The prevalence of osteopenia and osteoporosis after heart transplantation assessed using CT

OBJECTIVE

Osteoporosis is frequently observed in patients after heart transplantation (HT), although the prevalence long-term post-HT is unknown. Most studies investigating bone mineral density (BD) after HT were performed using dual-energy X-ray absorptiometry. In this study BD, including the prevalence of osteopenia and osteoporosis, was investigated using coronary computed tomography (CCT) long-term post-HT. Moreover, risk factors for abnormal BD were investigated.

METHODS

All first CCT scans between February 2018 and June 2020 used for the annual screening for cardiac allograft vasculopathy were included. Retransplantations and scans with not fully imaged vertebrae were excluded. BD was measured as a mean of the BD of three consecutive thoracic vertebrae and categorized into normal BD, osteopenia or osteoporosis. Binary logistic regression was used to find determinants for an abnormal BD. Linear regression was used to explore determinants for the mean Hounsfield unit (HU) value of the BD.

RESULTS

In total, 140 patients were included (median age 55.2 [42.9-64.9] years, 51 (36%) female). Time between HT and CT scan was 11.0 [7.3-16.1] years. In total, 80 (57%), 43 (31%), and 17 (12%) patients had a normal BD, osteopenia, or osteoporosis, respectively. Osteoporotic fracture or vertebrae fractures was seen in 11 (8%) patients. Determinants for an abnormal BD were recipient age (OR 1.10 (1.06-1.14), p<0.001) and prednisolone use (OR 3.75 (1.27-11.01), p=0.016). In linear regression, left ventricular assist device use pre-HT (p=0.024) and time since HT (p=0.046) were additional BD determinants.

DISCUSSION

Osteopenia and osteoporosis are frequently seen on CCT post-HT. More investigation on appropriate measures to maintain a normal BD in these patients are needed.

Characteristics and Outcome of COVID-19 Infection in Heart Transplantation Recipients in the Netherlands

Purpose

Immunocompromised patients are at high-risk for complicated COVID-19 infection. The aim of this study is to describe the characteristics and outcome of heart transplantation (HTx) recipients infected with COVID-19 in the Netherlands.

Methods

All HTx patients with a COVID-19 infection between February 2020 and June 2021, proven by positive polymerase chain reaction-test or positive serology in one of the three heart transplant centers in the Netherlands were retrospectively included. The primary endpoint of this study is all-cause mortality.

Results

COVID-19 was diagnosed in 54/665 (8%) HTx patients, mean time from HTx was 11±8 years, mean age 53±14 years and 39% were female. Immunosuppressive therapy was reduced in 37%, 21 (39%) patients required hospitalization and all-cause mortality was 6%. Severe COVID-19 disease (hospitalized with ICU admission or mortality) was seen in 7 (13%) patients. Compared to patients with mild (not hospitalized) or moderate (hospitalized, no ICU admission) COVID-19 infection, patients with severe COVID-19 infection were generally older (p=0.007) and had a history of ischemic heart failure (p=0.004) more frequently. Compared to patients with moderate COVID-19 infection, severe COVID-19 patients were transplanted earlier and had a significantly higher body mass index (30±3 vs 26±3; p=0.01). Myocardial infarction, cellular rejection and pulmonary embolism were observed once in three different HTx patients. Physical complaints post-infection persisted with a median of 30 days (IQR 30-83 days) in 16 (39%) cases.

Conclusion

HTx patients are at increased risk for complicated COVID-19 infection with frequent hospitalization, but mortality is substantially lower than previously described.

VAD related infections and the risk of pump thrombosis and thromboembolic events: a EUROMACS study

Background

In patients supported by a ventricular assist device (VAD) major infections are a frequently reported adverse event with increased morbidity and mortality.

Purpose

The purpose of this study was to investigate the possible association between infections and cerebrovascular accidents (CVAs) in VAD patients.

Methods

An analysis of the European Registry for Patients Assisted with Mechanical Circulatory Support (EUROMACS) was performed identifying all patients aged ≥18 years with a LVAD or BiVAD implantation. Infections were categorized as VAD-specific infections, VAD-related infections and, non-VAD infections. An extended Kaplan-Meier analysis for the risk of CVA and mortality with infection as a time-dependent covariate was performed. Furthermore, a multivariable Cox proportional hazard model was performed including 24 variables.

