Advanced Respiratory Failure Requiring Tracheostomy-A Marker of Unfavourable Prognosis after Heart Transplantation

Advanced respiratory failure with tracheostomy requirement is common in heart recipients. The aim of the study is to assess the tracheostomy rate after orthotopic heart transplantation and identify the subgroups of patients with the highest need for tracheostomy and these groups' association with mortality at a single centre through a retrospective analysis of 140 consecutive patients transplanted between December 2012 and July 2018. As many as 28.6% heart recipients suffered from advanced respiratory failure with a need for tracheostomy that was performed after a median time of 11.5 days post-transplant. Tracheostomy was associated with a history of stroke (OR 3.4; 95% CI) 1.32-8.86; p = 0.012), previous sternotomy (OR 2.5; 95% CI 1.18-5.32; p = 0.017), longer cardiopulmonary bypass time (OR 1.01; 95% CI 1.00-1.01; p = 0.007) as well as primary graft failure (OR 6.79; 95% CI2.93-15.71; p < 0.001), need of renal replacement therapy (OR 19.2; 95% 2.53-146; p = 0.004) and daily mean SOFA score up to 72 h (OR 1.50; 95% 1.23-1.71; p < 0.01). One-year mortality was significantly higher in patients requiring a tracheostomy vs. those not requiring one during their hospital stay (50% vs. 16%, p < 0.001). The need for tracheostomy in heart transplant recipients was 30% in our study. Advanced respiratory failure was associated with over 3-fold greater 1-year mortality. Thus, tracheostomy placement may be regarded as a marker of unfavourable prognosis.

Safety of tracheostomy during extracorporeal membrane oxygenation support: A single-center experience

BACKGROUND

Some patients on extracorporeal membrane oxygenation (ECMO) require prolonged mechanical ventilation. An early tracheostomy strategy while on ECMO has appeared to be beneficial for these patients. This study aims to explore the safety of tracheostomy in ECMO patients.

METHODS

This is a retrospective observational single-center study.

RESULTS

Hundred and nine patients underwent tracheostomy (76 percutaneous and 33 surgical) during V-V ECMO support over an 8-year period. Patients with a percutaneous tracheostomy showed a significantly shorter ECMO duration [25.5 (17.3-40.1) vs 37.2 (26.5-53.2) days, p = 0.013] and a shorter ECMO-to-tracheostomy time [13.3 (8.5-19.7) vs 27.8 (16.3-36.9) days, p < 0.001] compared to those who underwent a surgical approach. There was no difference between the two strategies regarding both major and minor/no bleeding (p = 0.756). There was no difference in survival rate between patients who underwent percutaneous or surgical tracheostomy (p = 0.173). Patients who underwent an early tracheostomy (within 10 days from ECMO insertion) showed a significantly shorter hospital stay (p < 0.001) and a shorter duration of V-V ECMO support (p < 0.001). Our series includes 24 patients affected by COVID-19, who did not show significantly higher rates of major bleeding when compared to non-COVID-19 patients (p = 0.297). Within the COVID-19 subgroup, there was no difference in major bleeding rates between surgical and percutaneous approach (p = 1.0).

CONCLUSIONS

Percutaneous and surgical tracheostomy during ECMO have a similar safety profile in terms of bleeding risk and mortality. Percutaneous tracheostomy may favor a shorter duration of ECMO support and hospital stay and can be considered a safe alternative to surgical tracheostomy, even in COVID-19 patients, if relevant clinical expertise is available.

Comparison of outcomes between aortic root replacement and supra-coronary interposition graft for type A aortic dissection: A retrospective case series

BACKGROUND

The decision to conserve or replace the native aortic valve following acute type-A aortic dissection (ATAAD) is an area of cardiac surgery without standardized practice. This single-center retrospective study analysed the long-term performance of the native aortic valve and root following surgery for ATAAD.

METHODS

Between 2009 and 2018 all cases ATAAD treated at Royal Brompton and Harefield NHS Foundation Trust were analysed. Patients were divided into two groups: (a) ascending aorta (interposition) graft (AAG) without valve replacement and (b) nonvalve-sparing aortic root replacement (ARR). Preoperative covariates were compared, as well as operative characteristics and postoperative complications. Long-term survival and echocardiographic outcomes were analysed using regression analysis.

RESULTS

In total, 116 patients were included: 63 patients in the AAG group and 53 patients in the ARR group. In patients where the native aortic valve was conserved, nine developed severe aortic regurgitation and two patients developed dilation of the aortic root requiring subsequent replacement during the follow-up period. Aortic regurgitation at presentation was not found to be associated with subsequent risk of developing severe aortic regurgitation or reintervention on the aortic valve. Overall mortality was observed to be significantly lower in patients undergoing AAG (17.5% vs. 41.5%, p = .004).

