Estimation of Right Atrial Pressure by Ultrasound-Assessed Jugular Vein Distensibility in Patients With Heart Failure

BACKGROUND

Clinical evaluation of central venous pressure is difficult, depends on experience, and is often inaccurate in patients with chronic advanced heart failure. We assessed the ultrasound-assessed internal jugular vein (JV) distensibility by ultrasound as a noninvasive tool to identify patients with normal right atrial pressure (RAP ≤7 mm Hg) in this population.

METHODS

We measured JV distensibility as the Valsalva-to-rest ratio of the vein diameter in a calibration cohort (N=100) and a validation cohort (N=101) of consecutive patients with chronic heart failure with reduced ejection fraction who underwent pulmonary artery catheterization for advanced heart failure therapies workup.

RESULTS

A JV distensibility threshold of 1.6 was identified as the most accurate to discriminate between patients with RAP ≤7 versus >7 mm Hg (area under the receiver operating characteristic curve, 0.74 [95% CI, 0.64-0.84]) and confirmed in the validation cohort (receiver operating characteristic, 0.82 [95% CI, 0.73-0.92]). A JV distensibility ratio >1.6 had predictive positive values of 0.86 and 0.94, respectively, to identify patients with RAP ≤7 mm Hg in the calibration and validation cohorts. Compared with patients from the calibration cohort with a high JV distensibility ratio (>1.6; n=42; median RAP, 4 mm Hg; pulmonary capillary wedge pressure, 11 mm Hg), those with a low JV distensibility ratio (≤1.6; n=58; median RAP, 8 mm Hg; pulmonary capillary wedge pressure, 22 mm Hg; P<0.0001 for both) were more likely to die or undergo a left ventricular assist device implant or heart transplantation (event rate at 2 years: 42.7% versus 18.2%; log-rank P=0.034).

CONCLUSIONS

Ultrasound-assessed JV distensibility identifies patients with chronic advanced heart failure with normal RAP and better outcomes.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03874312.

The Exercise aNd hEArt transplant (ENEA) trial - a registry-based randomized controlled trial evaluating the safety and efficacy of cardiac telerehabilitation after heart transplant

BACKGROUND

Heart transplant (HTx) is gold-standard therapy for patients with end-stage heart failure. Cardiac rehabilitation (CR) is a multidisciplinary intervention shown to improve cardiovascular prognosis and quality of life. The aim in this randomized controlled trial is to explore the safety and efficacy of cardiac telerehabilitation after HTx. In addition, biomarkers of rehabilitation outcomes will be identified, as data that will enable treatment to be tailored to patient phenotype.

METHODS

Patients after HTx will be recruited at IRCCS S. Maria Nascente - Fondazione Don Gnocchi, Milan, Italy (n = 40). Consenting participants will be randomly allocated to either of two groups (1:1): an intervention group who will receive on-site CR followed by 12 weeks of telerehabilitation, or a control group who will receive on-site CR followed by standard homecare and exercise programme. Recruitment began on 20th May 2023 and is expected to continue until 20th May 2025. Socio-demographic characteristics, lifestyle, health status, cardiovascular events, cognitive function, anxiety and depression symptoms, and quality of life will be assessed, as well as exercise capacity and muscular endurance. Participants will be evaluated before the intervention, post-CR and after 6 months. In addition, analysis of circulating extracellular vesicles using Surface Plasmon Resonance imaging (SPRi), based on a rehabilomic approach, will be applied to both groups pre- and post-CR.

CONCLUSION

This study will explore the safety and efficacy of cardiac telerehabilitation after HTx. In addition, a rehabilomic approach will be used to investigate biomolecular phenotypization in HTx patients.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT05824364.

Intravenous continuous home inotropic therapy in advanced heart failure: Insights from an observational retrospective study

INTRODUCTION

Intravenous inotropic support represents an important therapeutic option in advanced heart failure (HF) as bridge to heart transplantation, bridge to mechanical circulatory support, bridge to candidacy or as palliative therapy. Nevertheless, evidence regarding risks and benefits of its use is lacking.

METHODS

we conducted a retrospective single center study, analysing the effect of inotropic therapies in an outpatient cohort, evaluating the burden of hospitalizations, the improvement in quality of life, the incidence of adverse events and the evolution of organ damage.

RESULTS

twenty-seven patients with advanced HF were treated in our Day Hospital service from 2014 to 2021. Nine patients were treated as bridge to heart transplant while eighteen as palliation. Comparing data regarding the year before and after the beginning of inotropic infusion, we observed a reduction of hospitalization (46 vs 25, p<0,001), an improvement of natriuretic peptides, renal and hepatic function since the first month (p<0,001) and a better quality of life in 53% of the population treated. Two hospitalizations for arrhythmias and seven hospitalizations for catheter-related complications were registered.

