Relationship between iron deficiency and expression of genes involved in iron metabolism in human myocardium and skeletal muscle

BACKGROUND

Iron deficiency (ID) is associated with adverse prognosis in patients with heart failure. This study aims to investigate the relationship between ID and expression of genes involved in iron metabolism in human myocardium and skeletal muscle, focusing on Transferrin 1 receptor (TfR1), the main pathway of cellular iron uptake.

METHODS

Patients undergoing elective CABG were assessed prior to surgery with echocardiography and serum iron parameters. Core needle biopsies were collected from the left and right ventricle (LV, RV), the right atrium and intercostal skeletal muscle (SM). Gene expression analyses were done by mRNA sequencing.

RESULTS

Of 69 patients (median age 69 years, 91% men), 28% had ID. 26% had HFrEF, 25% had HFpEF physiology according to echocardiographic findings and NT-proBNP levels, and 49% had normal LV function. The expression of TfR1 was increased in patients with ID compared to patients without ID in ventricular tissue (p = 0.04) and in intercostal SM (p = 0.01). The increase in TfR1 expression in LV and RV was more pronounced when analysing patients with absolute ID (S-Ferritin<100 μg/L). Analysing the correlation between various iron parameters, S-Ferritin levels showed the strongest correlation with TfR1 expression. There was no correlation with NT-proBNP levels and no difference in TfR1 expression between different HF phenotypes.

CONCLUSIONS

In patients undergoing elective CABG we found an association between ID and increased TfR1 expression in myocardium regardless of LV function, indicating physiologically upregulated TfR1 expression in the presence of ID to restore intracellular iron needs.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.govNCT03671122.

Heart failure therapy in new onset heart failure versus chronic heart failure: an analysis of 90,383 patients from the Swedish Heart Failure Registry (SwedeHF)

Background

The period after newly diagnosed heart failure (HF) presents challenges in HF management. Although recent HF guidelines recommend immediate initiation of HF therapies, little is known about real life HF therapy.

Purpose

We analyzed differences in treatment management in patients with new onset and chronic HF across the ejection fraction (EF) spectrum in the large nationwide Swedish HF registry.

Methods

In patients enrolled 2000–2018 in the Swedish HF registry, clinical characteristics, co-morbidities, laboratory values and use of therapy were analyzed in all HF patients with new onset HF (HF duration &lt;3 months from diagnosis) and chronic HF (HF duration ≥3 months from diagnosis). Additionally, therapy use was studied separately for patients with HFrEF (defined as EF &lt;40%).

Results

Of 90,383 patients, 40% had new onset and 60% had chronic HF. Patients with new onset HF were more likely females (42 vs. 37%) compared to chronic HF. They had lower NYHA class, with higher EF, less often had atrial fibrillation (46 vs. 60%) and left bundle branch block (14 vs. 21%). They more often had hypertension (31 vs. 24%), and less often ischemic heart disease (34 vs. 44%), dilated cardiomyopathy (4.1 vs. 8.1%) and known alcoholic cardiomyopathy (0.6 vs. 0.8) as cause of HF. Chronic HF was associated with worse renal function (eGFR 58 [41, 77] vs. 69 [51, 87] mL/min/1.73 m2) and higher co-morbidity burden. Overall, new onset HF were less often on beta-blockers (85 vs. 88%) and MRAs (26 vs. 40%), whereas patients with chronic HF more often received HF medication and HF related device therapy. Patients with new onset HFrEF and thus with an indication for guidelines directed medical therapies were more often treated with beta-blockers (93 vs. 92%), ACE/ARB (91 vs. 83%), but less often ARNi (2.5 vs. 16%) and device therapy.

Conclusions

In this large HF population, patients with new onset HF were more often females, with less severe HF symptoms, and with fewer co-morbidities; New onset HF was associated with less MRA use. Our findings implies that faster and concomitant HF therapy initiation as recommended in 2021 ESC HF/HFA guidelines should occur in new onset HF patients.

Funding Acknowledgement

Type of funding sources: None.

