First-Phase Ejection Fraction Predicts Response to Cardiac Resynchronization Therapy and Adverse Outcomes

First-phase ejection fraction to predict adverse outcomes in patients with heart failure

BACKGROUND

First-phase ejection fraction (EF1) is a novel measurement of early left ventricular systolic dysfunction. We investigate its prognostic value in patients with heart failure (HF).

METHODS AND RESULTS

Patients with HF were prospectively enrolled from July 2019 to September 2021. A total of 228 patients were included in the final analysis. The primary endpoint was the composite of all-cause mortality or rehospitalization for HF, which occurred in 74 patients (32.46%). EF1 as well as other parameters for left ventricular function were measured in echocardiography. Time-dependent ROC showed the cutoff value of EF1 was 18.55%. Kaplan-Meier analysis indicated a higher rate of adverse events in the lower EF1 group (EF1 ≤ 18.55%) (Log-rank test P < 0.001). Cox regression analyses showed EF1 was an independent predictor with adverse events as a continuous variable (Cox model 1: per 1% change in EF1: HR = 0.92, 95%CI: 0.87-0.97, P < 0.001), as well as a categorical variable (Cox model 2: EF1 > 18.55%: HR = 0.21, 95%CI: 0.08-0.53, P < 0.001) after adjustment for hypertension, coronary artery disease (CAD), Log10 (NT-proBNP), eGFR, E/e' and loop diuretics. Restricted cubic splines revealed a linear association between EF1 levels and the incidence of adverse events (P for non-linearity = 0.145). The subgroup analyses showed the predictive ability of elevated EF1 on the decreased risk of adverse events did not change substantially stratified by HF classification, age, CAD and hypertension.

CONCLUSION

EF1, as a novel measurement of early systolic function, is a promising predictor of adverse events among HF patients. EF1 might be considered a new measurement for risk stratification of HF.

Decline in Left Ventricular Early Systolic Function with Worsening Kidney Function in Children with Chronic Kidney Disease: Insights from the 4C and HOT-KID Studies

INTRODUCTION

Adults with childhood-onset chronic kidney disease (CKD) have an increased risk of cardiovascular disease. First-phase ejection fraction (EF1), a novel measure of early systolic function, may be a more sensitive marker of left ventricular dysfunction than other markers in children with CKD.

OBJECTIVE

To examine whether EF1 is reduced in children with CKD.

METHODS

Children from the 4C and HOT-KID studies were stratified according to estimated glomerular filtration rate (eGFR). The EF1 was calculated from the fraction of left ventricular (LV) volume ejected up to the time of peak aortic flow velocity.

RESULTS

The EF1 was measured in children ages 10.9 ± 3.7 (mean ± SD) years, 312 with CKD and 63 healthy controls. The EF1 was lower, while overall ejection fraction was similar, in those with CKD compared with controls and decreased across stages of CKD (29.3% ± 3.7%, 23.5% ± 4.5%, 19.8% ± 4.0%, 18.5% ± 5.1%, and 16.7% ± 6.6% in controls, CKD 1, 2, 3, and ≥ 4, respectively, P < .001). The relationship of EF1 to eGFR persisted after adjustment for relevant confounders (P < .001). The effect size for association of measures of LV structure or function with eGFR (SD change per unit change in eGFR) was greater for EF1 (β = 0.365, P < .001) than for other measures: LV mass index (β = -0.311), relative wall thickness (β = -0.223), E/e' (β = -0.147), and e' (β = 0.141) after adjustment for confounders in children with CKD.

CONCLUSIONS

Children with CKD exhibit a marked and progressive decline in EF1 with falling eGFR. This suggests that EF1 is a more sensitive marker of LV dysfunction when compared to other structural or functional measures and that early LV systolic function is a key feature in the pathophysiology of cardiac dysfunction in CKD.

First-Phase Ejection Fraction and Long-Term Survival in Patients Who Underwent Transcatheter Aortic Valve Implantation

Early recognition of deteriorating left ventricular function plays a key prognostic role in patients with aortic stenosis (AS). First-phase ejection fraction (EF1), the ejection fraction (EF) up to time of maximal contraction, has been suggested for detection of early left ventricular dysfunction in patients with AS with preserved EF. This work aims to evaluate the predictive value of EF1 for assessment of long-term survival in patients with symptomatic severe AS and preserved EF who undergo transcatheter aortic valve implantation (TAVI). We included 102 consecutive patients (median age 84 years [interquartile range 80 to 86 years]) who underwent TAVI between 2009 and 2011. Patients were retrospectively stratified into tertiles by EF1. Device success and procedural complications were defined according to the Valve Academic Research Consortium-3 criteria. Mortality data were retrieved from a computerized interface of the Israeli Ministry of Health. Baseline characteristics, co-morbidities, clinical presentation, and echocardiographic findings were similar among groups. The groups did not differ significantly regarding device success and in-hospital complications. During a potential follow-up period of >10 years, 88 patients died. Kaplan-Meier analysis (log-rank p = 0.017) followed by multivariable Cox regression analysis showed that EF1 predicted long-term mortality independently, either as continuous variable (hazard ratio 1.04, 95% confidence interval 1.01 to 1.07, p = 0.012) or for each decrease in tertile group (hazard ratio 1.40, 95% confidence interval 1.05 to 1.86, p = 0.023). In conclusion, low EF1 is associated with a significant decrease in adjusted hazard for long-term survival in patients with preserved EF who undergo TAVI. Low EF1 might delineate a population at great risk who would benefit from prompt intervention.

First-Phase Left Ventricular Ejection Fraction as an Early Sign of Left Ventricular Dysfunction in Patients with Stable Coronary Artery Disease

Left ventricular (LV) systolic function is often measured with echocardiography using LV ejection fraction (LVEF) or global longitudinal peak systolic strain (GLPSS). Global wasted work (GWW), global work efficiency (GWE), and first-phase ejection fraction (LVEF-1) are newer LV systolic function indices. We examined these parameters in 45 healthy individuals and 50 patients with stable coronary artery disease (CAD), normal LV contractility, and LVEF > 50%. Compared to healthy individuals, CAD patients had similar LVEF but increased GLPSS and GWW and reduced GWE and LVEF-1. The highest area under the receiver operating characteristic for detecting CAD was found for LVEF-1 (0.84; 95% CI 0.75-0.91; p < 0.0001), and it was significantly larger than for GLPSS (+0.166, p = 0.0082) and LVEF (+0.283, p = 00001). For LVEF-1 < 30%, the odds ratio for the presence of CAD was 22.67 (95% CI 6.47-79.44, p < 0.0001) in the logistic regression adjusted for age, sex, and body mass index. Finding LVEF-1 < 30% in an individual with normal LV myocardial contraction and preserved LVEF strongly suggests the presence of CAD.