CONCLUSIONS

in a selected population of advanced HF patients, continuous home inotropic infusion were able to reduce hospitalizations, improving end organ damage and quality of life. We provide a practical guidance on starting and maintaining home inotropic infusion while monitoring a challenging group of patients.

Immune checkpoint inhibitor-associated myocarditis: from pathophysiology to rechallenge of therapy - a narrative review

Even if immune checkpoint inhibitors have revolutionized the landscape of cancer therapy, their use may be complicated by immune-related adverse events. Among these, myocarditis is the most severe complication. The clinical suspicion often arises after clinical symptoms onset and increase in cardiac biomarkers or electrocardiographic manifestations. Echocardiography and cardiac magnetic resonance imaging are recommended for each patient. However, since they may be misleadingly normal, endomyocardial biopsy remains the gold standard for establishing the diagnosis. Until now, treatment has been based on glucocorticoids even if increasing interest has risen in other immunosuppressive agents. Although myocarditis currently imposes immunotherapy discontinuation, case reports have suggested a safety rechallenge in low-grade myocarditis paving the way for further studies to respond to this unmet clinical need.

139 INTRAVENOUS CONTINUOUS HOME INOTROPIC THERAPY IN ADVANCED HEART FAILURE - RESULTS AND PRACTICAL GUIDELINES

Background

no firm data exist regarding continuous intravenous inotropic infusion in outpatients with advanced heart failure (AHF).

Methods

We reviewed medical records of all inotrope dependent patients discharged from our institution on continuous home inotropes infusion for AHF after a hospitalization between 2014 and 2021. Indications for inotropic agents included bridge to transplant (BTT) or to candidacy (BTC) strategies or palliative care. We compared the number of hospitalizations the year before and the year after beginning the inotrope continuous infusion, assessing the main hospital diagnosis and the duration of hospital recovery in days, through hospital charts revision. Moreover, we used a linkert 7 item scale to assess quality of life (QoL) and, using peripheral blood sample, we esteemed the end organ damage trend evaluating NTproBNP, creatinine, blood urea nitrogen (BUN) and bilirubin.

Results

From 2014 to 2021, 27 patients (Median age 56 years (Q1-Q3 50-63 years), 74% male and 26% female) were dismissed with continuous inotrope infusion from our institution. The total number of days of hospital stay was 1591 the year before beginning inotropic support (average 58.93 ± 38.70 for patient), significantly different if compared with the post inotropes period (average 22,19 ± 36,84 days for patients, IC 95% 17,488-55,994 p &lt; 0,001). Moreover, the number of hospitalizations per patient fell from 1.93 ± 0.997 to 0,93 ± 0,958 (IC 95% 0,522- 1,478, p &lt; 0,001). After 6 months, 53% of the patients experienced an improvement in quality of life. Regarding end organ damage, while creatinine and BUN showed a significant reduction in the first month, with a trend to stability in the following period, bilirubin and NTproBNP significantly trended to reduction during the 6 month of monitoring.

Conclusions

In a real world population of contemporary AHF, continuous inotropes home infusion documented an improvement in hospitalization, QoL and end organ damage. We offer a practical guideline on initiation, selection and maintenance of chronic inotrope therapy in a population of challenging patients.

143 ESTIMATION OF RIGHT ATRIAL PRESSURE BY ULTRASOUND-ASSESSED JUGULAR VEIN DISTENSIBILITY IN PATIENTS WITH CHRONIC ADVANCED HEART FAILURE

Aims

In patients with chronic advanced heart failure (HF) signs of congestion are not always evident on clinical examination. We aim to validate the ultrasound (US)-assessed jugular vein distensibility (JVD), as a non-invasive tool to identify patients with normal right atrial pressure (RAP≤7 mmHg).

Methods and Results

In a single-center prospective study, we assessed chronic HF patients with a left ventricular ejection fraction (LVEF)&lt;50% who underwent a pulmonary artery catheterization in the setting of advanced HF therapies workup. We first identify the JVD threshold (Valsalva/rest ratio of the vein diameter) of 1.6 that allowed the most accurate discrimination between patients with RAP≤7 vs. &gt;7 mmHg (area under the curve [AUC] of 0.74; p&lt;0.0001) in a calibration cohort of 100 patients (mean age 53 years, median LVEF 25%). Based on this JVD threshold, we defined patients with low JVD (≤1.6; n=58; median RAP 8 mmHg) and high JVD (&gt;1.6, n=42; median RAP 4 mmHg). Then, we tested the threshold in 101 patients (validation cohort), where we found comparable results (AUC of 0.82; p&lt;0.0001). The JVD threshold had 0.86 and 0.94 predictive positive values to identify patients with RAP≤7 mmHg in the calibration and validation cohorts. Finally, the low JVD vs. high JVD group had a 42.7% vs. 16.1% incidence of major cardiac events at 2 years (log-rank p=0.006), showing its prognostic value.

