Mortality risk is increased in chronotropic incompetent device carriers with acute heart failure

Introduction

In heart failure (HF), chronotropic incompetence is a major factor limiting cardiac output and exercise capacity. In patients carrying cardiac implantable electronic devices (CIED), accelerometer-based rate adaption (R-mode) counterbalances chronotropic incompetence during physical activity but fails to modulate heart rate under circumstances of high metabolic demand.

Purpose

We hypothesized that an activated R-mode, a surrogate of chronotropic incompetence, indicates worse prognosis during and after episodes of acutely decompensated HF (AHF).

Methods

We analysed 632 patients enrolled between 01/2014 and 02/2018 in an ongoing registry that phenotypes and follows patients admitted for AHF. We compared CIED carriers with activated R-mode (CIED-R; n=37, 16% women) with CIED carriers not in R-mode (CIED-0; n=64, 23% women) and patients without CIEDs (no-CIED; n=511, 43% women). Information on survival status was collected up to 12 months after discharge from index hospitalisation (IH). Uni- and multivariable Cox proportional hazard regression was used to identify predictors of 12-month mortality risk.

Results

Mean age of the study sample was 74 (11) years, 39% were women, median LVEF on admission was 51 (quartiles 32, 59) % and de novo HF was detected in 20% of all patients. Median length of IH was 10 (7, 14) days. In-hospital mortality was similar across groups, but 12-month mortality risk was affected by chronotropic incompetence as indicated by R-mode activation: age- and sex-associated hazard ratio (HR) for CIED-R was 2.61 (95% CI 1.59–4.29, p<0.001) compared to group no-CIED, and 2.44 (95% CI 1.25–4.74, p=0.009) compared to group CIED-0. Amongst univariable predictors of mortality risk, strong associations were found for NT-proBNP levels (p<0.001), Charlson comorbidity index (p=0.001), and de novo HF (p=0.003). These effects persisted after multivariable adjustment for comorbidity burden. Within CIED-R, mortality risk was similar in patients with pacemakers vs. ICDs (HR 1.20, 95% CI 0.49–2.95) and in subgroups with LVEF <50% vs. ≥50% (HR 1.10, 95% CI 0.79–1.53). Mean heart rate on admission was lower in CIED-R vs. CIED-0 or no-CIED (70 bpm vs. 80 bpm or 82 bpm; both p<0.001). Heart rate on admission had no impact on frequency of in-hospital worsenings or death. However, we found a 36% increase in mortality risk per tertile of heart rate at discharge (HR 1.36, 95% CI 1.10–1.69, p=0.004) after exclusion of patients with an activated R-mode.

Conclusion

In AHF, R-mode stimulation was associated with an increased 12-month mortality risk, independent of LVEF, type of CIED, burden of comorbidities and type of presentation. Further, increased resting heart rate at discharge predicted 12-month mortality risk only in patients without an activated R-mode. Our findings suggest that chronotropic incompetence per se worsens outcome in AHF and may not be adequately treated through accelerometer-based R-mode stimulation.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Comprehensive Heart Failure Centre (CHFC) Würzburg is funded by the Federal Ministry of Education and Research, Integrated Research and Treatment Centre “Prevention of Heart Failure and its Complications”.

Long-term safety and efficacy of anacetrapib in patients with atherosclerotic vascular disease

AIMS

REVEAL was the first randomized controlled trial to demonstrate that adding cholesteryl ester transfer protein inhibitor therapy to intensive statin therapy reduced the risk of major coronary events. We now report results from extended follow-up beyond the scheduled study treatment period.

METHODS AND RESULTS

A total of 30 449 adults with prior atherosclerotic vascular disease were randomly allocated to anacetrapib 100 mg daily or matching placebo, in addition to open-label atorvastatin therapy. After stopping the randomly allocated treatment, 26 129 survivors entered a post-trial follow-up period, blind to their original treatment allocation. The primary outcome was first post-randomization major coronary event (i.e. coronary death, myocardial infarction, or coronary revascularization) during the in-trial and post-trial treatment periods, with analysis by intention-to-treat. Allocation to anacetrapib conferred a 9% [95% confidence interval (CI) 3-15%; P = 0.004] proportional reduction in the incidence of major coronary events during the study treatment period (median 4.1 years). During extended follow-up (median 2.2 years), there was a further 20% (95% CI 10-29%; P < 0.001) reduction. Overall, there was a 12% (95% CI 7-17%, P < 0.001) proportional reduction in major coronary events during the overall follow-up period (median 6.3 years), corresponding to a 1.8% (95% CI 1.0-2.6%) absolute reduction. There were no significant effects on non-vascular mortality, site-specific cancer, or other serious adverse events. Morbidity follow-up was obtained for 25 784 (99%) participants.

CONCLUSION

The beneficial effects of anacetrapib on major coronary events increased with longer follow-up, and no adverse effects emerged on non-vascular mortality or morbidity. These findings illustrate the importance of sufficiently long treatment and follow-up duration in randomized trials of lipid-modifying agents to assess their full benefits and potential harms.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN) 48678192; ClinicalTrials.gov No. NCT01252953; EudraCT No. 2010-023467-18.