Results

For this analysis 3784 patients were included, with 45 patients being supported by a BiVAD and 3739 by an LVAD. The majority of patients were male (83.2%) and 60.5% had an INTERMACS patient profile 2 or 3. During follow-up, 3108 major infections were identified in 1385 (36.6%) of the patients, while 673 CVAs were identified in 545 (14.4%) of the patients. Extended Kaplan-Meier analysis with first infection as time-dependent covariate revealed a hazard ratio (HR) for CVA of 1.95 (95% CI: 1.57–2.36; p&lt;0.005) (Figure) and 1.50 (95% CI: 1.33–1.68, p&lt;0.005) for mortality. Multivariable analysis confirmed a significant association for infection and CVAs with a HR of 1.46 (95% CI: 1.29–1.64). With infections subcategorized, VAD-specific (HR: 1.57 (95% CI: 1.18–2.09)) and VAD-related infections (HR: 2.04 (95% CI: 1.44–2.89)) remained significantly associated with CVA but non-VAD infections (HR: 1.22 (95% CI: 0.92–1.64)) were not.

Conclusion

Both VAD-related and VAD-specific infections are associated with a significantly increased risk of CVA with increased risk of mortality.

Funding Acknowledgement

Type of funding sources: None. KM freedom of CVA and infection

Endovascular renal sympathetic denervation to improve heart failure with reduced ejection fraction: the IMPROVE-HF-I study

Introduction

The aim of the present study was to assess the safety and efficacy of renal sympathetic denervation (RDN) in patients with heart failure with reduced ejection fraction (HFrEF).

Methods

We randomly assigned 50 patients with a left ventricular ejection fraction (LVEF) ≤ 35% and NYHA class ≥ II, in a 1:1 ratio, to either RDN and optimal medical therapy (OMT) or OMT alone. The primary safety endpoint was the occurrence of a combined endpoint of cardiovascular death, rehospitalisation for heart failure, and acute kidney injury at 6 months. The primary efficacy endpoint was the change in iodine-123 meta-iodobenzylguanidine (¹²³I‑MIBG) heart-to-mediastinum ratio (HMR) at 6 months.

Results

Mean age was 60 ± 9 years, 86% was male and mean LVEF was 33 ± 8%. At 6 months, the primary safety endpoint occurred in 8.3% vs 8.0% in the RDN and OMT groups, respectively (p = 0.97). At 6 months, the mean change in late HMR was −0.02 (95% CI: −0.08 to 0.12) in the RDN group, versus −0.02 (95% CI: −0.09 to 0.12) in the OMT group (p = 0.95) whereas the mean change in washout rate was 2.34 (95% CI: −6.35 to 1.67) in the RDN group versus −2.59 (95% CI: −1.61 to 6.79) in the OMT group (p-value 0.09).

Conclusion

RDN with the Vessix system in patients with HFrEF was safe, but did not result in significant changes in cardiac sympathetic nerve activity at 6 months as measured using ¹²³I‑MIBG.

Supplementary Information

The online version of this article (10.1007/s12471-021-01633-z) contains supplementary material, which is available to authorized users.

Listing criteria for heart transplantation in the Netherlands

The updated listing criteria for heart transplantation are presented on behalf of the three heart transplant centres in the Netherlands. Given the shortage of donor hearts, selection of those patients who may expect to have the greatest benefit from a scarce societal resource in terms of life expectancy and quality of life is inevitable. The indication for heart transplantation includes end-stage heart disease not remediable by more conservative measures, accompanied by severe physical limitation while on optimal medical therapy, including ICD/CRT‑D. Assessment of this condition requires cardiopulmonary stress testing, prognostic stratification and invasive haemodynamic measurements. Timely referral to a tertiary centre is essential for an optimal outcome. Chronic mechanical circulatory support is being used more and more as an alternative to heart transplantation and to bridge the progressively longer waiting time for heart transplantation and, thus, has become an important treatment option for patients with advanced heart failure.