Conclusion

US-assessed JVD is an accurate diagnostic tool to identify advanced HF patients with normal RAP. This tool could be tested in the ambulatory setting to modulate diuretic/vasodilator therapies.

[ANMCO Position paper: Cardiovascular disease in women - prevention, diagnosis, treatment and organization of care]

Cardiovascular diseases are still the main cause of death among women despite the improvements in treatment and prognosis achieved in the last 30 years of research. The determinant factors and causes have not been completely identified but the role of "gender" is now recognized. It is well known that women tend to develop cardiovascular disease at an older age than men, and have a high probability of manifesting atypical symptoms not often recognized. Other factors may also co-exist in women, which may favor the onset of specific cardiac diseases such as those with a sex-specific etiology (differential effects of estrogens, pregnancy pathologies, etc.) and those with a different gender expression of specific and prevalent risk factors, inflammatory and autoimmune diseases and cancer. Whether the gender differences observed in cardiovascular outcomes are influenced by real biological differences remains a matter of debate.This ANMCO position paper aims at providing the state of the research on this topic, with particular attention to the diagnostic aspects and to care organization.

P217 SACUBITRIL/VALSARTAN IN ADVANCED HEART FAILURE: SAFETY AND EFFECTS ON HAEMODYNAMIC PARAMETERS

Aims

The angiotensin–II receptor neprilysin inhibitor (ARNI), sacubitril/valsartan has been shown to be effective in treatment of patients with heart failure (HF), but limited data is available in patients with advanced disease. This retrospective observational study assessed the effects of ARNI treatment in patients with advanced HF.

Methods

We reviewed medical records of all advanced HF patients evaluated at our center for unconventional therapies from September 2016 to January 2019. We studied 44 patients who started ARNI therapy and who had a hemodynamic assessment before beginning ARNI and after 6 ± 2 months. The primary endpoint was variation in pulmonary pressures and filling pressures at 6 months after starting ARNI therapy.

Results

Mean patient age was 51.6±7.4 years; 84% were male. At 6±2 months after starting ARNI, there was significant reduction of systolic pulmonary artery pressure (PAP) (32 mmHg, IQR 27–45 vs 25 mmHg, IQR 22.3–36.5; p &lt; 0.0001) and median PAP (20 mmHg, IQR 15.3–29.8 vs 17 mmHg, IQR 13–24.8; p = 0.046). Five of 22 patients (23%) were deferred from the heart transplant (HTx) list because of improvement, while four were listed de novo. After 23 ± 9 months, 3 patients were treated with a left ventricular assist device (LVAD) implantation, while 6 patients underwent Heart transplantation (one in emergency conditions for refractory ventricular tachycardia).

Conclusions

Sacubitril/valsartan is effective in reducing filling pressures and pulmonary pressures in patients with advanced HF. The absence of adverse events during follow–up suggests that sacubitril/valsartan is safe and well–tolerated in this cohort of patients.

Haemodynamic effects of sacubitril/valsartan in advanced heart failure

Aims

The angiotensin receptor–neprilysin inhibitor (ARNI), sacubitril/valsartan, has been shown to be effective in treatment of patients with heart failure (HF), but limited data are available in patients with advanced disease. This retrospective observational study assessed the effects of ARNI treatment in patients with advanced HF.

Methods and results

We reviewed medical records of all advanced HF patients evaluated at our centre for unconventional therapies from September 2016 to January 2019. We studied 44 patients who started ARNI therapy and who had a haemodynamic assessment before beginning ARNI and after 6 ± 2 months. The primary endpoint was variation in pulmonary pressures and filling pressures at 6 months after starting ARNI therapy. Mean patient age was 51.6 ± 7.4 years; 84% were male. At 6 ± 2 months after starting ARNI, there was significant reduction of systolic pulmonary artery pressure [32 mmHg, interquartile range (IQR) 27–45 vs. 25 mmHg, IQR 22.3–36.5; P < 0.0001] and mean pulmonary artery pressure (20 mmHg, IQR 15.3–29.8 vs. 17 mmHg, IQR 13–24.8; P = 0.046). Five of 22 patients (23%) were deferred from the heart transplant list because of improvement, whereas four were listed de novo. After 23 ± 9 months, three patients were treated with a left ventricular assist device implantation, whereas six patients underwent heart transplantation (one in emergency conditions for refractory ventricular tachycardia).