CONCLUSIONS

With careful patient selection, the native aortic root shows good long-term durability both in terms of valve competence and stable root dimensions after surgery for ATAAD. This study supports the consideration of conservation of the aortic valve during emergency surgery for type-A dissection, in the absence of a definitive indication for root replacement, including in cases where aortic regurgitation complicates the presentation.

Prognostic significance of serum lactate following cardiac transplantation

Aim: Hyperlactatemia is common post-heart transplantation. Lactate measurements in the first 24 h were analyzed with respect to mortality. Methods: A total of 153 consecutive cardiac transplant patients were reviewed. Recipients of organs maintained in a state of ex vivo perfusion were included. Results: A total of 143 heart recipients were included. Hyperlactatemia (>2 mmol/l) was present in all patients. Despite maximum lactate and lactate clearance being significantly higher in nonsurvivors (p = 0.002, p = 0.004), neither receiver operator curve analysis nor multivariate logistic regression showed association with 1-year mortality. In comparison, the minimum lactate was significantly associated with mortality (area under the curve 0.728 [p < 0.001]; odds ratio 1.28 [95% 1.01-162; p = 0.04]). Conclusion: The minimum lactate, a surrogate of persistent hyperlactatemia, was demonstrated to be superior compared with maximum lactate and lactate clearance in determining patient prognosis.

Utility of echocardiographic right ventricular subcostal strain in critical care

AIMS

Right ventricular (RV) strain is a known predictor of outcomes in various heart and lung pathologies but has been considered too technically challenging for routine use in critical care. We examined whether RV strain acquired from the subcostal view, frequently more accessible in the critically ill, is an alternative to conventionally derived RV strain in intensive care.

METHODS AND RESULTS

RV strain data were acquired from apical and subcostal views on transthoracic echocardiography (TTE) in 94 patients (35% female), mean age 50.5 ± 15.2 years, venovenous extracorporeal membrane oxygenation (VVECMO) (44%). RV strain values from the apical (mean ± standard deviation; -20.4 ± 6.7) and subcostal views (-21.1 ± 7) were highly correlated (Pearson's r -0.89, P < 0.001). RV subcostal strain correlated moderately well with other echocardiography parameters including tricuspid annular plane systolic excursion (r -0.44, P < 0.001), RV systolic velocity (rho = -0.51, P < 0.001), fractional area change (r -0.66, P < 0.01), and RV outflow tract velocity time integral (r -0.49, P < 0.001). VVECMO was associated with higher RV subcostal strain (non-VVECMO -19.6 ± 6.7 vs. VVECMO -23.2 ± 7, P = 0.01) but not apical RV strain. On univariate analysis, RV subcostal strain was weakly associated with survival at 30 days (R2 = 0.04, P = 0.05, odds ratio =1.08) while apical RV was not (P = 0.16).

CONCLUSION 

RV subcostal deformation imaging is a reliable surrogate for conventionally derived strain in critical care and may in time prove to be a useful diagnostic marker in this cohort.

Cardiac Decompression by Pericardiectomy for Constrictive Pericarditis: Multimodality Imaging to Identify Patients at Risk for Prolonged Inotropic Support

BACKGROUND

Post-pericardiectomy right ventricular (RV) failure has been reported but it remains not well-studied. To investigate imaging parameters that could predict RV function and the outcome of patients post-pericardiectomy.

METHODS

We analysed data from a total of 53 CP patients undergoing pericardiectomy. Preoperative, early and at 6 months postoperative echocardiographic (echo) imaging datasets were analysed and correlated with preoperative cardiac magnetic resonance (CMR), cardiac computed tomography scans and histology. The primary endpoint of the study was RV functional status early postoperatively and at 6 months. Secondary endpoint was the need for prolonged inotropic support.

RESULTS

A cause of CP was identified in 26 patients (49%). Inotropic support ≥ 48 hours was required in n = 28 (53%) of patients and was correlated with lower preoperative RV areas by echo or RV volumes by CMR (p < 0.05 for all). A pericardial score based on pericardial thickness/calcification and epicardial fat thickness had good diagnostic accuracy to identify patients requiring prolonged use of inotropes (area under the curve, 0.825; 95% confidence interval, 0.674–0.976). Pericardiectomy resulted in RV decompression and impaired RV function early postoperatively (fractional area change: 40.5% ± 8.8% preoperatively vs. 31.4% ± 10.4% early postoperatively vs. 42.5% ± 10.2% at 6 months, p < 0.001).