The value of 18F-FDG PET/CT for the diagnosis of device related infections in patients with a left ventricular assist device - a dual centre study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Partnership UMCG Siemens for building the future of Health (PUSH)

Background

Left ventricular assist devices (LVADs) are increasingly used for the treatment of end-stage heart failure. LVADs improve quality of life and long-term survival, but device specific infections remain cumbersome. These infections can lead to life threatening complications and are difficult to diagnose with conventional radiological imaging. In this study, FDG-PET/CT accuracy for the diagnosis of LVAD specific infections was evaluated with specific focus on potential confounders and the additive value of semi-quantitative analysis.

Materials/methods

All LVAD recipients with an available FDG-PET/CT from September 2013 until August 2020 in two LVAD centres in the Netherlands, with a suspicion of driveline and/or central device infection were included. FDG-PET/CT was performed according to European Association of Nuclear Medicine (EANM) guidelines. Potential confounders were documented and assessors were blinded to the clinical context of included patients. Assessment of FDG-PET/CT was performed visually and semi-quantitatively with 6 regions of interest alongside the driveline and central device components. The final clinical diagnosis of either driveline infection or central device infection, based on findings during surgical intervention or multidisciplinary consensus, was used as the reference for diagnosis.

Results

In total 38 patients (average age 55 years, 84% males) were evaluated for a total of 55 episodes of suspected device-specific infection. Clinical evaluation established driveline infection in 28 cases, central device infection in 7 and combined infection in 4. Visual analysis obtained  a sensitivity and specificity of 0.83 and 0.75 respectively, in differentiation between infected and non-infected drivelines. Visual analysis of FDG-PET/CT of central device components showed excellent sensitivity: 1.0, but suffered from poor specificity: 0.23.  Semi-quantitative analysis using a SUVmax was comparable to visual analysis for establishing driveline infections, with a sensitivity and specificity of 0.80 and 0.84 respectively, while for central device infections, semi-quantitative analysis using a SUVratio outperformed visual analysis, with a sensitivity and specificity reaching 0.88 and 0.90 respectively.

Conclusions

FDG-PET/CT is a valuable tool for the assessment of device-specific infections in LVAD recipients. Semi-quantitative analysis can significantly increase diagnostic accuracy of FDG-PET/CT for the analysis of the central device components and should be considered in cases where the diagnosis cannot be rejected based on visual analysis.

Sex-specific temporal evolution of circulating biomarkers in patients with chronic heart failure with reduced ejection fraction

BACKGROUND

We aimed to assess differences in clinical characteristics, prognosis, and the temporal evolution of circulating biomarkers in male and female patients with HFrEF.

METHODS

We included 250 patients (66 women) with chronic heart failure (CHF) between 2011 and 2013 and performed trimonthly blood sampling during a median follow-up of 2.2 years [median (IQR) of 8 (5-10) urine and 9 (5-10) plasma samples per patient]. After completion of follow-up we measured 8 biomarkers. The primary endpoint (PE) was the composite of cardiac death, cardiac transplantation, left ventricular assist device implantation, and hospitalization due to acute or worsened CHF. Joint models were used to determine whether there were differences in the temporal patterns of the biomarkers between men and women as the PE approached.

RESULTS

A total of 66 patients reached the PE of which 52 (78.8%) were male and 14 (21.2%) were female. The temporal patterns of all studied biomarkers were associated with the PE, and overall showed disadvantageous changes as the PE approached. For NT-proBNP, HsTnT, and CRP, women showed higher levels over the entire follow-up duration and concomitant numerically higher hazard ratios [NT-proBNP: women: HR(95%CI) 7.57 (3.17-21.93), men: HR(95%CI) 3.14 (2.09-4.79), p for interaction = 0.104, HsTnT: women: HR(95%CI) 6.38 (2.18-22.46), men: HR(95%CI) 4.91 (2.58-9.39), p for interaction = 0.704, CRP: women: HR(95%CI) 7.48 (3.43-19.53), men: HR(95%CI) 3.29 [2.27-5.44], p for interaction = 0.106). In contrast, temporal patterns of glomerular and tubular renal markers showed similar associations with the PE in men and women.