Global wasted myocardial is unrelated to conventional markers of systolic and diastolic function in patients with acute heart failure

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The AHF Register is supported by an unrestricted grant of Behringer Ingelheim, and grants of the German Ministry of Research and Education within the Comprehensive Heart Failure Center, Würzburg (BMBF 01E01004 and 01E01504)

onbehalf

AHF Registry

Background & Aim Myocardial Work (MyW) analysis quantifies myocardial performance using non-invasively derived pressure-strain loops. It is considered less load-dependent than left ventricular ejection fraction (LVEF) and longitudinal strain, since it integrates blood pressure into the assessment. We assessed associations between MyW indices, natriuretic peptide (NT-proBNP), and conventional markers of systolic and diastolic cardiac function mirroring the hemodynamic changes occurring during hospitalization, in patients hospitalized for acute heart failure (AHF).

Methods Consecutive patients (≥18 years) hospitalized for AHF with serial high-quality pairs of echocardiograms (i.e., early after hospitalization and prior to discharge) were eligible. Exclusion criteria were high output AHF, cardiogenic shock, and being listed for high urgency transplantation. The following MyW measures [definition in brackets] were analyzed from the stored recordings: Global constructive work (GCW) [sum of positive work performed during systolic shortening plus negative work during lengthening in isovolumetric relaxation (IVR)], global wasted work (GWW) [sum of negative work performed during systolic lengthening plus work performed during shortening in IVR], global work efficiency (GWE) [constructive work/(constructive work + wasted work)]; global work index (GWI) [total work performed from mitral valve closure to mitral valve opening]. Associations were determined using scatter plots and Pearson Product-Moment correlation coefficients.

Results N = 126 patients (73 ± 12 years, 37% female) were eligible. GWI and GCW proved significantly correlated with surrogates measured both on admission and at discharge, NT-proBNP, LVEF, and e’ (Table). By contrast, GWW did not correlate with any of these variables. GWE was also correlated with NT-proBNP (and e’ at discharge), but at both time points respective correlations were more pronounced.

Conclusion In patients hospitalized for AHF, GWI, GCW and GWE were associated with conventional parameters of myocardial stress and LV dysfunction. In contrast, GWW was unrelated with any of these established markers. Future studies in larger cohorts and with longer-term follow-up need to clarify to what extent might GWW carry complementary clinical and prognostic significance.

Abstract Figure.

Prevalence, severity and clinical correlates of left ventricular diastolic dysfunction in patients hospitalized with acute cardiac decompensation – a sub-study from the Acute Heart Failure

Background

To date, there are few prospective studies which characterize left ventricular diastolic dysfunction (LVDD) in patients with acute heart failure (AHF) using contemporary echo- and Doppler-techniques and take heart failure (HF) phenotype into account. Furthermore, prevalence and clinical correlates of different degrees of LVDD are unknown.

Purpose

To determine prevalence and echo characteristics of LVDD and identify clinical and biomarker correlates in patients hospitalized for AHF with either preserved (HFpEF, LVEF ≥50%) or reduced (HFrEF, LVEF &lt;50%) LV systolic function.

Methods

The AHF Registry Würzburg enrols consecutive patients hospitalized for AHF. For the current analysis, patients with complete high-quality echo- and Doppler studies performed during the index hospitalization allowing for full quantitative analysis were eligible. Left ventricular ejection fraction (LVEF) was determined using Simpson's biplane method. LVDD was graded according to 2016 ESC recommendations based on the E/A-ratio and markers of left ventricular (LV) filling pressure: E/E'-ratio, LA volume, and estimated systolic pulmonary artery pressure (sPAP, derived from peak tricuspid regurgitant flow velocity and estimated right atrial pressure). E/A-ratio &lt;0.8 or E/A-ratio 0.8–2.0 without evidence of increased LV filling pressure was classified as LVDD°I, an E/A-ratio between 0.8–2.0 with evidence of elevated filling pressure as LVDD°II, and an E/A-ratio &gt;2.0 as LVDD°III. LVDD prevalence rates were determined overall and in patients with HFrEF and HFpEF, respectively. Furthermore, other echocardiographic, clinical, and biomarker characteristics were studied.

Results

Overall, 155 patients were eligible (37.4% female, mean age 71.6±12.0 years, LVEF 45.7±17.8%, 49.7% HFpEF, 50.3% HFrEF). Most patients (83.9%) had Doppler evidence of increased filling pressures, with either LVDD°II (48.4%, LVEF 48.6±18.6%) or LVDD°III (35.5%, LVEF 40.3±15.4%). Overall, HFrEF-patients had higher rates of LVDD°III (47.4 vs 23.4%, p=0.002), while HFpEF-patients had higher rates of LVDD°II (58.4 vs 38.5%, p=0.013) (Figure). LVDD°I was present in only 16.1% of all patients (HFpEF: n=14, HFrEF: n=11, LVEF 48.9±15.4%). Compared to patients with LVDD°II-III, this subgroup had lower E/E'-ratio (11.7 vs 19.5 p&lt;0.001), sPAP (30.9±15.8 vs 44±12.5 mmHg, p&lt;0.001) and LA volume index (36.4±17.67 vs 53.5±21.0 ml/m2, p&lt;0.001). Furthermore, NT-proBNP-levels were lower (median [IQR] 2236 [1336; 5204] vs 4125 [2390; 4125] pg/ml, p=0.042) and heart failure (HF) history shorter (56.0 vs 33.1% HF known &lt;1 year, p=0.029).