CONCLUSIONS

We show that a smaller RV cavity size and a pericardial scoring system are associated with prolonged inotropic support in CP patients undergoing pericardiectomy. RV systolic impairment post decompression is present in most patients, but it is only transient.

Right ventricular dysfunction in critically ill COVID-19 ARDS

Aims

Comprehensive echocardiography assessment of right ventricular (RV) impairment has not been reported in critically ill patients with COVID-19. We detail the specific phenotype and clinical associations of RV impairment in COVID-19 acute respiratory distress syndrome (ARDS).

Methods

Transthoracic echocardiography (TTE) measures of RV function were collected in critically unwell patients for associations with clinical, ventilatory and laboratory data.

Results

Ninety patients (25.6% female), mean age 52.0 ± 10.8 years, veno-venous extracorporeal membrane oxygenation (VVECMO) (42.2%) were studied. A significantly higher proportion of patients were identified as having RV dysfunction by RV fractional area change (FAC) (72.0%,95% confidence interval (CI) 61.0–81.0) and RV velocity time integral (VTI) (86.4%, 95 CI 77.3–93.2) than by tricuspid annular plane systolic excursion (TAPSE) (23.8%, 95 CI 16.0–33.9), RVS’ (11.9%, 95% CI 6.6–20.5) or RV free wall strain (FWS) (35.3%, 95% CI 23.6–49.0). RV VTI correlated strongly with RV FAC (p ≤ 0.01). Multivariate regression demonstrated independent associations of RV FAC with NTpro-BNP and PVR. RV-PA coupling correlated with PVR (univariate p < 0.01), as well as RVEDAi (p < 0.01), and RVESAi (p < 0.01), and was associated with P/F ratio (p 0.026), PEEP (p 0.025), and ALT (p 0.028).

Conclusions

Severe COVID-19 ARDS is associated with a specific phenotype of RV radial impairment with sparing of longitudinal function. Clinicians should avoid interpretation of RV health purely on long-axis parameters in these patients. RV-PA coupling potentially provides important additional information above standard measures of RV performance in this cohort.

Supravalvular mitral remnant: The other side of the… valve

We report a challenging clinical case of an atypical supravalvular mitral remnant in recent mitral and aortic valve replacement with mechanical valve prostheses, associated with postoperative recurrent inflammatory episodes overlapped with difficult anticoagulation. Negative myocardial scintigraphy was associated with persistence of negative blood cultures. Serial echocardiographic evaluation was performed before and after antimicrobial treatment, and at 3 months follow-up a transesophageal echocardiography showed the persistence of the mass. Diagnostic suspect was finally confirmed.

P6325Gas exchange improvements during exercise correlate with hemodynamic changes in heart failure patients with a left ventricular assist device

Background

The implantation of left ventricular assist devices (LVAD) has established its role in therapy for patients with end stage heart failure.

Benefits in survival as well as an improved quality of life, compared to optimized medical therapy (OMT) alone, has been proven.

There are limited data in the literature on the metabolic changes during exercise in LVAD patients, and in most studies no increase in peak oxygen consumption on cardiopulmonary exercise test (CPET) could be shown early after surgery. However, recent data suggests an improvement in peak oxygen uptake (VO2) as a late effect after rehabilitation.

To further investigate these findings we sought to analyse CPET data from patients before LVAD implantation as well as in the early and late follow up in correlation with hemodynamic changes at these times.

Methods

We collected and retrospectively analysed data of heart failure patients who had undergone LVAD implantation, and in whom a right heart catheterization, a cardiopulmonary exercise test and an echocardiography had been performed at time before, as well as 6 Months and 12 months after LVAD implantation, respectively.

Results

Data of 43 patients implanted with an LVAD between 2011 and 2017 were analysed. There was significant improvement in cardiac output (3,2 vs 4,3 L/min, p<0,001) and VE/VCO2 slope (46 vs 38, p=0,001) 6 months after LVAD implant as well as a significant reduction in PCWP (26 vs 11 mmHg, p<0,001), PAP mean (40 vs 22 mmHg, p<0,001), RA mean (12 vs 8 mmHg, p=0,002) and PVR (4,2 vs 2,5 WU, p<0,001). However, there was no significant increase in peak VO2 after 6 months.

12 months after LVAD implantation there were no further significant changes in cardiac output, intracardiac pressures or VE/VCO2 slope, which all remained similar to the 6 months follow up. However, at that point, a significant increase in peak VO2 was seen, compared to baseline (1060 vs 1410ml/min, p=0,001) and to 6 months after surgery (Figure 1).