Fungal Planet description sheets: 1383-1435

Novel species of fungi described in this study include those from various countries as follows: Australia, Agaricus albofoetidus, Agaricus aureoelephanti and Agaricus parviumbrus on soil, Fusarium ramsdenii from stem cankers of Araucaria cunninghamii, Keissleriella sporoboli from stem of Sporobolus natalensis, Leptosphaerulina queenslandica and Pestalotiopsis chiaroscuro from leaves of Sporobolus natalensis, Serendipita petricolae as endophyte from roots of Eriochilus petricola, Stagonospora tauntonensis from stem of Sporobolus natalensis, Teratosphaeria carnegiei from leaves of Eucalyptus grandis × E. camaldulensis and Wongia ficherai from roots of Eragrostis curvula. Canada, Lulworthia fundyensis from intertidal wood and Newbrunswickomyces abietophilus (incl. Newbrunswickomyces gen. nov.) on buds of Abies balsamea. Czech Republic, Geosmithia funiculosa from a bark beetle gallery on Ulmus minor and Neoherpotrichiella juglandicola (incl. Neoherpotrichiella gen. nov.) from wood of Juglans regia. France, Aspergillus rouenensis and Neoacrodontium gallica (incl. Neoacrodontium gen. nov.) from bore dust of Xestobium rufovillosum feeding on Quercus wood, Endoradiciella communis (incl. Endoradiciella gen. nov.) endophytic in roots of Microthlaspi perfoliatum and Entoloma simulans on soil. India, Amanita konajensis on soil and Keithomyces indicus from soil. Israel, Microascus rothbergiorum from Stylophora pistillata. Italy, Calonarius ligusticus on soil. Netherlands, Appendopyricularia juncicola (incl. Appendopyricularia gen. nov.), Eriospora juncicola and Tetraploa juncicola on dead culms of Juncus effusus, Gonatophragmium physciae on Physcia caesia and Paracosmospora physciae (incl. Paracosmospora gen. nov.) on Physcia tenella, Myrmecridium phragmitigenum on dead culm of Phragmites australis, Neochalara lolae on stems of Pteridium aquilinum, Niesslia nieuwwulvenica on dead culm of undetermined Poaceae, Nothodevriesia narthecii (incl. Nothodevriesia gen. nov.) on dead leaves of Narthecium ossifragum and Parastenospora pini (incl. Parastenospora gen. nov.) on dead twigs of Pinus sylvestris. Norway, Verticillium bjoernoeyanum from sand grains attached to a piece of driftwood on a sandy beach. Portugal, Collybiopsis cimrmanii on the base of living Quercus ilex and amongst dead leaves of Laurus and herbs. South Africa, Paraproliferophorum hyphaenes (incl. Paraproliferophorum gen. nov.) on living leaves of Hyphaene sp. and Saccothecium widdringtoniae on twigs of Widdringtonia wallichii. Spain, Cortinarius dryosalor on soil, Cyphellophora endoradicis endophytic in roots of Microthlaspi perfoliatum, Geoglossum lauri-silvae on soil, Leptographium gemmatum from fluvial sediments, Physalacria auricularioides from a dead twig of Castanea sativa, Terfezia bertae and Tuber davidlopezii in soil. Sweden, Alpova larskersii, Inocybe alpestris and Inocybe boreogodeyi on soil. Thailand, Russula banwatchanensis, Russula purpureoviridis and Russula lilacina on soil. Ukraine, Nectriella adonidis on overwintered stems of Adonis vernalis. USA, Microcyclus jacquiniae from living leaves of Jacquinia keyensis and Penicillium neoherquei from a minute mushroom sporocarp. Morphological and culture characteristics are supported by DNA barcodes. Citation: Crous PW, Boers J, Holdom D, et al. 2022. Fungal Planet description sheets: 1383-1435. Persoonia 48: 261-371. https://doi.org/10.3767/persoonia.2022.48.08.

Cardiac resynchronization therapy in patients with a history of atrial fibrillation: insights from five major clinical trials

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Heart, Lung, and Blood Institute

Background

Many patients with heart failure who are considered for cardiac resynchronization therapy (CRT) have a history of (h/o) atrial fibrillation (AF) but there are doubts about the efficacy of CRT in patients with AF.

Purpose

To investigate the association of CRT on morbidity and mortality among patients with and without a h/o AF.

Methods

Original, patient-level data from five clinical trials of CRT that permitted enrolment of patients with a h/o AF were included: COMPANION, MADIT-CRT, BLOCK HF, REVERSE, and MIRACLE trial. Patients with permanent or persistent AF were excluded from these trials, and therefore from this analysis. The outcomes of interest were the composite endpoint of time to heart failure hospitalization (HFH) or all-cause mortality or all-cause mortality alone. The association of CRT (versus no CRT) with outcomes for patients with and without a h/o AF was assessed using a Bayesian-Weibull survival regression model with random terms for the trial-specific treatment effects and the trial-specific baseline hazard functions including an interaction between history of paroxysmal AF and CRT. All results are presented as hazard ratios (HRs) with 95% posterior credible intervals (CIs) and posterior probabilities of no association, adjusting for baseline characteristics.

Results

A total of 4062 patients were included, 661 (16.3%) of whom had a h/o AF. Patients with a h/o AF were older (mean [SD] age 68 [10] years versus 64 [11] years) and had a higher proportion of ischemic cardiomyopathy (67% versus 53%, p&lt;0.001), a higher baseline serum creatinine (1.3 mg/dl versus 1.2 mg/dl, p&lt;0.001), and a lower left ventricular ejection fraction (25% versus 26%, p&lt;0.001). The HRs for all outcomes and the interaction term are shown in Table 1. For the overall population, CRT delayed the time to HFH or all-cause mortality (HR: 0.74, 95% CI: 0.62 – 0.87, p=0.005); for patients with a h/o AF, it did not (HR: 0.87, 95% CI: 0.64 to 1.19, p=0.37). In this patient-level meta-analysis, CRT was not associated with a reduction in mortality, overall or by h/o AF. Howevber, the interaction (estimate shown as a ratio of HRs) between those with or without a h/o AF and the effects of CRT was not significant for either outcome (Table 1).

Conclusion

In the largest post hoc analysis to date, we confirm the benefits of CRT in patients without a h/o AF in reducing HFH or mortality. There was no statistically significant interaction between CRT and h/o AF for any analysed outcome.

Combined assessment of septal scar and septal flash by cardiac magnetic resonance identifies responders to cardiac resynchronization therapy

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): South-Eastern Norway Regional Health Authority. Research grants of the University of Leuven.

Background

Left ventricular (LV) scar, particularly in the lateral wall and septum, reduces response rate to cardiac resynchronization therapy (CRT), whereas a dyssynchronous LV contraction pattern (septal flash) suggests good response. Lateral wall scar abolishes septal flash. Therefore, a combined approach of septal scar and septal flash may characterize the myocardial substrate responsive to CRT. Cardiac magnetic resonance (CMR) may assess both scar and contraction pattern.

Purpose

The present study aimed to determine if combined assessment of septal scar and septal flash by CMR as single image modality identifies responders to CRT.

Methods

We investigated all CRT recipients with available CMR from a prospective, multicenter study (n = 136), with both ischemic and non-ischemic heart failure. Septal scar was assessed by late gadolinium enhancement (LGE) from a stack of short axis slices (n = 128) and septal flash determined visually on ordinary cine sequences (n = 136). CRT response was defined as ≥15% reduction in LV end-systolic volume by echocardiography at 6 months follow-up. We also assessed heart transplantation or death of any cause 39 ± 13 months after device implantation.