Conclusions

Sacubitril/valsartan is effective in reducing filling pressures and pulmonary pressures in patients with advanced HF. The absence of adverse events during follow‐up suggests that sacubitril/valsartan is safe and well‐tolerated in this cohort of patients.

Long-term administration of intravenous inotropes in advanced heart failure

Background

Patients in heart transplantation (HTx) waiting list for advanced heart failure (HF) are susceptible to acute deterioration refractory to standard HF medical therapies. Limited data are available on long‐term in‐hospital continuous intravenous (IV) inotropic therapy as bridge to definite therapies.

Methods and results

We reviewed medical records of all heart transplant recipients treated in the pre‐HTx phase with in‐hospital continuous IV inotropes at our institution between 2012 and 2018. We analysed data before the beginning of continuous IV therapy and at the moment of HTx. We report data of 24 patients (mean age of 43.5 ± 15.7 years) treated with IV inotropes as bridge to HTx (median follow‐up of 28 months after HTx). The main length of IV inotropic therapy was 84 ± 66 days (min 22; max 264 days). At the beginning, the most frequently used inotrope was dopamine (median dosage of 3 mcg/kg/min, interquartile range 2.5–3.75), alone (n = 11, 46%) or in combination with other inotropes (n = 13, 54%). In 18 patients, the class of inotropes was changed during the hospitalization. We registered a progressive improvement of perfusion markers and neuro‐hormonal activation.

Conclusion

In‐hospital continuous parenteral inotropic therapy may serve as a temporary pharmacological bridge to HTx in patients with advanced HF that are actively listed to HTx with good reply in terms of prognosis and perfusion markers.

COVID-19 in Heart Transplant Recipients: A Multicenter Analysis of the Northern Italian Outbreak

OBJECTIVES

The aim of this study was to assess the clinical course and outcomes of all heart transplant recipients affected by coronavirus disease-2019 (COVID-19) who were followed at the leading heart transplant centers of Northern Italy.

BACKGROUND

The worldwide severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic has created unprecedented challenges for public health, demanding exceptional efforts for the successful management and treatment of affected patients. Heart transplant patients represent a unique cohort of chronically immunosuppressed subjects in which SARS-CoV-2 may stimulate an unpredictable clinical course of infection.

METHODS

Since February 2020, we enrolled all 47 cases (79% male) in a first cohort of patients, with a mean age of 61.8 ± 14.5 years, who tested positive for SARS-CoV-2, out of 2,676 heart transplant recipients alive before the onset of the COVID-19 pandemic at 7 heart transplant centers in Northern Italy.

RESULTS

To date, 38 patients required hospitalization while 9 remained self-home quarantined and 14 died. Compared to the general population, prevalence (18 vs. 7 cases per 1,000) and related case fatality rate (29.7% vs. 15.4%) in heart transplant recipients were doubled. Univariable analysis showed older age (p = 0.002), diabetes mellitus (p = 0.040), extracardiac arteriopathy (p = 0.040), previous PCI (p = 0.040), CAV score (p = 0.039), lower GFR (p = 0.004), and higher NYHA functional classes (p = 0.023) were all significantly associated with in-hospital mortality. During the follow-up two patients died and a third patient has prolonged viral-shedding alternating positive and negative swabs. Since July 1st, 2020, we had 6 new patients who tested positive for SARS-CoV-2, 5 patients asymptomatic were self-quarantined, while 1 is still hospitalized for pneumonia. A standard therapy was maintained for all, except for the hospitalized patient.

CONCLUSIONS

The prevalence and mortality of SARS-CoV-2 should spur clinicians to immediately refer heart transplant recipients suspected as having SARS-CoV2 infection to centers specializing in the care of this vulnerable population.

P6315Effects of chronic heart failure unconventional therapies on endothelial function

Introduction

Endothelial Dysfunction (ED) of peripheral arteries in Chronic Heart Failure (CHF) subjects has been demonstrated.

Purpose

We assessed endothelial function in subjects undergoing unconventional treatments for CHF, namely Heart Transplantation (HTX), continuous-flow Left Ventricular Assist Device implantation (LVAD), and repeated levosimendan infusions (r-LEVO).

Methods

Twenty HTX recipients (median time from HTX 21 months), 20 patients supported with LVAD (median time from implant 39 months), and 20 patients receiving monthly Levosimendan infusions (median time on treatment 28 months) were enrolled and compared to a group of 20 healthy subjects. ED was evaluated with ultrasound assessment of the diameter before and after ischemic stress at the brachial artery level. The difference between the two diameters normalized for the baseline value (Flow Mediated Dilation – FMD) has been used for the analysis. All the patients were stable at the time of FMD assessment, with those on r-LEVO being evaluated prior to infusion.