Conclusion

Cardiac output increases in heart failure patients early after LVAD implantation. Consequently, permanent ventricular off loading results in the reduction of intracardiac pressures and improvement in the VE/VCO2 slope 6 months after surgery. However, a significant rise in peak oxygen consumption could only be noted 12 months after surgery, suggesting either a delayed long-term effect of improved hemodynamics or other causes such as enhanced mobility or training due to improved quality of life.

P1716Dual antiplatelet therapy on veno arterial ECMO to bleed or not to bleed?

Background

Patients presenting with INTERMACS-1 cardiogenic shock and necessitating VA-ECMO, often undergo coronary angiography and percutaneous coronary intervention (PCI). Therefore, a substantial subset of VA-ECMO patients will have an indication for dual antiplatelet therapy (DAPT) plus unfractionated heparin (UFH). According to atrial fibrillation registry data, bleeding incidence on DAPT combined with oral anticoagulation is significantly higher as compared to anticoagulation alone. Although it has been reported that the addition of low dose aspirin to UFH did not increase bleeding or transfusion in VenoVenous (VV)-ECMO patients, it remains to be elucidated whether the addition of DAPT to UFH on VA-ECMO-therapy enhances bleeding.

Methods

We report single center data for 100 VA-ECMO patients between 2011 and 2019. VA-ECMO-patients post-surgery were excluded. Patient demographics, blood product transfusions and reported/radiographically diagnosed bleeding or thrombotic complications were analysed. All VA-ECMO patients received UFH, aiming for an anti-Xa levels of at least 0,3 U/ml. Targets were hemoglobin 7 g/dl, fibrinogen 100 mg/dl (or 150 mg/dl when active bleeding) and platelet counts above 50/fL. DAPT-patients were on a low dose aspirin plus a P2Y12-inhibitor (clopidogrel or ticagrelor).

Results

51% Of the VA-ECMO-group received DAPT (59% clopidogrel and 41% ticagrelor). UFH-levels were comparable between both groups. Patients on DAPT were significantly older (DAPT 52.8 vs. Control 41.3; p<0.001) and predominantly male (DAPT 76% vs. Control 63%). Total bleedings (DAPT 52% vs. Control 55%; p=0,68) and major bleedings (BARC score of 3 or more; DAPT 41% vs. Control 45%; p=0,71) did not differ significantly. We observed a significant lower number of clinically or radiographically overt arterial/venous thromboses (DAPT 13.7% vs. Control 36.2%; p=0,02) in the DAPT-group. When comparing fresh frozen plasma (FFP), red blood cell and platelet pool transfusions between both groups, only FFP-tranfusion (DAPT 0.47 units/day vs. Control 1.18 units/day; p=0,047) intends to be lower for the DAPT-group.

DAPT (plus UFH) vs control (plus UFH)

Conclusions

Haemorrhage is frequent during extracorporeal support. However, in our cohort, DAPT on top of UFH in the treatment of VA-ECMO-supported ischemic cardiogenic shock does not increase the risk of major bleeding. Therefore, DAPT should not necessarily be witheld in the setting of VA-ECMO. Interestingly, our data support a lower incidence of overt thromboses and a trend towards less FFP-transfusion. These findings suggest DAPT-induced platelet inhibition being protective against both thrombotic events and posibly consumptive coagulopathy without paying a price for major bleeding.

P1718Veno-arterial ECMO versus Left Impella bleeding complications in cardiogenic shock patients on dual antiplatelet therapy

Background

Selective groups of patients, presenting with INTERMACS-1 cardiogenic shock due to acute ischaemic heart failure, may benefit from mechanical circulatory support (MCS). Patients with biventricular failure, severe septic shock or oxygenation problems should be selected for VA-ECMO, although the left Impella-CP heart pump can be considered as a less invasive alternative in supporting predominantly left ventricular failure. Bleeding issues are a major concern in patients on MCS, especially in this group where triple anticoagulation therapy (unfractionated heparin (UFH) for prevention of pump thrombosis and dual antiplatelet therapy (DAPT) after coronary stenting) is necessitated. We aim to investigate the bleeding and transfusion rate in DAPT-patients on VA-ECMO versus Impella.

Methods

We report single center data for 51 VA-ECMO and 8 Impella patients between 2011 and 2019. Indication for MCS was acute ischaemic cardiogenic shock. Patient demographics, transfusions and reported/radiographically diagnosed bleeding (BARC-classification) complications were analyzed. All patients received UFH and low dose aspirin plus clopidogrel or ticagrelor. Impella flow was at least 2.5 L/min. Transfusion targets were Hb >7 g/dl, fibrinogen >100 mg/dl (or >150 mg/dl when active bleeding) and platelet count >50/fL.