Conclusion

Among patients hospitalized for AHF, the majority had significant LVDD, irrespective of LVEF. However, LVDD°II was more common in HFpEF, whereas HFrEF patients had more LVDD°III. Furthermore, the small subgroup with LVDD°I had less severe sPAP elevation, lower LA volume and NT-proBNP and a shorter HF history indicating a less advanced HF stage.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Bundesministerium für Bildung und Forschung

Ischemic heart disease is more prevalent in low-income-countries and more often undertreated: data from report-hf

Background

The pathogenic role of ischemic heart disease (IHD) in heart failure is well known. However, little is known about the global differences in the prognostic significance and treatment patterns of IHD in acute heart failure (AHF).

Methods

We prospectively enrolled 18,553 patients with AHF from 44 countries and 365 centers in the REPORT-HF registry. Patients with a history of coronary artery disease, an ischemic etiology of the AHF event or coronary revascularization were classified as IHD. Differences in clinical characteristics, treatment and outcome were analyzed.

Results

Compared to 9,344 (50%) patients without IHD, the 9,189 (50%) patients with IHD were older, more often had a left ventricular ejection fraction [LVEF] &lt;40%, (HFrEF) and decompensated chronic HF (DCHF) and had a greater comorbidity burden. Despite patients from lower-income countries having a higher prevalence of IHD (55% vs. 45% in high-income countries), only 27% of patients with IHD from low-income countries were treated with medicines commonly prescribed for HF (Figure A) compared to 16% of patients with IHD from high income countries. After correction for clinical confounders and medication use, patients with IHD had a shorter “door-to-nitrates and -diuretics time” and worse 1-year mortality (hazard ratio: 1.18, 95% CI: 1.09, 1.27, Figure B) irrespective of geographic region (Pinteraction &gt;0.1). We found a significant interaction for prognosis (Pinteraction &lt;0.001) between IHD and HF diagnosis (DCHF vs. new-onset HF) as well as HF subtype (HFrEF vs. HF with preserved ejection fraction) respectively, such that IHD conveyed worse outcomes in patients with new-onset HF and HFrEF respectively in all world regions.

Conclusion

In this large global contemporary cohort of patients with AHF, IHD was more common in patients from low income countries, conveyed worse 1-year mortality, particularly in patients with new onset HF and patients with HFrEF. Despite worse outcomes, patients in regions with the greatest burden of IHD were more often undertreated.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novartis

P803 Myocardial work in acutely decompensated heart failure patients differs between HFrEF and HFpEF

OnBehalf

AHF Registry

Background & Aim A novel echocardiographic method to non-invasively determine left ventricular (LV) myocardial work (MyW) based on speckle-tracking derived longitudinal strain and blood pressure has recently been validated against invasive reference measurements. MyW is considered less load-dependent than LV ejection fraction (EF) and LV longitudinal strain. We investigated MyW indices in patients with reduced ejection fraction (LVEF &lt;40%; HFrEF) and patients with preserved ejection fraction (LVEF ≥50%, HFpEF) admitted for acutely decompensated heart failure (AHF).

Methods The AHF registry is a monocentric prospective follow-up study that comprehensively phenotypes consecutive patients hospitalized for AHF. Echocardiography was performed on the day of admission. MyW assessment was performed off-line using EchoPAC (GE, version 202). Here we present MyW indices and performed two-sided t-tests to analyze differences in numerical baseline covariates.

Results We analyzed the echocardiograms of 94 AHF patients (72 ± 10 years; 36% female). 46 patients (49%) had an LVEF &lt;40%, while 48 patients (51%) presented with LVEF ≥50%. HFrEF patients were younger, less often female, and hat lower blood pressure (table). Consistent with lower LVEF, HFrEF patients had less negative global longitudinal strain and lower global constructive work, when compared to HFpEF patients. Since HFrEF patients also had higher global wasted work, this yielded a lower myocardial work efficiency compared to HFpEF patients (table).

Conclusions This analysis in patients with AHF exhibited marked differences in MyW indices according to subgroups with HFrEF and HFpEF, thus adding information to the classical measures of LV function. Future research has to determine whether constructive and/or wasted MyW are valuable diagnostic or therapeutic targets in patients with AHF.

Abstract P803 Figure.

P2612Anaemia and renal impairment in heart failure: prevalence and differential prognostic importance according to the AHA ACC heart failure classification

Background

Anaemia (A) and renal impairment (RI) are frequent comorbidities in heart failure (HF) and known to impact adversely on outcome.