Results

FMD was significantly lower in HTX and LVAD groups with respect to controls (9.8±7.4, 9.3±5.7, and 15.6±6.4% respectively, p=0.01), but not in r-LEVO group (12.5±6.9%).

When patients were analyzed according to time from the operation or on treatment, (< versus > of the median value), no differences were seen in HTX and r-LEVO group, while in LVAD group FMD was borderline significantly higher in patients with longer follow-up (8.4±6.4% versus 10.2±5.2%, p=0.05).

Conclusions

Based on this preliminary data we can inference the following: 1- FMD is abnormal in HTX recipients, despite their good functional status, probably due to factors unrelated to CHF (e.g. hypertension, renal insufficiency, denervation, and drug effects); 2- LVAD patients also show ED, with possible better adaptation in very long-term survivors; 3- Near-normal FMD values in CHF patients who remain stable with r-LEVO suggest that pulsed treatment may obtain favorable effects at peripheral level, persisting after clearance of the drug and its metabolites.

Acknowledgement/Funding

None

Single-center outbreak of Pneumocystis jirovecii pneumonia in heart transplant recipients

BACKGROUND

Pneumocystis jirovecii pneumonia (PJP) outbreaks are described in solid organ transplant recipients. Few reports suggest interhuman transmission with important infection control implications. We described a large PJP outbreak in heart transplant (HTx) recipients.

METHODS

Six cases of PJP occurred in HTx recipients within 10 months in our hospital. Demographics, clinical characteristics, treatment and outcomes were described. To identify contacts among individuals a review of all dates of out-patient visits and patient hospitalizations was performed. Cross exposure was also investigated using genotyping on PJ isolates.

RESULTS

At the time of PJP-related hospitalization, patients' mean age was 49 ± standard deviation 4 years, median time from HTx was 8 (25%-75% interquartile range [Q1-Q3] 5-12) months and none of the cases were on prophylaxis. At PJP-related admission, 5 patients had CMV reactivation, of whom 4 were on antiviral preemptive treatment. Median in-hospital stay was 30 (Q1-Q3, 28-48) days; and 2 cases required intensive care unit admission. All patients survived beyond 2 years. Transmission map analysis suggested interhuman transmission in all cases (presumed incubation period, median 90 [Q1-Q3, 64-91] days). Genotyping was performed in 4 cases, demonstrating the same PJ strain in 3 cases.

CONCLUSIONS

We described a large PJP cluster among HTx recipients, supporting the nosocomial acquisition of PJP through interhuman transmission. Based on this experience, extended prophylaxis for more than 6 months after HTx could be considered in specific settings. Further work is required to understand its optimal duration and timing based on individual risk factor profiles and to define standardized countermeasures to prevent and limit PJP outbreaks.

[Cardiac involvement in Churg-Strauss syndrome]

Churg-Strauss syndrome, recently renamed eosinophilic granulomatosis with polyangiitis (EGPA), is a rare form of systemic vasculitis, characterized by disseminated necrotizing vasculitis with extravascular granulomas occurring among patients with asthma and tissue eosinophilia. EGPA is classified as a small and medium-sized vessel vasculitis associated with antineutrophil cytoplasmic antibodies (ANCA) and the hypereosinophilic syndrome. Typical clinical features include asthma, sinusitis, transient pulmonary infiltrates and neuropathy. Blood eosinophils are often >1500/µl or more than 10% on the differential leukocyte count. Blood eosinophils should always be tested in unexplained cardiac disorders, and may normalize even after low doses of corticosteroids. ANCA are positive in 40-60% of cases, mainly anti-myeloperoxidase. Heart involvement occurs in approximately 15-60% of EGPA patients, especially those who are ANCA negative. Any cardiac structure can be involved, and patients present with myocarditis, heart failure, pericarditis, arrhythmia, coronary arteritis, valvulopathy, intracavitary cardiac thrombosis. Although cardiovascular involvement is usually an early manifestation, it can also occur later in the course of the disease. A significant proportion of patients with cardiac involvement is asymptomatic. In the absence of symptoms and major ECG abnormalities, cardiac involvement may be detected in nearly 40% of the patients. All patients with EGPA should be studied not only with a detailed history of cardiac symptoms and ECG, but also with echocardiography; if abnormalities are detected, a cardiac magnetic resonance study should be performed. Coronary angiography and endomyocardial biopsy should be reserved to selected cases. Heart involvement carries a poor prognosis and causes 50% of the deaths of these patients. It is often insidious and underestimated. Optimal therapy is therefore important and based on high-dose corticosteroids plus immunosuppressive agents, particularly cyclophosphamide in case of myocardial inflammation. Thus, early diagnosis of cardiac involvement and subsequent therapy may prevent progression of cardiac disease. At present, the role of troponin and brain natriuretic peptide in monitoring and therapy remains unclear. Orthotopic heart transplantation is feasible in case of severe disease, even if the experience is limited in -EGPA, and optimal post-transplantation immunosuppressive strategy has yet to be defined.

