. 70.5 ± 8.8 mm; P = 0.025) was greater in the death group, while PWT [5.2 mm (3.7-6.8) vs. 6.9 mm (5.3-8.6); P < 0.001], IVST [8.2 mm (6.5-9.5) vs. 9.3 mm (7.4-10.5); P = 0.005], RWTPW [0.15 (0.11-0.19) vs. 0.20 (0.15-0.25); P < 0.001], RWTIVS [0.22 (0.17-0.26) vs. 0.26 (0.22-0.31); P < 0.001], and LVM/LVEDV ratio (0.5 ± 0.2 vs. 0.7 ± 0.2 g/mL; P < 0.001) were lower. The presence of LGE [LGE(+)] was more frequent in the death group (75.6% vs. 58.3%; P = 0.048). However, the LGE extent was not significantly different between the two groups [4 (1-7) vs. 2 (0-6); P = 0.096]. Multivariate Cox regression analysis showed that PWT [hazard ratio (HR) 0.086, 95% confidence interval (CI) 0.665-0.976; P < 0.05] and RWTPW (HR 0.001, 95% CI 0.000-0.502; P < 0.05) were independent predictors of all-cause death. In contrast, IVST, RWTIVS , and the presence of LGE were not clearly associated with death.

CONCLUSIONS

PWT measured by CMR is an independent predictor of all-cause mortality in DCM patients. However, there was no significant correlation between septum wall thickness and mortality.

Identification of echocardiographic subgroups in patients with coronary heart disease combined with heart failure based on latent variable stratification

BACKGROUND

The prognosis of chronic heart failure is poor, and it remains a challenge to classify patients for better personalized intervention. This study aimed to explore potential subgroups in patients with coronary heart disease and chronic heart failure using comprehensive echocardiographic indices.

METHODS

5126 patients with coronary heart disease with chronic heart failure were included. Latent class analysis was applied to identify the grouping patterns of patients based on echocardiographic indices. Network maps and radar charts of echocardiographic indices were drawn to visualize the distribution of echocardiographic findings. The incidence of adverse outcomes was presented on the Kaplan-Meier curve and compared using the log-rank test. The Cox regression model was used to analyze the relationship between subgroups and mortality.

RESULTS

Three groups were identified: eccentric hypertrophy, concentric hypertrophy, and decreased diastolic function. Network plots showed a higher correlation between left atrial diameter, left ventricular mass index, and left ventricle ejection fraction in the eccentric hypertrophy group than in the other groups. The Kaplan-Meier curve showed a significant difference in mortality between the three subgroups (P < 0.001). Multivariate Cox analysis indicated that the eccentric hypertrophy group had the highest risk of death (HR = 1.586, 95% CI: 1.310-1.921, P < 0.001) compared with the other groups.

CONCLUSION

Patients with coronary heart disease and chronic heart failure can be classified into three subgroups based on echocardiographic indices. This grouping has been shown to be an independent risk factor for mortality in these patients. Accurate subgrouping based on echocardiographic indices is important for identifying high-risk patients.

The Impact of Noninvasive Ventilator Assisted Ventilation Nursing Combined with Mechanical Vibration on the Level of Heart Failure Indexes in ICU Patients with Acute Heart Failure

The acute attack of acute heart failure or the continuous deterioration of cardiac function leads to a series of changes such as reduced cardiac contractility, increased cardiac load, and a sudden drop of acute cardiac output, which eventually cause pulmonary circulation congestion and acute dyspnea due to acute pulmonary congestion. To observe the impact of noninvasive ventilator-assisted ventilation nursing combined with mechanical vibration on the level of heart failure indexes in intensive care unit (ICU) patients with acute heart failure, 120 patients with acute heart failure who were treated in the ICU ward of our hospital from September 2018 to March 2021 were selected, and the qualified subjects were divided into two groups according to the 1 : 1 principle by a simple random method. 120 patients were given conventional symptomatic treatment and noninvasive ventilator-assisted ventilation. The control group received conventional nursing intervention, and the observation group was given noninvasive ventilator-assisted ventilation nursing and mechanical vibration intervention. The respiratory system indexes, heart rate, blood pressure, central venous pressure, N-terminal B-type natriuretic peptide precursor (NT-proBNP), cardiac troponin T (cTnT), and cardiac function indexes of the two groups of patients are recorded, and the prognosis of the two groups is compared. After intervention, the partial pressure of oxygen (PaO2) and blood oxygen saturation (SpO2) in the two groups were higher than those before intervention, while the partial pressure of carbon dioxide (PaCO2), respiration (RR), heart rate, blood pressure, and central venous pressure were lower than those before intervention (P < 0.05). Compared with the control group, PaO2, SpO2, systolic blood pressure, diastolic blood pressure, and central venous pressure of the observation group after intervention were significantly higher, while PaCO2, RR, and heart rate were significantly lower (P < 0.05). Compared with the control group, the LVEF of the observation group after intervention was significantly higher, while NT-proBNP, cTnT, LVESD, and LVEDD were markedly lower (P < 0.05). The ventilation time and ICU hospitalization time in the observation group were shorter than those in the control group, and the pulmonary infection rate was lower than in the control group. The remission time of infection in patients with pulmonary infection was shorter than that in the control group. When comparing the 28d mortality rate with the control group, the difference was not statistically significant (P > 0.05). Noninvasive ventilator-assisted ventilation nursing combined with mechanical vibration can improve hypoxemia symptoms and heart function, stabilize hemodynamics, shorten the course of disease and reduce the occurrence of lung infections for those patients with acute heart failure in the ICU.