Results

Impella patients were significantly older (VA-ECMO 52.8 vs. Impella 62.4; p=0.02) as compared to the VA-ECMO group. Anti-Xa-levels and length of the MCS-run (mean 7.9 VA-ECMO vs. 6.4 days Impella) were comparable in both groups. Occurrences of minor bleeds was comparable between both groups (mainly oozing from the insertion site in the ImpellaTM group 63% vs. VA-ECMO 72%; p>0.05) but major bleedings with BARC score of 3 or more were significantly lower in the Impella group (13% vs. VA-ECMO 65%; p=0.005). Platelet and red blood cell transfusions were significantly lower in the Impella group (0.1 units of platelets per day vs. 1.1 units of platelets per day on VA-ECMO; p=0.002 and 0.8 units of RBCs per day vs. 2.6 units of RBCs per day on VA-ECMO; p=0.02).

Bleeding/transfusion VA-ECMO vs Impella

Conclusions

Bleeding is a frequent complication of MCS. However, in our cohort, triple anticoagulation in acute cardiogenic shock due to ischaemic left ventricle failure resulted in a lower major bleeding rate when support was given by the left Impella device as compared with VA-ECMO therapy group. As a result, platelet and red blood cell transfusions were lower in the Impella group. These findings are likely to be partly explained by the increased number and size of cannulas in VA-ECMO, as well as the increased risk of haemolysis and consumptive coagulopathy due to the complexity and extensive foreign body surface of the ECMO-circuit. We conclude that Impella support should be considered as a safer option than VA-ECMO with regards to bleeding in patients with ischaemic left ventricular failure who require DAPT and MCS as a bridge to recovery or other definitive therapy.

Extensive cardiac infiltrative melanoma

We report an unusual clinical case of a 66-year-old patient with cardiac involvement from a metastatic melanoma, causing the formation of a large right atrial mass with extensive infiltration of the right atrial free wall, the interatrial septum, the coronary sinus, and up to the mitral annulus and posterior wall of the right ventricle, unamendable to complete surgical excision. As secondary cardiac tumors are not part of routine daily clinical practice, we thought that this clinical case would be a good educational opportunity for the practicing clinicians, both specialists and nonspecialists.

Lessons of the month 1: Fatal oesophago-pericardial fistula with cerebral air embolism after elective atrial fibrillation ablation

Oesophago-pericardial fistula following any electrophysiological procedure is a rare, and potentially, life-threatening condition. Initial presentation can easily be misdiagnosed, as symptoms vary and are not specific. Echocardiography is an invaluable tool to diagnose and rule out complications. We present the case of a 68-year-old patient who developed an oesophago-pericardial fistula complicated with purulent pericarditis, sepsis and cerebral air embolism. In conclusion, this case report encourages physicians to use strategies that may help with early diagnosis and lead to potential lifesaving interventions.

Do rebreathing manoeuvres for non-invasive measurement of cardiac output during maximum exercise test alter the main cardiopulmonary parameters?

Background

Inert gas rebreathing has been recently described as an emergent reliable non-invasive method for cardiac output determination during exercise, allowing a relevant improvement of cardiopulmonary exercise test clinical relevance. For cardiac output measurements by inert gas rebreathing, specific respiratory manoeuvres are needed which might affect pivotal cardiopulmonary exercise test parameters, such as exercise tolerance, oxygen uptake and ventilation vs carbon dioxide output (VE/VCO2) relationship slope.

Method

We retrospectively analysed cardiopulmonary exercise testing of 181 heart failure patients who underwent both cardiopulmonary exercise testing and cardiopulmonary exercise test+cardiac output within two months (average 16 ± 15 days). All patients were in stable clinical conditions (New York Heart Association I–III) and on optimal medical therapy.

Results

The majority of patients were in New York Heart Association Class I and II (78.8%), with a mean left ventricular ejection fraction of 31 ± 10%. No difference was found between the two tests in oxygen uptake at peak exercise (1101 (interquartile range 870–1418) ml/min at cardiopulmonary exercise test vs 1103 (844–1389) at cardiopulmonary exercise test-cardiac output) and at anaerobic threshold. However, anaerobic threshold and peak heart rate, peak workload (75 (58–101) watts and 64 (42–90), p < 0.01) and carbon dioxide output were significantly higher at cardiopulmonary exercise testing than at cardiopulmonary exercise test+cardiac output, whereas VE/VCO2 slope was higher at cardiopulmonary exercise test+cardiac output (30 (27–35) vs 33 (28–37), p < 0.01).