Heart transplantation in patients with eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)

BACKGROUND

Heart involvement is the leading cause of death of patients with eosinophilic granulomatosis with polyangiitis (EGPA; formerly Churg-Strauss syndrome) and is more frequent in anti-neutrophil cytoplasm antibody (ANCA)-negative patients. Post-transplant outcome has only been reported once.

METHODS

We conducted a retrospective international multicenter study. Patients satisfying the criteria of the American College of Rheumatology and/or revised Chapel Hill Consensus Conference Nomenclature were identified by collaborating vasculitis and transplant specialists, and the help of the Churg-Strauss Syndrome Association.

RESULTS

Nine ANCA(-) patients who received transplants between October 1987 and December 2009 were identified. The vasculitis and cardiomyopathy diagnoses were concomitant for 5 patients and separated by 12 to 288 months for the remaining 4 patients. Despite ongoing immunosuppression, histologic examination of 7 (78%) patients' explanted hearts showed histologic patterns suggestive of active vasculitis. The overall 5-year survival rate was low (57%), but rose to 80% when considering only the 6 patients transplanted during the last decade. After survival lasting 3 to 60 months, 4 (44%) patients died sudden deaths.

CONCLUSIONS

The search for EGPA-related cardiomyopathy is mandatory early in the course of this type of vasculitis. Indeed, prompt treatment with corticosteroids and cyclophosphamide may achieve restore cardiac function. Most patients in this series were undertreated. For patients with refractory EGPA, heart transplantation should be performed, which carries a fair prognosis. No optimal immunosuppressive strategy has yet been identified.

Blood glutathione as a marker of cardiac allograft vasculopathy in heart transplant recipients

BACKGROUND

Cardiac allograft vasculopathy (CAV) limits survival after heart transplantation (HTx). Between immunologic and non-immunologic factors, reactive oxygen species generation has been proposed as pathogenetic mechanism. This study was aimed at evaluating redox status in HTx recipients and verifying whether it could be independently associated with CAV.

METHODS

Fifty-five consecutive male HTx recipients, median [interquartile range] age 60 yr [50, 64], underwent angiography 67 months [21, 97] after HTx to assess CAV, defined as significant stenosis in >or=1 epicardial vessel or any distal vessel attenuation. All patients underwent blood sampling 89 months [67, 119] after HTx for biochemical (glucose, creatinine, total and LDL cholesterol, and cyclosporin levels) and redox evaluation [plasma reduced and total homocysteine, cysteine, cysteinylglycine, glutathione, blood reduced glutathione (GSH(bl)) and vitamin E]. Univariate Odds Ratios (OR) with 95% confidence interval (95% CI, highest vs. lowest quartile) were estimated on the basis of a logistic regression analysis between clinical, conventional biochemical and redox data. Only the significant variables at univariate entered into multivariate analysis.

RESULTS

CAV was documented in 15 (27%) patients. Univariate analysis showed that time from HTx to angiography (OR 3.97, 95% CI 1.15-14, p = 0.03) and GSH(bl) (OR 0.31, 95% CI: 0.14-0.70, p = 0.005) were significantly associated with CAV. However, multivariate analysis revealed GSH(bl) as the only independent predictor of CAV (OR 0.31, 95% CI: 0.13-0.74, p = 0.008).

CONCLUSIONS

In HTx recipients reduced levels of GSH(bl) are independently associated with CAV. Given its potent intracellular scavenger properties, GSH(bl) may serve as a marker of antioxidant defence consumption, favouring CAV development.

Incorrect echocardiographic diagnosis in patients with mechanical prosthetic valve dysfunction: correlation with surgical findings

PURPOSE

To identify the rate of occurrence and type of incorrect echocardiographic diagnoses in patients with mechanical valve prostheses.

PATIENTS AND METHODS

We studied 170 consecutive patients (73 women and 97 men) with a total of 208 prostheses who underwent surgery for mitral (n = 136) or aortic (n = 72) valve dysfunction between January 1991 and December 1997. Preoperative echocardiographic data were compared with surgical findings. Any major discrepancy between the echocardiographic reports and surgery was judged to be unconfirmed when the preoperative echocardiographic diagnosis was not confirmed at surgery, but the prosthesis was found to be dysfunctioning; and was judged to be erroneous when the preoperative echocardiographic diagnosis was not confirmed, and surgical inspection failed to reveal any other prosthetic abnormality.