The Impact of Valvuloarterial Impedance on Left Ventricular Geometrical Change after Transcatheter Aortic Valve Replacement: A Comparison between Valvuloarterial Impedance and Mean Pressure Gradient

Increase in left ventricular (LV) mass develops as a compensatory mechanism against pressure overload in aortic valve stenosis. However, long-standing LV geometrical changes are related to poor prognosis. The LV geometrical change occurs after transcatheter aortic valve replacement (TAVR). The present study aimed to investigate the relationship between improvement in valvuloarterial impedance (Zva) and change in LV mass index (LVMI) and the ratio of LVMI to LV end-diastolic volume index (LVMI/LVEDVI). We compared these relationships to that between Zva and mean pressure gradient (MPG). Baseline and follow-up transthoracic echocardiograms of 301 patients who underwent TAVR from November 2011 to December 2015 were reviewed. Spearman correlation coefficient (ρ) was used to compare ΔLVMI and ΔLVMI/LVEDVI with Zva or MPG. The correlation between ΔZva and ΔLVMI (ρ = 0.47, p < 0.001) was superior to that between ΔMPG and ΔLVMI (ρ = 0.15, p = 0.009) (p for comparison < 0.001). The correlation between ΔZva and ΔLVMI/LVEDVI was statistically significant (ρ = 0.54, p < 0.001); in contrast, that of ΔMPG and ΔLVMI/LVEDVI was not. The improvement in Zva after TAVR was more closely related to LVMI and LVMI/LVEDVI reduction than MPG reduction.

Comparison of the prognostic values of three calculation methods for echocardiographic relative wall thickness in acute decompensated heart failure

Purpose

Left ventricular (LV) wall thickness can be measured at the posterior wall (PW) and the intraventricular septum (IVS) in a parasternal long axis view by transthoracic echocardiography. Thus, there are three methods to calculate relative wall thickness as follows: RWT_PW = 2 × PWth/LVDd; RWT_IVS + PW = (IVSth + PWth) /LVDd; and RWT_IVS = 2 × IVSth/LVDd (IVSth = interventricular septum thickness; LVDd = LV internal dimension at end--diastole; PWth = posterior wall thickness). The aim was to compare the prognostic values of these RWTs in patients with acute decompensated heart failure (ADHF).

Method

This was a single-center, retrospective, observational study at a Japanese community hospital. A total of 389 hospitalized ADHF patients were divided into two groups based on the three median RWT values. The primary outcome was all-cause death. Survival analysis was performed, and Cox proportional hazard models unadjusted and adjusted by Get With The Guideline score were used.

Results

High-RWT_PW had poor survival (log-rank, P = 0.009) and was a significant risk (unadjusted HR (95%CI), 1.72 (1.14–2.61), P = 0.01; adjusted HR, 1.95 (1.28–2.98), P = 0.02). High-RWT_IVS + PW was not associated with poor survival on survival analysis or the unadjusted Cox model. Only the adjusted Cox model showed that High-RWT_IVS + PW was associated with a significant risk of the primary outcome (unadjusted HR (95%CI), 1.45 (0.96–2.17), P = 0.07; adjusted HR, 1.53 (1.01–2.32), P = 0.045). High-RWT_IVS did not have significant prognostic value.

Conclusions

When calculating RWT, RWT_PW should be recommended for evaluating the mortality risk in ADHF.