Purpose

In this post-hoc analysis, we allocated HF patients from 4 studies of the Competence Network Heart Failure at baseline to subgroups according to American Heart Association/ American College of Cardiology (AHA/ACC) HF criteria and compared prevalence rates of A and RI at each HF stage and the individual and cumulative long-term impact of these comorbidities on all-cause mortality (ACM) over a 5-year follow-up (FUP) period.

Methods

To study A and RI prevalence, we performed a cross-sectional analysis in 3344 patients (40.6% female, 65.6±11.2 years, 7.8, 32.3, 38.5, and 21.4% in stages A, B, C1 and C2/D, respectively). FUP data were available for 2496 patients (37.4% female, 66.0±11.3 years, 8.1, 35.3, 32.9, and 23.7% in stages A, B, C1 and C2/D, respectively). A was defined as haemoglobin <13/12 g/dL in men/women and RI as estimated glomerular filtration rate <60 mL/min/1.73m2. Within each HF subgroup, participants were divided in those without these comorbidities (A-/RI-), with either A or RI (A+/RI- and A-/RI+), or with both, A and RI (A+/RI+). For survival analysis log rank tests and multivariable Cox regression models were used.

Results

Overall prevalence of A in the stages A, B, C1, and C2/D was 3.1, 7.6, 16.5, and 29.8% (p<0.001) and of RI 17.6, 21.3, 24.4, and 46.6% (p<0.001), respectively. In the 4 subgroups, prevalence rates of A-/RI- were 80.2, 74.3, 66.3, and 42.1%, (p<0.001). A+/RI- and A-/RI+ were present in 2.3, 4.4, 9.3, and 11.3% (p<0.001) and 16.8, 18.1, 17.2, and 28.1 (p<0.001). A+/RI+ was found in 0.8, 3.1, 7.1, and 18.5% (p<0.001). Kaplan Meier curves demonstrate the individual and cumulative prognostic impact of A and RI (Figure).

Conclusions

Our results demonstrate a high prevalence in particular of RI even in asymptomatic HF stages and significant individual and cumulative long-term adverse effects of A and RI across the entire HF continuum. This includes also the clinically asymptomatic HF stages. Both prevalence and the individual and cumulative negative prognostic impact increase with increasing HF severity calling for careful consideration and management of these comorbidities in the frame of holistic HF care.

CRP genetic variants are associated with mortality and depressive symptoms in chronic heart failure patients

OBJECTIVE

Heart failure (HF) is a complex medical condition with a multitude of genetic and other factors being involved in the pathogenesis. Emerging evidence points to an involvement of inflammatory mechanisms at least in subgroups of patients. The same is true for depression and depressive symptoms, which have a high prevalence in HF patients and are risk factors for the development and outcomes of cardiovascular disease.

METHODS

In 936 patients of the Interdisciplinary Network Heart Failure (INH) program, CRP and IL-6 protein blood levels were measured and genetic variants (single nucleotide polymorphisms) of the CRP and IL6 gene analyzed regarding their influence on mortality.

RESULTS

Less common recessive genotypes of two single nucleotide polymorphisms in the CRP gene (rs1800947 and rs11265263) were associated with significantly higher mortality risk (p < 0.006), higher CRP levels (p = 0.029, p = 0.006) and increased depressive symptoms in the PHQ-9 (p = 0.005, p = 0.003). Variants in the IL-6 gene were not associated with mortality.

CONCLUSION

Our results hint towards an association of less common CRP genetic variants with increased mortality risk, depressive symptoms and peripheral CRP levels in this population of HF patients thereby suggesting a possible role of the inflammatory system as link between poor prognosis in HF and depressive symptoms.

[Differential diagnosis of dyspnea - significance of clinic aspects, imaging and biomarkers for the diagnosis of heart failure]

Dyspnea is a frequent reason for emergency consultations in hospitals or community medical facilities. Besides heart failure, a wide variety of other disorders may cause this symptom. Thus, early and accurate differential diagnosis is mandatory in order to facilitate rapid institution of appropriate therapy. This CME article elaborates on the specific usefulness of traditional diagnostic tools as history, symptomatology and physical signs along with chest X-ray and ECG and the more recently introduced natriuretic peptides to discriminate heart failure from other causes of dyspnea in the emergency setting. According to a systematic search and meta-analysis of the respective literature, several features from history and physical examination as well as pulmonary congestion on chest X-ray, atrial fibrillation and a high level of confidence of the initial clinical judgment indicate a cardiac cause of dyspnea with high specificity, but less sensitivity. Thus, in patients presenting with one or several of these characteristic features, little further diagnostic yield is to be expected from natriuretic peptides. If, however, the suspicion of heart failure remains unsettled by these means, determination of biomarkers may be helpful, although it needs to be considered that moderately elevated levels have only a limited specificity in particular in elderly patients with comorbidities. As also recognized by the European Guidelines for diagnosis and treatment of chronic heart failure, a BNP level of <100 pg/ml has proven particularly useful for excluding heart failure. Thus, a directed history, symptoms, physical findings, chest-X-ray and ECG remain the diagnostic mainstay. If the diagnosis cannot be established by these traditional tools, BNP or NT-proBNP testing may be very helpful, especially for ruling out heart failure.