CONCLUSION

Although interaction terms are not statistically significant, the associations of temporal patterns of NT-proBNP, HsTnT, and CRP appear more outspoken in women than in men with HFrEF, whereas associations seem similar for temporal patterns of creatinine, eGFR, Cystatin C, KIM-1 and NAG. Larger studies are needed to confirm these potential sex differences.

Long-term post-LVAD surgery outcome in patients with and without pre-operative hemodynamic guided optimization

Background/Introduction

Despite improved surgical techniques and pump designs, LVAD therapy remains associated with high mortality and morbidity. CardioMEMS guided hemodynamic optimization shortly pre-LVAD surgery could improve the long-term post-surgery outcomes.

Purpose

The aim of this analysis was to investigate the feasibility of pre-operative optimization using the hemodynamic monitoring provided by the CardioMEMS in patients with an LVAD surgery, to improve the long-term outcome compared to a cohort of historical controls.

Methods

Ten consecutive chronic heart failure patients, with an INTERMACS Class 2–5, scheduled for (semi-) elective HeartMate 3 (HM3) LVAD surgery were enrolled in the HEMO-VAD pilot study. All patients received a CardioMEMS device prior to LVAD surgery. The daily hemodynamic readings were used to guide the patient optimization process pre- and post-operatively. Aims of hemodynamic optimization were the normalization of the mean pulmonary artery pressure (mPAP), decongesting of the right ventricle (RV) and optimization of the renal function. Patients were categorized into optimized patients (mPAP ≤25mmHg) and non-optimized mPAP (mPAP &gt;25mmHg). Additionally, a historical cohort, consisting of 24 (semi-) elective HM3 LVAD recipients were included in this analysis. The outcome of this analysis was the event-free survival of the combined endpoint of all-cause mortality, RV failure, acute kidney injury (AKI) and/or renal replacement therapy (RRT) during the first 12 months post-LVAD surgery (time to first event analysis).

Results

The median age was 60.3 [51.6–66.3], 58.7 [53.4–61.9] and 60.1 [53.5–65.2] years in the optimized patients, non-optimized patients and historical controls, respectively (p=0.90). Of the optimized patients, 66.7% were men, compared to 75.0% and 100.0% of the non-optimized patients and historical controls, respectively (p=0.02). During the first year post-LVAD surgery, the combined endpoint occurred in 19 patients, five (83%) events occurred in the non-optimized patients, and 14 (58%) events in the historical controls, while no (0%) events occurred in the optimized patients (p=0.018) (Figure).

Conclusion(s)

This analysis demonstrated the feasibility of hemodynamic guided optimization pre-LVAD surgery using the CardioMEMS. The hemodynamic optimized patients were at very low risk for all-cause mortality, right-sided HF, and AKI/RRT compared to non-optimized patients or historical controls.

Figure 1. Event-free survival for the combined endpoint (all-cause mortality, right ventricular failure, and acute kidney injury and/or renal replacement therapy).

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): This work was supported by Abbott with an independent research grant, partially covering personnel costs. This study was investigator-initiated and was designed, conducted, interpreted and reported independently of the funder

Serially measured cytokines and cytokine receptors in relation to clinical outcome in patients with stable heart failure

Background

Activation of the inflammatory response in heart failure (HF) may initially serve as a compensatory mechanism. However, on the longer term, this physiological phenomenon can become disadvantageous. Temporal patterns of inflammatory proteins other than CRP have not yet been investigated in patients with stable HF.

Purpose

We aimed to evaluate the association of 17 serially measured cytokines and cytokine receptors with clinical outcome in patients with stable heart failure.

Methods

In 263 patients, 1984 serial, tri-monthly blood samples were collected during a median follow-up of 2.2 (IQR: 1.4–2.5) years. The primary endpoint (PE) composed of cardiovascular mortality, HF-hospitalization, heart transplantation, and LVAD. We selected baseline blood samples in all patients, as well as the two samples closest to the primary endpoint, and the last sample available in event-free patients. Thus, in 567 samples we measured 17 cytokines and cytokine receptors using the Olink Proteomics Cardiovascular III multiplex assay. Associations between biomarkers and PE were investigated by joint modelling.