Results

In multivariate analysis including percentage septal scar (LGE), septal flash, QRS-duration and QRS-morphology, septal LGE and septal flash were the only independent predictors of CRT response (both p &lt; 0.001). A combined approach of septal LGE and septal flash predicted CRT response with area under the curve 0.86 (95% confidence interval (CI): 0.78-0.94) and long-term survival without heart transplantation with hazard ratio 0.18 (95% CI: 0.05-0.61).

A practical approach to selection of CRT candidates by septal LGE and septal flash is illustrated in the present figure. As shown, absence of septal LGE indicated excellent response rate (93%) to CRT independent of other parameters. When septal LGE was present, however, overall response rate was substantially lower (58%), but presence or absence of septal flash separated responders from non-responders with high accuracy. This sequential approach correctly classified 86% of patients. Importantly, the approach was equally accurate in patients with intermediate QRS duration (130-150ms), where 93% of patients were correctly classified.

Conclusions

Combined assessment of septal LGE and septal flash by CMR as single image modality identifies CRT responders with high accuracy and predicts long-term survival. Abstract Figure.

Eligibility for sacubitril/valsartan in heart failure across the ejection fraction spectrum: real-world data from the Swedish Heart Failure Registry

BACKGROUND

Randomized controlled trials (RCT) generalizability may be limited due to strict patient selection.

OBJECTIVE

In a real-world heart failure (HF) population, we assessed eligibility for sacubitril/valsartan based on PARADIGM-HF (sacubitril/valsartan effective)/PARAGON-HF [sacubitril/valsartan effective in mildly reduced ejection fraction (EF)].

METHODS

Outpatients from the Swedish HF Registry (SwedeHF) were analysed. In SwedeHF, EF is recorded as <30, 30-39, 40-49 and ≥50%. In PARAGON-HF, sacubitril/valsartan was effective with EF ≤ 57% (i.e. median). We defined reduced EF/PARADIGM-HF as EF < 40%, mildly reduced EF/PARAGON-HF ≤ median as EF 40-49%, and normal EF/PARAGON-HF > median as EF ≥ 50%. We assessed 2 scenarios: (i) criteria likely to influence treatment decisions (pragmatic scenario); (ii) all criteria (literal scenario).

RESULTS

Of 37 790 outpatients, 57% had EF < 40%, 24% EF 40-49% and 19% EF ≥ 50%. In the pragmatic scenario, 63% were eligible in EF < 50% (67% for EF < 40% and 52% for 40-49%) and 52% in EF ≥ 40% (52% for EF ≥ 50%). For the literal scenario, 32% were eligible in EF < 50% (38% of EF < 40%, 20% of EF 40-49%) and 22% in EF ≥ 40% (25% for EF ≥ 50%). Eligible vs. noneligible patients had more severe HF, more comorbidities and overall worse outcomes.

CONCLUSION

In a real-world HF outpatient cohort, 81% of patients had EF < 50%, with 63% eligible for sacubitril/valsartan based on pragmatic criteria and 32% eligible based on literal trial criteria. Similar eligibility was observed for EF 40-49% and ≥50%, suggesting that our estimates for EF < 50% may be reproduced whether or not a higher cut-off for EF is considered.

Importance of systematic right ventricular assessment in cardiac resynchronization therapy candidates: a machine-learning approach

Funding Acknowledgements

Type of funding sources: None.

Background

Despite having all a systolic heart failure and broad QRS, patients proposed for cardiac resynchronization therapy (CRT) are highly heterogeneous and it remains extremely complicated to predict the impact of the device on left ventricular (LV) function and outcomes.

Objectives

We sought to evaluate the relative impact of clinical, electrocardiographic, and echocardiographic data on the left ventricular (LV) remodeling and prognosis of CRT-candidates by the application of machine learning (ML) approaches.

Methods

193 patients with systolic heart failure undergoing CRT according to current recommendations were prospectively included in this multicentre study. We used a combination of the Boruta algorithm and random forest methods to identify features predicting both CRT volumetric response and prognosis (Figure 1). The model performance was tested by the area under the receiver operating curve (AUC). We also applied the K-medoid method to identify clusters of phenotypically-similar patients.

Results

From 28 clinical, electrocardiographic, and echocardiographic-derived variables, 16 features were predictive of CRT-response; 11 features were predictive of prognosis.

Among the predictors of CRT-response, 7 variables (44%) pertained to right ventricular (RV) size or function. Tricuspid annular plane systolic excursion was the main feature associated with prognosis. The selected features were associated with a very good prediction of both CRT response (AUC 0.81, 95% CI: 0.74-0.87) and outcomes (AUC 0.84, 95% CI: 0.75-0.93) (Figure 1, Supervised Machine Learning Panel). An unsupervised ML approach allowed the identifications of two phenogroups of patients who differed significantly in clinical and parameters, biventricular size and RV function. The two phenogroups had significant different prognosis (HR 4.70, 95% CI: 2.1-10.0, p &lt; 0.0001; log –rank p &lt; 0.0001; Figure 1, Unsupervised Machine Learning Panel).

Conclusions

Machine learning can reliably identify clinical and echocardiographic features associated with CRT-response and prognosis. The evaluation of both RV-size and function parameters has pivotal importance for the risk stratification of CRT-candidates and should be systematically assessed in patients undergoing CRT.

Abstract Figure 1

Septal scar predicts non-response to cardiac resynchronization therapy

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): South-Eastern Norway Regional Health Authority Norwegian Health Association

Background

Scar in the left ventricular (LV) posterolateral wall is associated with poor response to cardiac resynchronization therapy (CRT). The impact of septal scar, however, has been less thoroughly investigated. As recovery of septal function seems to be an important effect of CRT, we hypothesized that CRT response depends on septal viability.

Aim

The aim of the present study was to investigate the association between septal scar and volumetric response to CRT, and to compare the impact of scar located in septum to scar located in the posterolateral wall.