RESULTS

There were 25 (12%) diagnostic errors. Of the 136 mitral prostheses, there were 9 unconfirmed diagnoses of paravalvular regurgitation (6 had a fibrous tissue overgrowth, 1 had a thrombus with fibrous tissue overgrowth, 1 had endocarditis vegetations, and 1 had a ball variance) and 5 erroneous diagnoses. Eleven diagnostic errors were made in the 72 aortic prostheses: there were 9 unconfirmed diagnoses (paravalvular regurgitation was diagnosed as transvalvular in 7, and transvalvular regurgitation as paravalvular in 2 cases), and 2 erroneous diagnoses.

CONCLUSIONS

Although echocardiography has gained great credibility among clinicians, special care should be taken when assessing patients in whom prosthetic valve dysfunction is suspected.

A semiquantitative approach to the evaluation of acute cardiac allograft rejection at endomyocardial biopsy

BACKGROUND

Histopathologic criteria for grading of acute cardiac allograft rejection are focused on the most severe lesion that is recognized among the myocardial fragments provided by each endomyocardial biopsy specimen. Considering the distribution of rejection lesions among all the fragments improved the accuracy in characterizing the severity of rejection in pathologic studies. This study was undertaken to verify the usefulness of a semiquantitative evaluation of endomyocardial biopsy specimens, consisting of the calculation of the proportion of fragments showing rejection in the clinical setting.

METHODS

Of the 2386 biopsy specimens obtained during the first posttransplantation year in 168 consecutive cardiac allograft recipients, 290 biopsy specimens constituted by > or = 3 adequate fragments and showing rejection not followed by treatment (n = 159) or being the first biopsy specimen prompting treatment with augmented immunosuppression for that rejection episode (n = 131) were selected. These biopsy specimens (index biopsy specimens) were grouped according to whether rejection was present in < or = 33%, > 33% to < or = 67%, and > 67% of the fragments. The rejection grade (according to the standardized grading system) and the proportion of fragments positive for rejection were correlated with the occurrence of clinical symptoms and signs of rejection at index biopsy and with the results of the next biopsy.

RESULTS

Rejections graded > or = 3A were more frequently symptomatic (36% vs 9% for those graded < 3, p < 0.0001), as were those involving increasing proportions of fragments (< or = 33%: 5 of 124, 4%; > 33 to < or = 67%: 13 of 99, 13%; > 67%: 19 of 67, 28% [p < 0.0001]). Spontaneous resolution after untreated biopsies was more frequent in focal (grade 1A and 2) than in diffuse mild (1B) rejections (68% vs 38% [p < 0.04]), whereas progression to grade 3A or greater was less frequent (4% vs 27% [p < 0.01]). Increasing proportions of positive fragments were associated with lower frequencies of spontaneous resolution (p < 0.05) and higher frequencies of worsening (9%, 22%, 43% [p < 0.009]) or progression to grade 3A or greater (2%, 6%, 28% [p < 0.005]). Complete resolution after treatment was less frequent for increasing proportions of positive fragments at index biopsy (80%, 66%, 49% [p < 0.05]).

CONCLUSIONS

Diffuse versus focal rejection pattern and the proportion of positive fragments seem to be clinically relevant in terms of occurrence of symptoms, spontaneous evolution, and response to treatment.

[Possible influence of hemodynamic and neurohormonal factors on the heart's response to arterial hypertension]

Hypertrophy represents a frequent but inconstant response of the heart to hypertension and probably other nonhemodynamic factors are involved. We have performed 2D and Doppler echocardiography and assessed of neurohumoral pattern in 85 untreated patients with hypertension (diastolic blood pressure: 101 +/- 12.8 mmHg). Left ventricular hypertrophy was defined as a mass index greater than 134 g/m2 in males and 110 g/m2 in females. Doppler evaluation of left ventricular filling pattern was performed to detect the possible association of hypertrophy and diastolic dysfunction. In all patients the following neurohumoral substances were sampled and tested: plasmatic renin activity (PRA), aldosterone and norepinephrine. At Doppler echocardiography, 27 patients had hypertrophy and diastolic dysfunction, 15 only hypertrophy and 43 only diastolic dysfunction. The presence or absence of morpho-functional anomalies were independent of age, duration of hypertension and blood pressure levels. The mean value of neurohumoral substances were: norepinephrine 323.3 +/- 245 pg/ml, PRA 2.5 +/- 4 ng/ml/h, aldosterone 153.58 +/- 102 pg/ml. A significant correlation was found between PRA and blood pressure, and between aldosterone and all the Doppler-derived parameters of diastolic dysfunction. In conclusion, left ventricular hypertrophy seems to be related to alteration in ventricular geometry rather than to hemodynamic factors. Among nonhemodynamic factors, aldosterone may be the most responsible for abnormal filling, presumably through the activation of collagen matrix growth.