Results

Median age was 68 (IQR: 59–76) years, with 72% men, 74% NYHA class I-II and a median ejection fraction of 30% (23–38%). 70 patients reached a PE. After adjustment for clinical characteristics (age, sex, diabetes, atrial fibrillation, NYHA class at baseline, diuretics and systolic blood pressure), 7 biomarkers were associated with the PE (Figure). Interleukin-1 receptor type 1 (IL1RT1) showed the strongest association: HR 2.65 [95% CI: 1.78–4.21]) per standard deviation change in level (NPX) at any point in time during follow-up, followed by Tumor necrosis factor receptor 1 (TNF-R1): 2.25 [1.66–3.08], and C-X-C motif chemokine 16 (CXCL16): 2.18 [1.59–3.04]. After adjustment for baseline N-terminal pro–B-type natriuretic peptide, high-sensitive troponin T and C-reactive protein however, only IL1RT1 and TNF-R1 remained significantly associated with the PE.

Conclusion

Repeatedly measured levels of several cytokines and cytokine receptors are independently associated with clinical outcome in stable HF patients. These results suggest that repeated measurements of these biomarkers, in addition to established cardiac biomarkers, may contribute to personalized risk assessment and herewith better identify high-risk patients.

Figure 1. Associations between levels of cytokines and cytokine receptors and the primary endpoint.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): This work was supported by the Jaap Schouten Foundation and the Noordwest Academie.

Monitoring pulmonary pressures during long-term continuous-flow left ventricular assist device and fixed pulmonary hypertension: redefining alleged pathophysiological mechanisms?

Pulmonary hypertension (PH) type II (classified by the World Health Organization) is a common complication in chronic left-sided heart failure. In advanced heart failure therapy, fixed PH is an absolute contraindication for heart transplantation after which a left ventricular assist device (LVAD) is the only remaining option. With remote monitoring, we can now continuously evaluate the pulmonary artery pressures during long-term LV unloading by the LVAD. In this case, we demonstrate that fixed PH can be reversed with LVAD implantation, whereby previous thoughts of this concept should be redefined in the era of assist devices.

P931 Feasibility of comprehensive multi-plane right ventricular free wall longitudinal strain evaluation pre-LVAD implantation - preliminary results from a single centre experience

Conclusion

There is reasonable feasibility for assessing RV-FWLS using MPE in 3 out of the 4 free wall segments and mean values were considerably lower than normal reference values. A stronger negative correlation with increasing mPAP suggests that RV dysfunction may be detected better by strain than by TAPSE measurement in pre-LVAD recipients. Larger, multi-centre studies are required to further assess these preliminary findings.

Abstract P931 Figure. Multi-plane RV imaging with strain

5948Circulating biomarkers of cell adhesion in relation to clinical outcomes in patients with chronic heart failure: the Bio-SHiFT study

Background

Cardiovascular inflammation and vascular endothelial dysfunction are present in chronic heart failure (CHF), and cellular adhesion molecules are considered to play a key role in these mechanisms. The temporal patterns of the blood biomarkers involved could provide further insights into these processes.

Purpose

We aimed to evaluate the prognostic value of the temporal patterns of blood biomarkers of cell adhesion in stable patients with CHF.

Methods

In 263 patients, a median of 9 (IQR: 5–10) serial, tri-monthly blood samples were collected during a median follow-up of 2.2 (IQR: 1.4–2.5) years. The composite primary endpoint (PE) of cardiovascular mortality, HF-hospitalization, heart transplantation and LVAD was reached in 70 patients. For efficiency, we selected all baseline samples, the two samples closest to a PE, and the last sample available for event-free patients. Thus, in 567 samples we measured twelve biomarkers of cell adhesion using the Olink Proteomics Cardiovascular III multiplex assay. Associations between biomarkers and first PE were investigated by combining linear mixed effect models and Cox regression (so-called joint model).