Methods

128 patients with symptomatic heart failure undergoing CRT implantation based on current guidelines (ejection fraction 30 ± 8%, QRS-width 164 ± 17 ms) were included in the study. Volumes and ejection fraction were measured by echocardiography using the biplane Simpson’s method at baseline and six months follow up. Non-response was defined as less than 15% reduction in end-systolic volume. Scar was assessed by late gadolinium enhancement cardiac magnetic resonance, and reported as percentage scar per regional myocardial volume. Numbers are given in [median ;10-90% percentile].

Results

Scar was present in 62 patients (48%). Scar burden was equal in septum [0% ;0-34%] and the posterolateral wall [0% ;0-36%], p = 0.10. 31 patients (24%) did not respond to CRT. The non-responders had higher scar burden than the responders in both septum [16% ;0-57% vs 0% ;0-23%, p &lt; 0.001] and the posterolateral wall [6% ;0-74% vs 0% ;0-22%, p &lt; 0.001].

In univariate regression analysis both septal and posterolateral scars correlated with non-response to CRT (r = 0.51 and r = 0.33, respectively). However, combined in a multivariate model only septal scar remained a significant marker of non-response (p &lt; 0.001), while posterolateral scar did not (p = 0.23).

Septal scar ≥ 7.1% predicted non-response with a specificity of 81% and a sensitivity of 70% by receiver operating characteristic curve analyses. The area under the curve was 0.79 (95% confidence interval 0.70 – 0.89) (Figure).

Conclusions

Septal scar is more closely associated with volumetric non-response to CRT than posterolateral scar. Future studies should explore the correlation between regional scar burden and different functional parameters, and how they relate to CRT response.

Abstract Figure. Septal scar predicts non-response to CRT

National healthcare expenditure influences CRT implantations- results from CRT Survey II with 11088 patients

Background

Cardiac Resynchronization Therapy (CRT) reduces morbidity and mortality in selected patients with heart failure (HF) and electrical dyssynchrony. This treatment receives level I recommendations in ESC guidelines from both HFA and EHRA. However, despite these strong recommendations, CRT implantation practice varies greatly in ESC member states.

Purpose

To describe how countries' healthcare expenditure affects CRT implantation practice.

Methods

Between 2015 and 2017, two ESC associations, EHRA and HFA, conducted the CRT Survey II, a survey of CRT implantations in 11,088 patients in 42 ESC member states. We divided these countries into three groups according to their current health expenditure per capita.

Results

The countries with the lowest health care expenditure were more likely to implant CRT in patients who had strong guideline recommendations for implantation such as symptomatic heart failure, LVEF≤35%, sinus rhythm, QRS duration ≥150 ms and LBBB. These countries were also less likely to implant patients with weaker recommendation level such as those with atrial fibrillation, and were more likely to implant CRT in patients hospitalized for HF in the past year or with NYHA functional class III or IV HF.

Conclusions

CRT Survey II has demonstrated a non-uniform delivery of healthcare. Countries with low health care expenditure appear to be reserving CRT therapy for younger patients, those with guideline recommendation level I indications and patients with more severe symptoms of heart failure.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): The work was supported by the European Heart Rhythm Association; the Heart Failure Association; Biotronik; Boston Scientific; Medtronic; Sorin; St. Jude; Abbott; Bayer; Bristol-Myers Squibb and Servier.

P1585 Cardiac magnetic resonance estimated extracellular volume fraction, but not native T1 mapping, detects scar in patients referred for cardiac resynchronization therapy

Funding Acknowledgements

The study was supported by Center for Cardiological Innovation

Background

Myocardial scar burden (focal fibrosis) is associated with poor response to cardiac resynchronization therapy (CRT), and should preferably be detected prior to device implantation. Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) is considered reference standard for scar detection, but is not available in renal failure. Diffuse fibrosis is assessed by T1 mapping CMR with or without calculation of extracellular volume fraction (ECV). The method is vulnerable to partial volume effects, thus subendocardial tissue is most often not included in mapping analyses. Whether the contrast-free native T1mapping could replace LGE in the preoperative evaluation of patients referred for CRT is unknown.

Purpose

To investigate if native T1 mapping and calculation of ECV can adequately detect scar in patients referred for CRT.

Methods

Scar was quantified as percentage segmental LGE in 45 patients (age 65 ± 10 years, 71% male, QRS-width 165 ± 17ms) referred for CRT. In total 720 segments were analyzed, and LGE≥50% was considered transmural scar. T1-mapping before and after contrast agent injection was performed in all patients. ECV was calculated based on the ratio between tissue T1 relaxation change and blood T1 relaxation change after contrast agent injection, corrected for the haematocrit level. The agreement between native T1/ECV and scar was evaluated with receiver operating characteristic (ROC) curves with calculation of area under the curve (AUC) and 95% confidence interval (CI).

Results

LGE was present in 255 segments, 465 segments were without LGE. Average native T1 in segments with LGE was 1028 ± 88 ms, and 1040 ± 60 ms in segments without LGE (p = 0.16). The corresponding numbers for ECV were 38.7 ± 10.9% and 30.0 ± 4.7%, p &lt; 0.001. Native T1 showed poor agreement to scar independent of scar size (AUC = 0.532, 95% CI 0.485-0.578 for scars of all sizes, and AUC = 0.572, 95% CI 0.495-0.650 for transmural scars). ECV, on the other hand, showed reasonable agreement with scar of all sizes (AUC = 0.777, 95% CI 0.739-0.815), and good agreement with transmural scars (AUC = 0.856, 95% CI 0.811-0.902). (Figure)

Conclusion

The contrast-free CMR technique T1 mapping does not adequately detect scars in patients referred for CRT. Adding post contrast T1 measurements and calculating ECV improves accuracy, especially for transmural scars. Future studies should investigate if diffuse fibrosis could be predictive of CRT response.