High frame rate myocardial integrated backscatter. Does this change our understanding of this acoustic parameter?

AIMS

Integrated backscatter (IB) and its cyclic variation (CV) derived from radio-frequency (RF) data have been used as parameters to attempt myocardial tissue characterization. Prior imaging systems used to measure IB and its CV typically acquired data at frame rates of 20-30 Hz and at a resolution of 6-8 bits. If changes in IB levels are in part related to specific short-lived events, occurring within the cardiac cycle, this frame rate and resolution could have been too low to resolve adequately what might be a more complex data set.

METHODS AND RESULTS

To investigate this possibility, we acquired real time two-dimensional (2D) myocardial IQ data (the 'in-phase quadrature' sampled RF data) at high frame rate (> 100 Hz), high dynamic resolution (theoretical 19-bit) and a sector angle of 20 degrees. Several consecutive heart cycles of myocardial data were acquired from individual cardiac walls in five closed chest dogs and 10 healthy, young volunteers at normal heart rates. On the reconstructed RF data regions of interest were indicated, and IB and its CV were calculated. The extracted high frame rate curves showed that the CV of IB is not a smooth sinusoidal-like curve, but is made up of multiple reproducible peaks and troughs with local minima and maxima which are temporally related to active or passive mechanical events, i.e. systolic contraction, early ventricular relaxation and ventricular filling due to atrial contraction.

CONCLUSIONS

This study shows that increasing the rate of real-time RF data acquisition results in a more complex, reproducible IB curve. The resolved maxima and minima in IB levels are related to specific phases of the myocardial contraction. Furthermore, spectral analysis showed that IB curves acquired at normal heart rates contain information up to 40 Hz. Hence, cardiac imaging data sets used to analyse regional myocardial function obtained at frequencies lower than 80 frames per second can contain aliased information.

Single-center randomized trial comparing tacrolimus (FK506) and cyclosporine in the prevention of acute myocardial rejection

BACKGROUND

To compare the efficacy and safety of tacrolimus and cyclosporine in heart transplantation, this single-center, prospective, randomized, open-label clinical trial was undertaken.

METHODS

Seventy-three adult patients were randomly assigned at the time of transplantation to receive either tacrolimus (n=43) or cyclosporine (n=30) as the primary immunosuppressant. Ten of the 43 patients in the tacrolimus group received the drug intravenously in the perioperative period; all other patients received only oral tacrolimus.

RESULTS

With a mean follow-up of 27 months, patient survival rates (tacrolimus 83%, cyclosporine 81%) were similar. Fewer patients experienced acute rejection in the tacrolimus group (79%) than in the cyclosporine group (100%), but the difference was not statistically significant. The number of infections and dialysis and insulin requirements were similar for the 2 treatment groups, but the proportion of patients requiring multidrug antihypertensive regimens was lower in the tacrolimus group (12.5% vs 50.0% at month 6; p=.025). The interpatient variance in pharmacokinetic parameters in a subset of 10 patients was much higher after the first oral dose of tacrolimus than at steady-state (eg, first-dose time at which maximal concentration is reached (t(max)): 3.5+/-2.5h, steady-state t(max): 2.0+/-0.7h), and patients treated with intravenous tacrolimus (n=13) rather than oral tacrolimus (n=30) reached target concentrations faster and with less interpatient variability (eg, at day 0: 9.72+/-10.9 ng/mL intravenously vs 3.31+/-8.1 orally).

CONCLUSIONS

Tacrolimus was associated with similar efficacy and safety profiles compared with cyclosporine. The higher interpatient variance in absorption associated with oral tacrolimus during the first few days after transplantation would suggest that intravenous tacrolimus should be used during the perioperative period.

[Stress reaction of pulmonary artery pressure in the early and chronic phase after heart transplantation: comparison with healthy control probands]

The pulmonary artery pressure response to exercise frequently reflects ventricular diastolic properties. The aim of this study was to determine noninvasively cardiac allograft function and pulmonary artery pressure response to stress in the early and late phases after heart transplantation (HTX). Ten patients in the early postoperative phase (3.7 +/- 1.6 months postoperatively, group I) and ten patients at least 2 years after HTX (34.3 +/- 8.3 months postoperatively, group II) were studied by two-dimensional (2 D-), M-Mode, and Doppler echocardiography during supine graded bicycle exercise (25, 50, 75, 100 watts). The patients' data were compared to those obtained in eight normal controls. The peak pressure gradient between the right ventricle and right atrium during systole was derived from saline contrast-enhanced Doppler echocardiography of the tricuspid regurgitant jet and used as an estimate of pulmonary artery systolic pressure. In group I- and group II-patients, resting and exercise left ventricular diameters as well as systolic function were normal. The right ventricle was enlarged (3.2 +/- 0.4 cm/3.0 +/- 0.6 cm in group I/group II versus 2.1 +/- 0.3 cm in normal controls, p < 0.05). During exercise, heart rate increased less in heart transplant recipients (+26%/+36% in group I/group II, p < 0.05) than in normals (+67% at 100 watts, p < 0.05). Resting pulmonary artery pressures were similar in heart transplant recipients in the early and late postoperative stage and in normals.(ABSTRACT TRUNCATED AT 250 WORDS)