Conclusion

The similar anaerobic threshold and peak oxygen uptake in the two tests with a lower peak workload and higher VE/VCO2 slope at cardiopulmonary exercise test+cardiac output suggest a higher respiratory work and consequent demand for respiratory muscle blood flow secondary to the ventilatory manoeuvres. Accordingly, VE/VCO2 slope and peak workload must be evaluated with caution during cardiopulmonary exercise test+cardiac output.

Clinical and prognostic impact of chronotropic incompetence in patients with hypertrophic cardiomyopathy

BACKGROUND

A blunted heart rate (HR) response is associated with an impaired peak oxygen uptake (pVO₂), a powerful outcome predictor in hypertrophic cardiomyopathy (HCM). The present multicenter study sought to determine the prognostic role for exercise-induced HR response in HCM.

METHODS

A total of 681 consecutive HCM outpatients on optimized treatment were recruited. The heart failure (HF) end-point was death due to HF, cardiac transplantation, NYHA III-IV class progression, HF worsening leading to hospitalization and severe functional deterioration leading to septal reduction. The sudden cardiac death (SCD) end-point included SCD, aborted SCD and appropriate implantable cardioverter defibrillator discharges.

RESULTS

During a median follow-up of 4.2 years (25-75th centile: 3.9-5.2), 81 patients reached the HF and 23 the SCD end-point. Covariates with independent effects on the HF end-point were left atrial diameter, left ventricular ejection fraction, maximal left ventricular outflow tract gradient and exercise cardiac power (ECP = pVO₂∗systolic blood pressure) (C-Index = 0.807) whereas the HCM Risk-SCD score and the ECP remained associated with the SCD end-point (C-Index = 0.674). When the VO₂-derived variables were not pursued, peak HR (pHR) re-entered in the multivariate HF model (C-Index = 0.777) and, marginally, in the SCD model (C-index = 0.656). A pHR = 70% of the maximum predicted resulted as the best cut-off value in predicting the HF-related events.

CONCLUSIONS

The cardiopulmonary exercise test is pivotal in the HCM management, however the pHR remains a meaningful alternative parameter. A pHR < 70% identified a HCM population at high risk of HF-related events, thus calling for a reappraisal of the chronotropic incompetence threshold in HCM.

Exercise performance, haemodynamics, and respiratory pattern do not identify heart failure patients who end exercise with dyspnoea from those with fatigue

AIMS

The two main symptoms referred by chronic heart failure (HF) patients as the causes of exercise termination during maximal cardiopulmonary exercise testing (CPET) are muscular fatigue and dyspnoea. So far, a physiological explanation why some HF patients end exercise because of dyspnoea and others because of fatigue is not available. We assessed whether patients referring dyspnoea or muscular fatigue may be distinguished by different ventilator or haemodynamic behaviours during exercise.

METHODS AND RESULTS

We analysed exercise data of 170 consecutive HF patients with reduced left ventricular ejection fraction in stable clinical condition. All patients underwent maximal CPET and a second maximal CPET with measurement of cardiac output by inert gas rebreathing at peak exercise. Thirty-eight (age 65.0 ± 11.1 years) and 132 (65.1 ± 11.4 years) patients terminated CPET because of dyspnoea and fatigue, respectively. Haemodynamic and cardiorespiratory parameters were the same in fatigue and dyspnoea patients. VO₂ was 10.4 ± 3.2 and 10.5 ± 3.3 mL/min/kg at the anaerobic threshold and 15.5 ± 4.8 and 15.4 ± 4.3 at peak, in fatigue and dyspnoea patients, respectively. In fatigue and dyspnoea patients, peak heart rate was 110 ± 22 and 114 ± 22 beats/min, and VE/VCO₂ and VO₂ /work relationship slopes were 31.2 ± 6.8 and 30.6 ± 8.2 and 10.6 ± 4.2 and 11.4 ± 5.5 L/min/W, respectively. Peak cardiac output was 6.68 ± 2.51 and 6.21 ± 2.55 L/min (P = NS for all).

CONCLUSIONS

In chronic HF patients in stable clinical condition, fatigue and dyspnoea as reasons of exercise termination do not highlight different ventilatory or haemodynamic patterns during effort.

Clinical and echocardiographic predictors of long-term outcome of a large cohort of patients with bicuspid aortic valve

BACKGROUND AND OBJECTIVES

Bicuspid aortic valve (BAV) disease is the most common congenital cardiac malformation. The aim of the present article is to determine clinical and echocardiographic prognostic factors and provide a predictive model of outcome of a large cohort of patients with BAV.