Abstract P1585 Figure. Detection of transmural scars

561 Targeting septal work and viability identifies responders to cardiac resynchronization therapy

Funding Acknowledgements

The study was supported by Center for Cardiological Innovation.

Introduction

Septal dysfunction is the dominant mechanism of left ventricular (LV) failure in left bundle branch block (LBBB). We hypothesize that, provided septum is viable, septal function can recover and hence LV function improve after cardiac resynchronization therapy (CRT).

Purpose

To determine if combined assessment of septal function and viability identifies responders to CRT.

Methods

In a prospective multicenter study of 200 unselected patients referred for CRT, we measured myocardial strain by speckle-tracking echocardiography and regional work by pressure-strain analysis before and 7 ± 1 months after CRT. Viability was assessed by late gadolinium enhancement cardiac magnetic resonance imaging (n = 123). CRT response was defined as ≥15% reduction in LV end-systolic volume.

Results

Before CRT, septal work was 258 ± 463 and LV lateral wall work 1469 ± 674 mmHg·% (p &lt; 0.0001). In CRT responders, septal work was restored to 1243 ± 495 mmHg·%, whereas non-responders showed less marked improvement (p &lt; 0.0001). The figure illustrates a typical CRT responder with negative septal work and a large difference between work in the LV lateral wall and septum (panel A). There was no septal scar (panel B) and, after 6 months with CRT, septal work was recovered (panel C). Pressure-strain loops illustrate that CRT converted inefficient septal contractions with substantial negative (wasted) work to positive work throughout systole. For the entire study population, the difference between work in the LV lateral wall and septum predicted CRT response with area under the curve (AUC) 0.75 (95% CI: 0.68-0.83) and was feasible in 98% of patients. Furthermore, septal scar predicted non-response to CRT with AUC 0.76 (95% CI: 0.65-0.86). Combining work difference and septal viability improved AUC for CRT response to 0.85 (95% CI: 0.76-0.94) (figure panel D). The AUC was similar for QRS 120-150 and &gt;150 ms.

Conclusions

The proposed combined approach with assessment of septal work and viability identified CRT responders with high precision.

Abstract 561 Figure.

P2790Novel endomyocardial micro-biopsy device for higher precision and reduced complication risks

Introduction

Endomyocardial biopsy (EMB) is the gold standard for diagnosis of several cardiac diseases, yet its use is limited by low diagnostic yield and significant complication risks. The size of the current devices allows only limited steering to different parts of the ventricle walls. In transplant monitoring, repeated biopsies with the current devices can cause scarring that makes it increasingly difficult to obtain adequate samples. We hypothesised that several of the shortcomings of EMB can be avoided with a smaller and more steerable device. Further, we hypothesised that the novel sampling procedure could be coupled to a low-input molecular analysis method, such as RNA-sequencing (RNA-seq), to provide molecular characterisation of the tissue without the need of large biopsy samples.

Purpose

To develop an EMB device with significantly smaller dimensions, for future use in diagnostics and research investigations. Specific aims were to test feasibility and safety of the procedure, as well as the quality of the generated molecular data.

Methods

65 “micro biopsy” (micro-EMB) device prototypes were designed and evaluated in-house. The prototypes were evaluated either in an ex-vivo simulator or in acute non-survival pig experiments (n=23). Once the final device design was reached, an in vivo trial was set up using six naive Yorkshire farm pigs. Micro-EMB, conventional EMB, skeletal muscle and blood samples were collected for RNA-seq characterisation and comparison. In half of the animals (n=3), micro-EMB was the only intervention in order to prioritise safety evaluations. The animals were monitored for one week.

Results

The final device design has an outer diameter (OD) of 0.4 mm, compared to a conventional 11 mm device (in the opened position), Fig 1A. The device can be directed to different parts of the myocardium in both ventricles. In the in vivo evaluation in swine, 81% of the biopsy attempts (n=157) were successful. High quality RNA-seq data was generated from 91% of the sequenced heart micro-biopsy samples (n=32). The gene expression signatures of samples taken with the novel device were comparable with samples taken with a conventional device, Fig 1B. No major complications were detected either during periprocedural monitoring or during the follow-up. The tissue mark after micro-biopsy was markedly smaller than after conventional endomyocardial biopsy.

A) Bioptome dimensions. B) RNA-seq data.

Conclusions

Our preliminary data suggest that the novel submillimeter biopsy device, coupled with RNA-seq, provides a feasible method to obtain molecular data from the myocardium. The method is less traumatic and has a higher flexibility compared to conventional methods, enabling safer and more specific sampling from different parts of the myocardium. In the long term, the procedure could open unprecedented diagnostic and research possibilities. Future studies should be directed to establish the capabilities of the novel method in a relevant disease model.

Acknowledgement/Funding

Family Erling Persson Foundation. The Söderberg foundations. KID (Karolinska Institutet). The 4D project. Stockholm county council. Astra Zeneca.

2177Cardiac resynchronization therapy in patients greater than 75 years of age - results from the European Society of Cardiology Survey II with 11 088 patients

Background

Cardiac Resynchronization Therapy (CRT) reduces morbidity and mortality in selected patients with heart failure (HF) and electrical dyssynchrony. The median age for patients included in the CRT landmark trials ranged from 62–68 years, therefore limited trial evidence exists on CRT in patients ≥75 years of age.

Purpose

To assess similarities and differences in patient demographics and implantation practice in different age groups implanted with a CRT device.

Methods

Between 2015 and 2017, two European Society of Cardiology (ESC) associations, European Heath Rhythm Society and the Heart Failure Association, conducted the CRT Survey II, a survey of CRT implantations in 11,088 patients in 42 ESC member states.