Results

Median age was 68 (IQR: 59–76) years, with 72% men and 74% NYHA class I-II. Levels of CD93 (Complement component C1q receptor), CDH5 (VE cadherin), CHI3L1 (Chitinase-3-like protein 1), EPHB4 (Ephrin type-B receptor 4) and JAM-A (Junctional adhesion molecule A) differed at baseline already. The average biomarker evolutions of these markers, and additionally of ICAM-2 (Intercellular adhesion molecule-2), showed different patterns in patients approaching the PE versus those who remained event-free (Figure 1). Repeatedly measured levels of these biomarkers were independently associated with the PE. Corresponding HRs [95% CI] per 1SD increase in log2 level (arbitrary unit) were: CD93: 1.85 [1.29–2.70], CDH5: 1.72 [1.23–2.44], CHI3L1: 2.45 [1.73–3.56], EPHB4: 1.83 [1.33–2.55], ICAM2: 1.74 [1.24–2.46] and JAM-A: 2.07 [1.39–3.18], adjusted for clinical characteristics (age, sex, diabetes, atrial fibrillation, baseline NYHA class, diuretics, systolic blood pressure and eGFR).

Figure 1. Average temporal patterns of cell adhesion biomarkers during follow-up.

Conclusion

CD93, CDH5, CHI3L1, EPHB4, ICAM2 and JAM-A show different patterns as adverse events approach in CHF patients, and their temporal patterns strongly predict clinical outcome. These findings demonstrate the incremental value of repeated measurements of biomarkers of cell adhesion in stable patients with CHF.

Acknowledgement/Funding

This work was supported by the Jaap Schouten Foundation and the Noordwest Academie.

P1675Evolution of lactate dehydrogenase levels in patients with HeartMate II, HeartWare and HeartMate 3 left ventricular assist devices during first-year follow-up

Background

Lactate dehydrogenase (LDH) is considered as a biomarker of thrombotic events in patients receiving a left ventricular assist device (LVAD).

Purpose

This study aimed to investigate the evolution of LDH levels over time between patients supported with a HeartMate II (HMII), HeartMate 3 (HM3) or HeartWare (HVAD) LVAD during their first-year post implantation.

Methods

We analyzed in this multi-center retrospective study, all patients with HMII, HM3 and HVAD LVAD implanted between December 2006 and April 2017. Patients were classified into three groups based on their device type. Loess splines over time were used to depict the repeated measurements of LDH.

Results

In total, 134 patients received an LVAD (77% male, mean age 55 [46–61]), of whom 64 (48%) were HMII, 22 (16%) HM3 and 48 (36%) were HVAD. Loess splines over time indicate that there could be a considerable difference between evolution of LDH (Figure). During the first-year follow-up, 3 (5%) patients had a confirmed and 10 (16%) patients had a suspected pump thrombosis in the HMII group. For the HVAD, there were 6 (13%) patients with confirmed thrombosis and 1 (2%) case of suspected thrombosis, whereas none of the patients in the HM3 group experienced a suspected or confirmed pump thrombosis (p=0.01). The 1-year overall survival rate for HM II, HM3 and HVAD was 84%, 86% and 72% respectively (p=0.311). The overall stroke-free rate at one year was: 89%, 77% and 91% for HMII, HVAD and HM3 respectively (p=0.15).

Means of observed LDH values over time

Conclusion

During the first-year post LVAD implantation, there appear to be different evolutions of LDH levels over time in HMII device patients compared to HVAD or HM3 device patients. Given differences in baseline hemolysis levels between devices, currently used LDH thresholds for detection of impending pump thrombosis may be less sensitive and thus thresholds may be device specific.

P1678Feasibility of comprehensive multi-plane echocardiographic evaluation of right ventricular function pre-LVAD implantation - preliminary results from a single centre experience

Introduction

Right sided heart failure (RVF) is recognized as a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. Despite the publication of several risk scores and predication models, identifying patients at risk for RVF after LVAD implantation remains a challenge. The right ventricle is complex in structure and not possible to fully assess from one echocardiographic 2D plane. Our centre previously introduced a novel multi-plane approach whereby four different RV free wall segments (lateral, anterior, inferior and inferior coronal – figure 1) can be imaged from the same echocardiographic position using electronic plane rotation.