METHODS

We retrospectively enrolled 337 patients consecutively assessed for echocardiography at our Cardiology Department from 1993 to 2014. We considered aortic valve replacement, aortic surgery and cardiovascular death as a clinical combined end-point. Predictors of outcome were determined by Cox regression.

RESULTS

Mean age was 29.2 ± 19.8 years, median 27.1 years. A total of 38.4% patients presented a history of hypertension. Mean duration of follow-up was 8.4 ± 6.1 years, range 0-21 years. A total of 73 patients underwent aortic valve replacement and/or aortic surgery during follow-up. Age at surgery was 45.2 ± 15.6 years. Seven patients died because of cardiovascular causes. At multivariate analysis, baseline clinical predictors were history of hypertension [hazard ratio (HR) 2.289, 95% confidence interval (CI) 1.350-3.881, P = 0.002], larger ascending aortic diameter (HR 2.537, 95% CI 1.888-3.410, P < 0.001), moderate-to-severe aortic regurgitation (HR 2.266, 95% CI 1.402-3.661, P = 0.001) and moderate-to-severe aortic stenosis (HR 2.807, 95% CI 1.476-5.338, P = 0.002). A predictive model was created by integrating these four independent covariates. It allows the calculation of calculate a risk score for each patient, which helps better tailor appropriate treatment in BAV patients.

CONCLUSION

At enrolment, history of hypertension, a wider aortic diameter, moderate-to-severe aortic regurgitation and aortic stenosis were independently correlated to combined end-point. Long-term follow-up showed low cardiovascular mortality (2.1%) and a high prevalence of cardiac surgery (21.6%).

Routine use of bilateral internal thoracic artery grafting in women: A risk factor analysis for poor outcomes

BACKGROUND

Concerns about increased risk of postoperative complications, primarily deep sternal wound infection (DSWI), prevent liberal use of bilateral internal thoracic artery (BITA) grafting in women. Consequently, outcomes after routine BITA grafting remain largely unexplored in female gender.

METHODS

Of 786 consecutive women with multivessel coronary disease who underwent isolated coronary bypass surgery at the authors' institution from 1999 throughout 2014, 477 (60.7%; mean age: 70±7.7years) had skeletonized BITA grafts; their risk profiles, operative data, hospital mortality and postoperative complications were reviewed retrospectively. Risk factor analysis for hospital death, DSWI and poor late outcomes were performed by means of multivariable models.

RESULTS

There were 19 (4%) hospital deaths (mean EuroSCORE II: 5.2±6.1%); glomerular filtration rate<50ml/min was an independent risk factor (p=0.035). Prolonged invasive ventilation (11.3%), multiple blood transfusion (12.1%) and DSWI (10.7%) were most frequent major postoperative complications. Predictors of DSWI were body mass index >35kg/m² (p=0.0094), diabetes (p=0.005), non-elective surgical priority (p=0.0087) and multiple blood transfusions (p=0.016). The mean follow-up was 6.8±4.5years. The non-parametric estimates of the 13-year freedom from cardiac and cerebrovascular deaths, major adverse cardiac and cerebrovascular events, and repeat myocardial revascularization were 76.1 [95% confidence interval (CI): 73.1-79.1], 59.5 (95% CI: 55.9-63.1) and 91.9% (95% CI: 90.1-93.7), respectively. Preoperative congestive heart failure (p=0.04) and left main coronary artery disease (p=0.0095) were predictors of major adverse cardiac and cerebrovascular events.

CONCLUSIONS

BITA grafting could be performed routinely even in women. The increased rates of early postoperative complications do not prevent excellent late outcomes.

Flexible band versus rigid ring annuloplasty for functional tricuspid regurgitation: two different patterns of right heart reverse remodelling

OBJECTIVES

Annuloplasty bands and rings are widely used to treat functional tricuspid regurgitation (TR). However, the question as to which is the ideal annuloplasty device remains open. Early and late outcomes of tricuspid valve annuloplasty with flexible band (B-TVA) or rigid ring (R-TVA) are compared in the present study.

METHODS

Between 1999 and 2014, 462 consecutive patients (mean age, 69.2 ± 9.5 years) with grade ≥1+ functional TR (graded from 0 to 3+) underwent either B-TVA (n = 345; mean EuroSCORE II 9.2 ± 10.8%) or R-TVA (n = 117; mean EuroSCORE II 12 ± 13.4%) in addition to other cardiac procedures at the authors' institution.