Evaluation of the effectiveness of isradipine SRO in the treatment of hypertensive patients with left ventricular hypertrophy

Myocardial hypertrophy is a response to many diseases, above all hypertension, that involves morphological and functional damage and may be the basis for the development of myocardial dysfunction. We attempted to verify the effectiveness of a new calcium antagonist, isradipine 5 mg SRO, on the reversal of left ventricular hypertrophy. For this purpose 13 hypertensive patients (pts) were treated for 12 weeks, which is the minimum period described in the literature for the regression of hypertrophy. At the end of the study, blood pressure in all patients returned to normal levels (mean blood pressure from 120.15 +/- 4.4 to 108 +/- 6.4 mmHg, p < 0.001); end-systolic stress (from 128 +/- 30 to 65 +/- 14 g/cm2, p < 0.001), and left ventricular mass index (from 142 +/- 31 to 97 +/- 23 g/m2, p < 0.001) showed significant reduction. Moreover, Doppler-derived indexes of left ventricular filling improved, particularly early to late peak velocity of the mitral valve (E/A ratio) and deceleration time (from 235 +/- 37 to 198 +/- 17 msec, p < 0.001), which were normalized after 12 weeks. In conclusion isradipine shows rapid effects in the reversal of morphofunctional damage in hypertension. For this reason it also appears to be useful for the treatment of myocardial hypertrophy in the absence of chronic hypertension.

[Pulmonary venous flow in atrial fibrillation evaluated by transesophageal Doppler echocardiography]

Pulmonary venous flow (PVF) can be recorded by transesophageal echocardiography. In normal subjects the PVF is triphasic with 2 peaks in systole and 1 peak in diastole. At atrial contraction it is possible to record a reversal flow (A wave). The evaluation of PVF pattern in patients in atrial fibrillation can better explain the role of atrial contraction. We considered 18 patients with chronic atrial fibrillation with transesophageal Doppler echocardiography. Then we compared the pattern obtained from patients with atrial fibrillation with the normal pattern. During atrial fibrillation we observed a flow reversal during early systolic period. The diastolic wave was increased and prolonged. We also observed that the A wave seems to disappear. The loss of atrial contraction deeply modifies the Doppler PVF.

[Transesophageal Doppler study of pulmonary venous flow: the role of atrial contraction]

Pulmonary venous flow (PVF) pattern can be easily recorded by using transesophageal Doppler echocardiography. Recent reports suggest that the analysis of PVF pattern could be useful to better understand the role of atrial contraction on left ventricular filling. In order to evaluate the effect of loss of atrial contraction, we studied 50 consecutive patients with atrial fibrillation. We then compared the PVF pattern of atrial fibrillation with the normal pattern obtained from 20 healthy subjects. The reversal flow (A wave) resulting from atrial contraction was lost in patients with atrial fibrillation. The systolic flow was composed by 1 wave in almost all the patients and the peak velocity was reduced compared to normal sinus rhythm. On the contrary, the diastolic flow was increased comparing to normal subjects. In atrial fibrillation the flow shifted from systolic to diastolic filling. The restore of sinus rhythm induced a normalization of PVF pattern.

[Diagnosis and assessment of thrombolytic efficacy in left atrial thrombosis using transesophageal echocardiography]

In order to evaluate the incidence of atrial thrombosis 17 patients underwent transesophageal echocardiography (TEE). They were referred to our department because of a recent systemic embolic event and we found thrombi located in the left atrial appendage in 14 patients, in 5 cases in the left atrium and in 4 cases in the right atrium. Transthoracic echocardiography showed left atrial masses in 5 patients. Transesophageal echocardiography was more sensitive than transthoracic echocardiography in detecting atrial thrombi. Fifteen patients were treated with thrombolytic therapy using urokinase or rt-PA. To evaluate the efficacy of thrombolysis, we repeated TEE immediately after the infusion and 24 hours later. We observed a reduction of the mass of thrombi in all patients; the effect of therapy was not different 24 hours later. Our study underlines the diagnostic power of TEE in detecting atrial thrombosis and also suggests the use of TEE in the evaluation of the efficacy of thrombolytic therapy.