Atrial septal aneurysm in adult patients. A multicenter study using transthoracic and transesophageal echocardiography

BACKGROUND

An atrial septal aneurysm (ASA) is a well-recognized abnormality of uncertain clinical relevance. We reevaluated the clinical significance of ASA in a large series of patients. The aims of the study were to define morphological characteristics of ASA by transesophageal echocardiography (TEE), to define the incidence of ASA-associated abnormalities, and to investigate whether certain morphological characteristics of ASA are different in patients with and without previous events compatible with cardiogenic embolism.

METHODS AND RESULTS

Patients with ASA were enrolled from 11 centers between May 1989 and October 1993. All patients had to undergo transthoracic and transesophageal echocardiography within 24 hours of each other; ASA was defined as a protrusion of the aneurysm > 10 mm beyond the plane of the atrial septum as measured by TEE. Patients with mitral stenosis or prosthesis or after cardiothoracic surgery involving the atrial septum were excluded. Based on these criteria, 195 patients 54.6 +/- 16.0 years old (mean +/- SD) were included in this study. Whereas TEE could visualize the region of the atrial septum and therefore diagnose ASA in all patients, ASA defined by TEE was missed by transthoracic echocardiography in 92 patients (47%). As judged from TEE, ASA involved the entire septum in 100 patients (51%) and was limited to the fossa ovalis in 95 (49%). ASA was an isolated structural defect in 62 patients (32%). In 106 patients (54%), ASA was associated with interatrial shunting (atrial septal defect, n = 38; patent foramen ovale, n = 65; sinus venosus defect, n = 3). In only 2 patients (1%), thrombi attached to the region of the ASA were noted. Prior clinical events compatible with cardiogenic embolism were associated with 87 patients (44%) with ASA; in 21 patients (24%) with prior presumed cardiogenic embolism, no other potential cardiac sources of embolism were present. Length of ASA, extent of bulging, and incidence of spontaneous oscillations were similar in patients with and without previous cardiogenic embolism; however, associated abnormalities such as atrial shunts were significantly more frequent in patients with possible embolism.

CONCLUSIONS

As shown previously, TEE is superior to the transthoracic approach in the diagnosis of ASA. The most common abnormalities associated with ASA are interatrial shunts, in particular patent foramen ovale. In this retrospective study, patients with ASA (especially with shunts) showed a high frequency of previous clinical events compatible with cardiogenic embolism; in a significant subgroup of patients, ASA appears to be the only source of embolism, as judged by TEE. Our data are consistent with the view that ASA is a risk factor for cardiogenic embolism, but thrombi attached to ASA as detected by TEE are apparently rare.

Antimyosin monoclonal antibodies for early detection of cardiac allograft rejection

Sixty-eight indium 111-labeled antimyosin Fab-DTPA imaging studies (0.5 mg intravenously with a radioactivity of 65 to 75 MBq) were executed on 37 of 116 patients undergoing heart transplantation to assess diagnostic accuracy and clinical utility. As controls, 21 patients with cardiomyopathy (n = 8), unstable angina (n = 9), and myocardial infarction (n = 4) were selected. After 48 hours, single photon emission computed tomographic images were evaluated visually, and heart/lung ratios were measured, using the "region of interest" technique. They were compared with echocardiographic and endomyocardial biopsy results. In 40 studies a heart/lung ratio less than or equal to 1.6 corresponded to a negative biopsy result in 98% (40/41). Echocardiography enabled correct identification of 95% of the patients with normal biopsy findings. In 91% (22/24) a positive biopsy finding correlated with a heart/lung ratio greater than 1.6 including 20 mild rejections, but in only 64%, with an increase in wall thickness and/or decrease of fractional diameter shortening seen on echocardiogram. In addition, the various stages of rejection episodes determined the amount of the heart-lung ratio. There was a significant relationship between the histologic findings and the antimyosin uptake. In 13 patients a second investigation was performed after rejection therapy. All patients had a negative biopsy result, and the heart/lung ratio decreased to normal ranges (less than or equal to 1.6). Five antimyosin antibody studies were excluded, as in these cases, negative uptake results were found during rejection therapy with high-dose steroids. The overall sensitivity was calculated at 93% and the specificity at 98%.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative myocardial contrast echocardiography for assessment of regional bypass perfusion