Purpose

The aim of the study was to determine the feasibility of using multi-plane echocardiography to quantify right ventricular function in a small cohort of advanced heart failure patients prior to LVAD implantation.

Methods

Twelve advanced heart failure patients underwent detailed RV assessment by multi-plane echocardiography prior to LVAD implantation (median -15 [6.3–29.8] days before). Feasibility and values of the established RV functional echo parameters tricuspid annular plane systolic excursion (TAPSE) and tissue Doppler imaging derived tricuspid annular peak systolic velocity (TDI S') were assessed by an experienced sonographer on each of the 4 free wall segments. Mean values were calculated from an average of 3 measurements. Conventional 2D echo parameters and clinical outcome data post LVAD implantation were also collected.

Results

Feasibility of TAPSE and TDI measurements in all four RV free wall segments was 100%, with the exception of the inferior coronal wall (91.7% – TDI S' only). Mean 4 wall averaged TAPSE was 13.9±5.1mm, whilst mean TDI S' was 9.4±2.6cm/s. Mean TAPSE and TDI values were lower in the inferior and inferior coronal walls (13.3±5.8mm; 8.8±3.1cm/s and 10.9±5.7mm; 8.9±3.7cm/s) than those of the lateral and anterior walls (15.6±5.1mm; 9.9±2.3cm/s and 15.9±5.1mm; 10.1±2.6cm/s). The cohort was split by using a four wall averaged TAPSE value of 16mm as a cutoff. Mean 4 wall averaged TAPSE was 20.6±1.9mm in the >16mm group compared to 10.5±1.7mm for the <16mm group, whilst mean TDI S' was 9.4±2.6cm/s vs 7.7±0.7cm/s. Post LVAD implantation, there were 3 (25%) deaths and 6 (50%) incidences of acute kidney injury. Median length of stay in ICU and hospital was 4 (1–13.5) and 42.5 (30.3–65) days respectively. The <16mm group had higher incidences of negative outcomes and longer stay in both ICU and hospital following LVAD implantation (p: 0.07).

Conclusion

Multi-plane echocardiographic evaluation of the right ventricle appears feasible in advanced heart failure with potential for a more comprehensive quantification of right ventricular function pre-LVAD implantation. Larger, ideally multi-centre studies are required to further assess these preliminary findings.

P5428QRS narrowing more than 15 ms after CRT implantation is strongly associated with the long-term survival

Background

Cardiac resynchronization therapy (CRT) is used in selected heart failure patients with electrical cardiac dyssynchrony with a prolonged QRS duration and a left ventricle ejection fraction (LVEF) ≤35%. QRS duration post CRT implantation can probably predict responders and survivors. The aim of our study is to investigate the effect of QRS change on long-term survival post CRT implantation.

Methods

We performed a retrospective cohort study in patients receiving a CRT device in our tertiary referral center between January 2009 and January 2018. Clinical and electrocardiographic (ECG) data were collected at baseline, one week after CRT implantation, six months, and yearly during follow-up. The primary endpoint was death, left ventricle assisting device implantation, or heart transplantation. At the end, the cohort was dichotomized to the cut-off value of ≥15ms according current literature.

Results

The study population consisted of 219 patients of whom 145 (66%) patients were survivors and 74 (34%) non-survivors. Non-survivors were significantly older (63 vs. 68 years, p=0.001), male gender (67% vs. 82%, p=0.015), had more often diabetes mellitus (20% vs. 39%, p=0.002), chronic obstructive pulmonary disease (12% vs. 28%, p=0.003), an ischemic etiology of heart failure (42% vs. 61%, p=0.009) with previous myocardial infarction (29% vs 53%, p=0.001), previous revascularization (32% vs. 49%, p=0.019), atrial fibrillation (21% vs. 39%, p=0.004), worser NYHA class (p=0.008), and amiodarone use (10% vs. 22%, p=0.024). Blood urea nitrogen (BUN) (8.1 mmol/L vs. 10.4 mmol/L, p<0.001) and creatinine levels (96 μmol/L vs. 114 μmol/L, p=0.001) were also higher in the non-survivors group. Median QRS duration (168 ms IQR [154 to 182]) at baseline was comparable between survivors and non-survivors (170 ms vs. 166 ms, p=0.17). However, median QRS change one week after CRT implantation was significantly better in the survivors (−19 ms IQR [−30 to −2] vs. −6 ms IQR [−24 to +12], p=0.004). The QRS change at the last FU (median 5.1 years IQR [2.9 to 7.8] was consistently higher in the survivor group (−16 ms IQR [−29 to 0] vs. +1 ms IQR [−27 to +20], p=0.004). Dichotomized to ΔQRS narrowing of ≥15 ms after CRT implantation showed significantly better long-term survival (figure).