Results

In our survey 32% of patients included were ≥75 years of age. These patients were more frequently in NYHA Class III or IV, had more comorbidity (including hypertension, atrial fibrillation, anaemia and renal dysfunction) and had significantly higher NT-pro BNP levels than younger patients. Slightly fewer patients ≥75 years of age had LBBB but all groups had the same median QRS duration. Despite substantially more patients ≥75 years of age having HF of ischaemic aetiology compared with those <65 year of age, far fewer patients in oldest age group category were implanted with a CRT-defibrillator (CRT-D) compared with those in the youngest group.

CRT Survey II Patients by Age Categories Demographics Age <65 years Age 65–74 years Age ≥75 years N 3478 (32%) 4025 (36%) 3536 (32%) NYHA class III & IV 52% 59% 66%* Ischaemic HF aetiology 33% 49% 50%* Atrial fibrillation 17% 27% 33* NT proBNP (pg/ml, median, IQR) 1651 (670, 3811) 2319 (1070, 5169) 3510 (1647, 7631)* CRT-D 81% 76% 52%* Peri-procedural complications 5% 6% 6% Adverse Events during hospitalization 4% 5% 5% CRT-D, Cardiac resynchronization therapy – defibrillator; HF, heart failure; IQR, interquartile range. *Differences between groups is significant with p<0.001.

Conclusions

Patients ≥75 years of age had greater comorbidity and experienced more symptoms from their heart failure. However, they did not suffer more complications or adverse events during the index hospitalization, suggesting that CRT may safely be offered to elderly patients.

Acknowledgement/Funding

The work was supported by EHRA, the HFA, Biotronik, Boston Scientific, Medtronic, Sorin, St. Jude, Abbott, Bayer, Bristol-Myers Squibb and Servier

217Metabolomic profile of patients with new onset heart failure; more microvascular dysfunction in patients with preserved ejection fraction compared to reduced ejection fraction - the PREFERS Study

Background

Heart failure with preserved (HFpEF) and reduced (HFrEF) ejection fraction are both associated with metabolic derangements which may have different pathophysiological implications

Purpose

To identify metabolites and pathways differentially altered with the potential to differentiate HFpEF from HFrEF.

Methods

In the PREFERS Stockholm study (Preserved and Reduced Ejection Fraction Epidemiological Regional Study) 121 endogenous plasma metabolites were assessed by targeted mass spectrometry. Partial Least Squares Discriminant Analysis (PLS-DA) was used to identify metabolites differentially altered in new onset HF divided into HFpEF (EF ≥50%, n=46) versus HFrEF (ÈF<40%, n=75) patients. Multivariable logistic regression was used to assess independent associations between HF group and selected metabolites, including sex, age and eGFR as co-variates.

Results

Compared to HFrEF, HFpEF patients were older; 77 vs 65 years (p<0.001), more often female 54% vs 46% (p=0.004) with hypertension 60% vs 40% (p<0.001) and diabetes 63% vs 37% (p=0.007), and lower NT-proBNP 720 vs 1295 ng/L (p=0.014) and eGFR 63 vs 72 mL/min/1.73 m2 (p<0.001).

HFpEF patients had higher levels of hydroxyproline, cysteine, symmetric dimethyl arginine, alanine, kynurenine and acylcarinitines and lower levels of cAMP, lysoPC, L-carnitine, arginine, cGMP, serine and lactate (Figure). HFpEF was independently associated with reduced levels of cGMP (OR 0.98 [95% CI: 0.97–0.99; p=0.008]), serine (0.97 [0.95–1.00; 0.047]) and cAMP (0.97 [0.94–0.99; 0.009]).

Figure 1

Conclusions

In new onset HF patients, HFpEF was associated with decreased cGMP, cAMP and serine indicating increased oxidative stress, impaired innate immune function and myocardial hypertrophy. HFpEF patients displayed a distinct metabolic profile reflecting increased endothelial dysfunction, hypoxia, inflammation and myocardial fibrosis pointing towards more involvement of microvascular dysfunction compared to HFrEF.

Acknowledgement/Funding

Science for Life Laboratory–Astra Zeneca; Mölndal, Sweden collaborative grant No. 1377

P764A quality improvement program for heart failure involving structured patient data, diagnosis and organization of care - results from the 4D heart failure project

Background

Heart failure (HF) management is suboptimal in Sweden despite available evidence-based treatments.

Purpose

We hypothesized that a comprehensive organizational improvement programme could improve HF management, treatment and outcome.

Methods

Between 2012 and 2017 a HF improvement programme (the 4D Heart Failure project) was conducted in an urban region in Sweden (>2.2 million inhabitants). The steering committee led working groups 2012–17 including all health care providers with 250 primary care centers to build a standardized care process. HF outpatient care was centralized at five hospital-based HF clinics and included multidisciplinary health care teams.

The outcomes were: 1) prescription withdrawals of HF medication (RAS-inhibitors and beta-blockers, MRA) per year, expressed as percentage (%), 2) one-year all-cause mortality or heart failure readmission by multivariable Cox regression, 3) total number of admitted HF patients, subdivided by new-onset and previously known HF, per million inhabitants and year.

Results

Between 2012 and 2017, yearly visits to the five HF clinics increased 3.5 times from 3200 to 11700, to a total of 47400 visits or 15800 patients (average 3 visits/patient). Prescription withdrawals of MRAs for readmitted HF patients increased from 37% to 60%, of beta-blockers and RAS-inhibitors from 80 to 90%. Similar increases were noted for all admitted patients. One-year mortality or HF readmission was 48% (n=17124/35880) over the period and decreased significantly (adjusted HR 0.98 per year, 95% CI 0.97–0.99, p<0.001). Number of admitted HF patients, new-onset or readmitted HF patients decreased by 16%, 13% and 20%, respectively (p<0.0001, Figure).

Numbers of admitted patients 2012-2017

Conclusion

A comprehensive standardized care HF management programme in an urban region substantially increased access to multidisciplinary hospital-based HF clinics, and increased use of evidence-based medications. HF admissions and readmissions were reduced, as was the risk of one-year mortality or HF rehospitalization.