The intraoperative determination of the success of surgical myocardial revascularization remains problematic because of major limitations in all currently used methods. To assess the regional blood flow of the bypass graft-dependent myocardial segments, 2 ml of sonicated iopromid (a nonionic x-ray contrast medium) was injected into the bypass graft in the beating heart. Simultaneously electromagnetic flow measurements were performed. Eleven graft injections in 8 men (mean age +/- standard deviation 60 +/- 4 years) were performed without any adverse effects. Excellent 2-dimensional cross-sectional views of the left ventricle were obtained in all cases. Ten of 11 injections resulted in adequate myocardial opacification. Computer-assisted evaluation by videodensitometry resulted in time-intensity curves with contrast decay half-times (T1/2) from 2.2 to 6.9 seconds (mean 4.3 +/- 1.4). The corresponding electromagnetic flow ranged from 55 to 100 ml/min (mean 80.0 +/- 16.2). there was no correlation between contrast 2-dimensional echocardiography-derived T1/2 and electromagnetic flow (r = 0.32; p = 0.38). Thus, myocardial contrast echocardiography is a feasible and safe method for intraoperative evaluation of the success of bypass graft surgery. It offers online visualization of perfusion of revascularized myocardium and may allow immediate intraoperative revision of unsuccessful bypass graft placement.

The influence of rejection episodes on the development of coronary artery disease after heart transplantation

Since 1981, 77 of 116 patients undergoing heart transplantation (HTx) have survived from 6 months to 8 years. Graft control involved a total of 871 endomyocardial biopsies (EMB) and 141 angiographies. Sixteen patients developed coronary artery disease (CAD) manifesting itself 7-60 months after HTx (20.7%). These patients (15 male, 1 female) experienced multiple rejection episodes (RE) and more than half suffered from hypercholesterolaemia and hypertension (n = 10). A mean rejection score (Billingham grading) of greater than 1 (mean = 1.6 +/- 1.1) was calculated in all patients with CAD at the time of angiography or autopsy. By contrast, the mean rejection score ranked less than 1 in patients with undetectable or resolved CAD (means = 0.4 +/- 0.38). This rate is not remarkably different from the rejection score in patients (n = 61) without CAD (mean = 0.2 +/- 0.4). The 8 patients alive (56 +/- 18 months) showed a low number of RE/year (mean = 1.1 +/- 0.4) compared with means = 1 +/- 0.9 in patients without CAD. Eight patients expired within a short period (mean = 31 +/- 26.9) and had a significantly higher number of RE/year (mean = 4.3 +/- 2.9; P less than 0.01 vs. no CAD, CAD alive). Autopsy (n = 6) and angiographic studies (n = 46) demonstrated diffuse, concentric, obliterative arterial disease in all vessels (type A) in 6 patients (RE/yr: mean = +/- 5.5 +/- 2.3), single stenoses in major coronary vessels (type B) in 7 patients and ordinary atherosclerosis (3-vessel disease) comparable to ischaemic heart disease (type C) in 3 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

New methods for noninvasive monitoring of rejection after heart transplantation

Between August 1981 and February 1987, 67 orthotopic heart transplants and three heart-lung transplants were performed in 69 patients at the University of Munich Hospital. The immunosuppressive regimen consisted of cyclosporine A, azathioprine, and prednisone. The diagnosis of acute rejection was based on cytoimmunologic monitoring, frequency analysis of fast Fourier transformed surface electrocardiograms (FFT-ECGs), and two-dimensional echocardiography. The results of these diagnostic methods were compared to the findings provided by endomyocardial biopsies, which were performed simultaneously with the noninvasive studies. Seventy patients underwent cytoimmunologic monitoring. In 88% of all rejection episodes, this technique revealed activated lymphocytes and lymphoblasts in the mononuclear concentrate of the peripheral blood samples; the presence of such cells is known to be an extremely early sign of acute rejection. Twenty-six patients were monitored by means of FFT-ECG. In 20 of the 21 cases of rejection, this method disclosed significant changes in the frequency spectrum of the QRS complex in the 70- to 110-Hz range; in 12 cases, these changes were the earliest sign of acute rejection. Therefore, FFT-ECG had a sensitivity of 95%. All of the QRS changes were reversible with rejection therapy. Forty-five patients were subjected to two-dimensional echocardiography. In 31 of the 35 cases of rejection, the echocardiogram showed a significant increase in the left ventricular wall thickness and a decrease in the left ventricular cross-sectional area during mild rejection. Moderate or severe rejection was characterized by an increase in the diastolic area, as well as a decrease in the systolic area change and in the diastolic maximum velocity of area change. Thus, two-dimensional echocardiography had a sensitivity of 89%. In the recent cases, the diagnosis of rejection was based on noninvasive methods alone. After rejection therapy had been instituted, endomyocardial biopsies were performed to assess the effectiveness of the treatment. With noninvasive rejection monitoring, the number of endomyocardial biopsies performed during the first three postoperative months was only 2.8 per patient; in comparison with invasive rejection monitoring, noninvasive follow-up was associated with a 75% reduction in the need for biopsy.