Kaplan-Meier curve

Conclusion

QRS narrowing cut-off of ≥15 ms post CRT implantation is strongly associated with the long term survival in chronic heart failure patients with reduced LVEF.

P5421Prevalence of electromagnetic interference from left ventricular assist devices in patients with implantable cardioverter defibrillator/pacemakers

Background

Many patients eligible for left ventricular assist device (LVAD) therapy already have an implantable cardioverter defibrillator (ICD) and/or pacemaker (PM). However, electromagnetic interference (EMI) between the LVAD and ICD/PM devices could be cumbersome.

Purpose

The aim of this study was to investigate the prevalence of EMI between different types of ICD/PM in patients implanted with an LVAD.

Methods

Data was obtained through a retrospective electronic patient database analysis of all LVAD patients (including HeartMate II (HMII) and HeartMate 3 (HM3)), from our tertiary referral center, from December 2006 to February 2019. Device switches have also been taken into account due to elective replacement. Electromagnetic interference was defined as ICD/PM telemetry interference (i.e. the inability to interrogate ICD/PM)

Results

In total, 109 patients received an LVAD (mean age 52±12, 83% male), Of these, 86 (79%) patients had an ICD/PM at LVAD implantation. One patient with ICD/PM was excluded from further analysis because of missing follow-up data. Among the 85 patients (45 HM II and 40 HM3), 11 (13%) experienced EMI; 5 (11%) with a HM II and 6 (15%) with a HM3 (p=0.59). The implanted ICD/PM devices were from Medtronic (n=25), Abbott (n=23), Biotronik (n=18), Boston Scientific (n=18), and Microport (n=1). EMI with the HM II was present in St Jude/Abbott devices (type 1 Atlas, 1 Unify, 1 Fortify, and 2 Promote). In HM 3 LVAD patients, EMI was observed in Biotronik devices (1 Lumax, 1 Ilivia, 1 Ilesto, and 2 Iperia) and Medtronic (Claria).

Conclusion

In our cohort of HM II and HM 3 LVAD patients, at least one in seven patients experienced EMI from either the HM II or HM3 LVAD with the ICD/PM. Electromagnetic interference from HM II LVADs was mainly present in patients with St Jude/Abbott ICD/PM devices However, in the HM3 patients, EMI was mainly present in patients with Biotronik devices, which is not yet widely known!

Acquired coagulopathy in patients with left ventricular assist devices

Chronic heart failure (HF) is a major emerging healthcare problem, associated with a high morbidity and mortality. Left ventricular assist devices (LVADs) have emerged as a successful treatment option for patients with end-stage HF. Despite its great benefit, the use of LVAD is associated with a high risk of complications. Bleeding, pump thrombosis and thromboembolic events are frequently observed complications, with bleeding complications occurring in over a third of the patients. Although the design of the third-generation LVAD has improved greatly, these hemostatic complications still occur. The introduction of an LVAD into the circulatory system results in an altered hematological balance as a consequence of blood-pump interactions, changes in hemodynamics, the rheology, and the concomitant need for anticoagulation while implanted with an LVAD. The majority, if not all, LVAD patients experience a form of platelet dysfunction and impaired von Willebrand factor activity, leading to acquired coagulopathy disorders. Different diagnostic tools and treatment strategies have been reported; however, they require validation in LVAD patients. The present review focuses on acquired coagulopathies, describing the incidence, impact and underlying mechanism of acquired coagulopathy disorders in patients supported by LVADs. In addition, we will discuss diagnostic and management strategies for these acquired coagulopathies.