Acknowledgement/Funding

County of Stockholm and the Karolinska Institute

EUROPEAN CARDIAC RESYNCHRONIZATION THERAPY SURVEY II: COMPARISON OF RESULTS IN GEORGIA WITH OTHER COUNTRIES

Cardiac resynchronization therapy (CRT) is an important treatment modality for patients with heart failure with a reduced ejection fraction and interventricular conduction delay which is supported by current guidelines from major medical societies. One of the largest international clinical practice surveys regarding the CRT - CRT Survey II was conducted from October 2015 to December 2016 in 42 ESC member countries. We compared the outcome data of the CRT Survey II with the Georgian cohort, where 24 patients were enrolled from 2 participating medical centers of Georgia. Despite CRT II Survey analysis did show us some similarities, there were also multiple, notable differencies between Georgian population and all other European countries' data, which can be explained by a number of socio-economic or healthcare-related factors.

Left atrial rather than left ventricular impaired mechanics are associated with the pro-fibrotic ST2 marker and outcomes in heart failure with preserved ejection fraction

AIMS

Left ventricular (LV) mechanics have been extensively investigated in heart failure with preserved ejection fraction (HFpEF) overshadowing for a long time the potential role of left atrium (LA) in that setting. Soluble suppression of tumorigenicity-2 receptor (ST2) is a novel biomarker of pro-fibrotic burden in HF. We hypothesized that due to the thinner LA wall, the fibrotic myocardial changes in HFpEF as indicated by elevated ST2 levels might more readily be reflected by impairments in the LA rather than the LV performance.

METHODS AND RESULTS

In 86 patients with HFpEF, enrolled in the Karolinska Rennes (KaRen) biomarker prospective substudy, global LA strain (GL-LS) along with other echocardiographic as well as haemodynamic parameters and ST2 levels were measured. ST2 levels were inversely associated with LA-GS (r = -0.30, P = 0.009), but not with LA size, LV geometry, systolic or diastolic LV function (P > 0.05 for all). Furthermore, symptom severity correlated with ST2 and LA-GS, but not with LV structural or functional indices. Finally, during a median 18-month follow-up, LA-GS independently predicted the composite endpoint of HF hospitalization and all-cause mortality, even after adjustment for potential clinical and cardiac mechanical confounders, including LV global longitudinal strain and filling pressures (odds ratio: 4.15; confidence interval: 1.2-14, P = 0.023).

CONCLUSIONS

Reduced LA-GS but not LV functional systolic and diastolic parameters were associated with the pro-fibrotic ST2 marker, HF symptoms and outcome in HFpEF.

Naming Notes: Transitions from Free Text to Structured Entry

To practice medicine in the near future, health care providers in the USA need an information infrastructure they do not yet have. We offer a contribution from social science research to discussions of current medical records practices and how health care activity systems may be transformed by the advent of electronic health records. The goal of the paper is to set forth a framework that connects over-arching questions concerning medical informatics systems development with the practical, cultural and conceptual issues involved in transitions from handwritten and other free text documentation to structured entry of medical records to build patient profiles. The research is broadly framed by an interest in how reciprocal modifications of the design and use of an electronic health record are negotiated in an iterative prototyping project. It is conducted as part of a complex multi-disciplinary research and development effort to create an electronic health record prototype for use in the integrated health care delivery environment of the Southern California Kaiser Permanente Medical Care Program.

Neural modulation for hypertension and heart failure

Hypertension (HTN) and heart failure (HF) have a significant global impact on health, and lead to increased morbidity and mortality. Despite recent advances in pharmacologic and device therapy for these conditions, there is a need for additional treatment modalities. Patients with sub-optimally treated HTN have increased risk for stroke, renal failure and heart failure. The outcome of HF patients remains poor despite modern pharmacological therapy and with established device therapies such as CRT and ICDs. Therefore, the potential role of neuromodulation via renal denervation, baro-reflex modulation and vagal stimulation for the treatment of resistant HTN and HF is being explored. In this manuscript, we review current evidence for neuromodulation in relation to established drug and device therapies and how these therapies may be synergistic in achieving therapy goals in patients with treatment resistant HTN and heart failure. We describe lessons learned from recent neuromodulation trials and outline strategies to improve the potential for success in future trials. This review is based on discussions between scientists, clinical trialists, and regulatory representatives at the 11th annual CardioVascular Clinical Trialist Forum in Washington, DC on December 5-7, 2014.

Difference in immune response in vaccinated and unvaccinated Swedish individuals after the 2009 influenza pandemic

BACKGROUND

Previous exposures to flu and subsequent immune responses may impact on 2009/2010 pandemic flu vaccine responses and clinical symptoms upon infection with the 2009 pandemic H1N1 influenza strain. Qualitative and quantitative differences in humoral and cellular immune responses associated with the flu vaccination in 2009/2010 (pandemic H1N1 vaccine) and natural infection have not yet been described in detail. We designed a longitudinal study to examine influenza- (flu-) specific immune responses and the association between pre-existing flu responses, symptoms of influenza-like illness (ILI), impact of pandemic flu infection, and pandemic flu vaccination in a cohort of 2,040 individuals in Sweden in 2009-2010.

METHODS

Cellular flu-specific immune responses were assessed by whole-blood antigen stimulation assay, and humoral responses by a single radial hemolysis test.

RESULTS

Previous seasonal flu vaccination was associated with significantly lower flu-specific IFN-γ responses (using a whole-blood assay) at study entry. Pandemic flu vaccination induced long-lived T-cell responses (measured by IFN-γ production) to influenza A strains, influenza B strains, and the matrix (M1) antigen. In contrast, individuals with pandemic flu infection (PCR positive) exhibited increased flu-specific T-cell responses shortly after onset of ILI symptoms but the immune response decreased after the flu season (spring 2010). We identified non-pandemic-flu vaccinated participants without ILI symptoms who showed an IFN-γ production profile similar to pandemic-flu infected participants, suggesting exposure without experiencing clinical symptoms.