RESULTS

One-to-one propensity score-matched analysis resulted in 98 pairs with similar baseline characteristics and operative risk. Hospital mortality was 7.5% after B-TVA and 12% after R-TVA (P = 0.14). R-TVA was associated with higher rates of low cardiac output (10.1 vs 17.9%, P = 0.025) and transient complete atrioventricular block (10.3 vs 17.2%, P = 0.046). Among the matched pairs, there were no significant differences in hospital mortality (5.1 vs 9.2%, P = 0.27) and perioperative complications. Both in overall series and matched pairs, between B-TVA and R-TVA patients, there were no significant differences in freedom from all-cause death (P = 0.29 and 0.91), cardiac and cerebrovascular deaths (P = 0.63 and 0.87) and grade ≥2+ TR (P = 0.68 and 0.77). Right atrial and tricuspid valve reverse remodelling combined with right ventricular reverse remodelling occurred after R-TVA but not after B-TVA.

CONCLUSIONS

B-TVA and R-TVA are equally effective in the treatment of functional TR. However, R-TVA causes over time a more complete right heart reverse remodelling.

Plasma immature form of surfactant protein type B correlates with prognosis in patients with chronic heart failure. A pilot single-center prospective study

BACKGROUND

Gas exchange abnormalities are part of the heart failure (HF) syndrome and growing interest raised on possible biomarkers of alveolar-capillary unit damage. The present pilot single-center study sought to investigate the prognostic values of circulating surfactant protein type B (SP-B) in a cohort of systolic HF patients.

METHODS

One hundred and fifty-one HF stable outpatients and 37 healthy subjects underwent a full clinical assessment, including pulmonary function and lung diffusion for carbon monoxide (DLco), maximal cardiopulmonary exercise test and measurements for both circulating immature and mature forms of SP-B. Study end-points were hospitalization due to HF worsening and cardiovascular mortality.

RESULTS

Immature SP-B, but not the mature form, was significantly higher in HF patients than in controls and was independently related to DLco, peak oxygen uptake and ventilatory efficiency. During the follow-up (median: 995 days; interquartile range: 739-1247 days), 97 patients experimented at least one HF hospitalization and 9 died for cardiovascular causes. At univariate analysis immature SP-B levels were significantly related to both cardiovascular death (p=0.033) and HF hospitalization (p<0.001). At multivariate analysis, immature SP-B levels remained independently associated to HF hospitalization (hazard ratio: 2.304; 95% confidence interval 1.858-3.019; p<0.001).

CONCLUSIONS

Present data confirm a strong relationship between circulating immature SP-B levels, gas exchange abnormalities and exercise limitations in stable HF as well as they are consistent with the use of immature SP-B in HF clinical risk assessment. Larger prospective studies are needed to confirm its prognostic role as well as to evaluate whether immature SP-B plasma concentration varies in response to specific treatment.

[Achieving optimal cholesterol levels in patients with chronic ischemic heart disease: from guidelines to the real world]

BACKGROUND

It is known that less than half of patients with coronary heart disease reaches the target of LDL cholesterol (LDL-C) <100 mg/dl. According to the latest international guidelines, this target has been lowered to <70 mg/dl in very high-risk patients.

METHODS

From November 1, 2009 to December 31, 2012, 4953 patients with coronary heart disease were enrolled in the Cardiovascular Registry of Trieste (Italy). We assessed clinical data, LDL-C levels, statin prescription and medium-term outcome in patients with coronary heart disease.

RESULTS

At first clinical evaluation, LDL-C values were available for only 61.5% of patients. The target level of LDL-C <70 mg/dl was reached in 17% of cases and LDL-C <100 mg/dl in 53%. Patients with lower LDL-C levels were more frequently males, with higher cardiovascular risk profile, more comorbidity and more frequent polypharmacy. LDL-C levels influenced statin prescription: in patients with LDL-C ≥ 100 mg/dl, cardiologists started or modified the dosage of statin therapy twice more than in patients with LDL-C <100 mg/dl, even if only in less than 20% of cases. Patients with LDL-C <100 mg/dl in statin therapy had better prognosis, whereas patients with low LDL-C levels without statin therapy had the worst prognosis. Other prognostic factors in this population with LDL-C <100 mg/dl were age, presence of heart failure, comorbidities (evaluated with Charlson index) and polypharmacy.

CONCLUSIONS

In our population of outpatients with coronary heart disease, the target of LDL-C <100 mg/dl was reached in 53% of cases. LDL-C levels influenced statin prescription and modification of dosages. The medium-term outcome is closely influenced by the achievement of target LDL-C levels and statin prescription.