[Cardiac manifestation of progressive muscular dystrophy of the Duchenne type]

Autopsy studies have shown that cardiomyopathy of Duchenne's muscular dystrophy (DMD) is characterized by fibrosis of the posterobasal and contiguous lateral wall of the left ventricle. This study was designed to determine whether stress testing would improve the sensitivity of echocardiography to detect secondary impairment of regional myocardial function. 12 patients aged 5 to 23 years with DMD were investigated. TM- and 2D-echocardiograms were performed before and during graded infusion of angiotensin (A) (0.5 to 5.0 mcg/min), and parameters of cardiac function analyzed. Satisfactory echocardiograms were obtained in all patients. Stress testing with A proved feasible in DMD and did not interfere with echocardiography. Before A all patients were in regular sinus rhythm and free of cardiac symptoms. Left ventricular function was normal in 9 patients and considered abnormal in 3 patients with hypokinesis and increased echo intensity of the posterobasal and lateral wall (2D short axis view) and/or a posterior wall to septal amplitude ratio of less than or equal to 1.1 (TM-echocardiogram). During A mean blood pressure rose and heart rate dropped significantly. 9 patients had marked supraventricular arrhythmias, 8 complained of dyspnea, cough or chest pain. Hypo- or akinesis of the posterobasal and sometimes the lateral wall was seen in 8, and a posterior wall to septal amplitude ratio of less than or equal to 1.1 in 9 patients. 3 patients, all with a muscle score of 60% or higher, remained free of symptoms and had no regional contraction abnormalities. Thus, clinical symptoms during A suggested latent congestive heart failure in many of the patients, and echocardiography identified provokable contraction abnormalities of such segments of the ventricular wall known to be most frequently involved in the dystrophic process in DMD. Stress testing revealed a correlation between clinical symptoms, abnormal echocardiographic findings and extent of the skeletal muscle disease in our study group. Physical limitation seems to protect the heart against demands that would otherwise cause earlier clinical manifestation of the cardiomyopathy in DMD.

[Comparative studies on the cardiodepressant effect of disopyramide, mexiletine and propafenon]

The effect of clinical antiarrhythmic doses of disopyramide (Di), mexiletine (Me), and propafenon (Pr) on cardiac function was studied in 7 normal volunteers by M-mode echocardiography and the extent of functional changes caused by the three drugs was compared. For each of the substances echocardiographic parameters of left ventricular function were determined before injection, 5-25 min. after an intravenous administration (Di 2.0 mg/kg, Me 3.0 mg/kg, Pr 1.5 mg/kg) at intervals of 5 min., and after 3 days of oral therapy (Di 4 X 200 mg/day, Me 4 X 200 mg/day, Pr 3 X 300 mg/day). Di, Me, and Pr each showed significant negative inotropic activity, though of varying degree. For each drug the effect was more pronounced after intravenous administration than under oral therapy. Maximum decreases in myocardial contraction occurred 5-15 min. after termination of injection, with an increase in endsystolic diameter (Di 30.3%, Me 13.6%, Pr 9.7%), no change in preejection diameter, and a reduction in the percentage and velocity of mean circumferential fiber shortening and systolic ventricular wall thickness (Di 18.1%-45.1%, Me 9.6%-23.7%, Pr 11.8%-16.7%). While the cardiodepressant activity of orally administered Di, Me and Pr did not statistically differ, for the first 20 min. after intravenous administration Di exhibited a marked negative inotropic effect that was significantly greater than those of Me and Pr. In view of the considerable hemodynamic side effects of Di, Me, and Pr observed in this study, the benefit to risk ratio must be evaluated carefully and individually before commencement of antiarrhythmic therapy. Because of its acute and pronounced cardiodepressant activity, intravenous Di should be used with particular caution; a dose reduction and slow injection are recommended in patients with left ventricular dysfunction.

[The effect of disopyramide of left ventricular function: an echocardiographic study of the extent and time course (author's transl)]

Seven healthy volunteers were evaluated for changes in left ventricular function after a therapeutic intravenous dose of Disopyramide (2 mg/kg, maximum 150 mg given over 5 min) and, subsequently, under oral maintenance therapy (200 mg every 6 h for 3 days). Parameters of left ventricular function were determined by Echocardiography. Measurements were taken before injection, 5--25 min after intravenous Disopyramide in intervals of 5 min and 120 min after the last oral dose of the drug. Peak changes occurred 5 min after termination of injection and included increases in mean arterial pressure (10%), heart rate (22%) and endsystolic ventricular diameter (30%) and decreases in percentage (43%) and mean velocity (36%) of diameter shortening, decreases of systolic thickness and percentage of thickening of left posterior wall (27 and 43% respectively) and of interventricular septum (15 and 22% respectively) as well as a decrease of the relative thickness of left ventricular wall (40%) and of left posterior (36%) and septal (39%) amplitude. After 20 min changes in all parameters were significantly less than 5 min after injection but still significantly greater than under oral maintenance therapy. After 25 min measurements differed from those under oral Disopyramide only slightly. At both times, however, all parameters were significantly different from control values. Thus, Disopyramide given intravenously and orally in therapeutic dosage is a potent myocardial depressant in man. As the acute negative inotropic effect of intravenous Disopyramide might be of clinical importance in patients with decreased myocardial function a slow injection over 15--20 min and a dose reduction is recommended in these cases.