CONCLUSIONS

Strong and long-lived flu-M1 specific immune responses, defined by IFN-γ production, in individuals after vaccination suggest that M1-responses may contribute to protective cellular immune responses. Silent flu infections appeared to be frequent in 2009/2010. The pandemic flu vaccine induced qualitatively and quantitatively different humoral and cellular immune responses as compared to infection with the 2009 H1N1 pandemic H1N1 influenza strain.

Cardiac resynchronization therapy: a breakthrough in heart failure management

Heart failure is now considered an epidemic. In patients with heart failure, electrical and mechanical dyssynchrony, evident primarily as prolongation of the QRS-complex on the surface electrocardiogram, is associated with detrimental effects on the cardiovascular system at several levels. In the past 10 years, studies have demonstrated that by stimulating both cardiac ventricles simultaneously, or almost simultaneously [cardiac resynchronization therapy (CRT)], the adverse effects of dyssynchrony can be overcome. Here, we provide a comprehensive overview of different aspects of CRT including the rationale behind and evidence for efficacy of the therapy. Issues with regard to gender effects and patient follow-up as well as a number of unresolved concerns will also be discussed.

Co-infection patterns and geographic distribution of a complex pathosystem targeted by pathogen-resistant plants

Increasingly, pathogen-resistant (PR) plants are being developed to reduce the agricultural impacts of disease. However PR plants also have the potential to result in increased invasiveness of nontarget host populations and so pose a potential threat to nontarget ecosystems. In this paper we use a new framework to investigate geographical variation in the potential risk associated with unintended release of genetically modified alfalfa mosaic virus (AMV)-resistant Trifolium repens (white clover) into nontarget host populations containing AMV, clover yellow vein virus (ClYVV), and white clover mosaic virus (WCIMV) in southeastern Australia. Surveys of 213 sites in 37 habitat types over a 300 000-km2 study region showed that T. repens is a significant weed of many high-conservation-value habitats in southeastern Australia and that AMV, ClYVV, and WClMV occur in 15-97% of nontarget host populations. However, T. repens abundance varied with site disturbance, habitat conservation value, and proximity to cropping, and all viral pathogens had distinct geographic distributions and infection patterns. Virus species frequently co-infected host plants and displayed nonindependent distributions within host populations, although co-infection patterns varied across the study region. Our results clearly illustrate the complexity of conducting environmental risk assessments that involve geographically widespread, invasive pasture species and demonstrate the general need for targeted, habitat- and pathosystem-specific studies prior to the process of tiered risk assessment.

Studies on the antibacterial effects of statins--in vitro and in vivo

Background

Statin treatment has been associated with a beneficial outcome on respiratory tract infections. In addition, previous in vitro and in vivo experiments have indicated favorable effects of statins in bacterial infections.

Aim

The aim of the present study was to elucidate possible antibacterial effects of statins against primary pathogens of the respiratory tract.

Methods

MIC-values for simvastatin, fluvastatin and pravastatin against S. pneumoniae, M. catarrhalis and H. influenzae were determined by traditional antibacterial assays. A BioScreen instrument was used to monitor effects of statins on bacterial growth and to assess possible synergistic effects with penicillin. Bacterial growth in whole blood and serum from healthy volunteers before and after a single dose of simvastatin, fluvastatin and penicillin (positive control) was determined using a blood culture system (BactAlert).

Findings

The MIC-value for simvastatin against S pneumoniae and M catarrhalis was 15 µg/mL (36 mmol/L). Fluvastatin and Pravastatin showed no antibacterial effect in concentrations up to 100 µg/mL (230 µmol/L). Statins did not affect growth or viability of H influenzae. Single doses of statins given to healthy volunteers did not affect growth of pneumococci, whereas penicillin efficiently killed all bacteria.

Conclusions

Simvastatin at high concentrations 15 µg/mL (36 µmol/L) rapidly kills S pneumoniae and M catarrhalis. However, these concentrations by far exceed the concentrations detected in human blood during simvastatin therapy (1–15 nmol/L) and single doses of statins given to healthy volunteers did not improve antibacterial effects of whole blood. Thus, a direct bactericidal effect of statins in vivo is probably not the mechanism behind the observed beneficial effect of statins against various infections.

Enhanced susceptibility of multidrug resistant strains of Mycobacterium tuberculosis to granulysin peptides correlates with a reduced fitness phenotype

Previously it was shown that the antimicrobial protein granulysin possesses potent membranolytic activity against Mycobacterium tuberculosis. Here we demonstrate that granF2 and G13, which are two short synthetic peptides derived from granulysin, inhibited the in vitro growth of clinical isolates of both multidrug resistant and drug susceptible strains of M. tuberculosis. Importantly, a particularly high activity against multidrug resistant M. tuberculosis correlated with a reduced growth rate compared to drug susceptible strains. A synergistic antibacterial effect of granF2 was further observed in combination with ethambutol, a compound with a documented effect on cell wall permeability. This finding suggests that granF2 and ethambutol exert their functions at different levels of the mycobacterial surface. Upon infection of macrophages in vitro, granF2 but not G13 efficiently reduced the intracellular growth of multidrug resistant M. tuberculosis in the presence of the pore-forming protein streptolysin O. The apoptotic function of granF2 apparently promoted destruction of host cells whereby the peptide gained access to and killed intracellular bacteria. Thus, a cost of resistance and a subsequent reduced fitness, measured as decreased growth among multidrug resistant strains of M. tuberculosis, could be associated with increased susceptibility to natural immune defense mechanisms, such as antimicrobial peptides of granulysin. However, a robust cell wall and the membrane of cells still provide physical shelter for the bacteria that may spare sensitive M. tuberculosis stains from being killed.