414 Ventricular-arterial interaction predicts response to cardiac resynchronization therapy: a link with improvement of endothelial function and arterial elastic properties

Background

Endothelial dysfunction (ED) is a hall mark of chronic heart failure and has been linked to disease progression, hospitalizations and mortality.

Purpose

to evaluate the impact of cardiac resynchronization therapy (CRT) in ED and to determine predictors of response to CRT

Methods

CRT recipients from 19/07/2016 until 19/10/2018 were studied at baseline and 3 months after. In each visit we evaluated a 12 lead ECG, carotid to femoral pulse wave velocity (cfPWV), flow-mediated dilatation of the brachial artery (FMD), left ventricle ejection fraction (LVEF) and left ventricle (LV) global longitudinal strain (GLS). We evaluated arterial elastance (Ea) to ventricular elastance (Ees) ratio (Ea/Ees) by echocardiography and the ratio of cfPWV to GLS, as valid markers of ventricular-arterial interaction. We also assessed the layer of endothelial glycocalyx by measurement of Perfused Boundary Region (PBR) of the sublingual microvessel range:5-25 microns.

Results

32 patients with a mean age 65.5 (±10.9) years and severe LV systolic dysfunction were enrolled. During follow-up, LVEF, GLS, LVESV and all ED markers exhibited significant improvement (table 1). 23 patients were responders. Among the baseline vascular function markers, only the ratio cfPWV/GLS predicted response to CRT (OR: 0.245, 95%CI: 0.042-0.759, p = 0.044).Threshold analysis showed that the best threshold of cfPWV/GLS for response to CRT was 2.75 (specificity: 0.67%, sensitivity: 0.94%).

Conclusions

After 3 months of CRT, endothelial function, arterial elasticity and ventricular arterial interaction are improved. The baseline ratio cfPWV/GLS, a novel marker of ventricular arterial interaction, can be applied to predict response to CRT.

table 1 Baseline Follow-up Change Measurement mean (sd) mean (sd) mean (sd) p-value SBP (mmHg) 126 (19) 128 (16) 2.18 (11.98) 0,465 DBP (mmHg) 79 (9) 80 (9) 1.06 (8.58) 0,618 LVEF (%) 27 (7) 35 (9) 7.50 (4.77) <0.001 LVESV (mL) 151 (42) 120 (46) -26.91 (17.20) <0.001 GLS (%) 6.47 (2.89) 9.33 (4.18) 2.85 (2.28) <0.001 FMD (%) 5.88 (2.79) 10.25 (3.67) 4.37 (3.34) <0.001 Ea/Ees 2.81 (1.10) 2.04 (0.99) -0.77 (0.47) <0.001 cfPWV 11.11 (2.61) 10.01 (2.45) -1.10 (1.56) 0,003 PBR 5-25(microns) 2.26 (0.20) 2.14 (0.24) -0.13 (0.25) 0,028 cfPWV/GLS 2.18 (1.46) 1.45 (1.11) -0.73 (0.55) <0.001 Measurements at baseline, follow-up and their change during study

Abstract 414 Figure. picture 1

P4991Effects of the glucagon like peptide-1 receptor analogue, sodium-glucose co-transporter 2 and their combination on myocardial work index and vascular function in diabetes after 3-month treatment

Methods

A hundred twenty, patients with type 2 diabetes were randomized to receive the insulin +/− metformin (n=30), GLP-1A, liraglutide (n=30), the SGLT-2, empagliflozin (n=30) or their combination (GLP-1R+SGLT-2) for 3 months (n=30). We measured at baseline and after treatment a) pulse wave velocity (PWV), central systolic blood pressure (cSBP) b) the perfusion boundary region (PBR-micrometers) of the sublingual arterial microvessels, as a marker of endothelial glycocalyx thickness. c) global LV longitundinal strain (GLS), peak LV untwisting velocity and global myocardial work index (GWI) derived by pressure–myocardial strain loops using speckle tracking imaging and PWV to GLS ratio, as a marker of ventricular-arterial coupling

Results

All treatment groups had similar vascular and cardiac markers, glucose levels and HbA1 at inclusion (p>0.05). After treatment, all patients had improved GLS, PWV and increased LV twisting-untwisting velocities (p<0.05). Patients under GLP-1R, SGLT-2 and their combination achieved a significant reduction of PBR, PWV, central SBP and a greater increase of GWI (30%, 25% and 50% respectively) and LV untwisting velocities (p<0.05) than those under insulin (15% reduction of GWI), despite a similar reduction of HbA1 (p<0.05). The combination of GLP-1A and SGLT-2 showed a greater improvement of the measured markers than each treatment alone (table, p<0.05). The reduction of PBR (indicating improvement of glycocalyx thickness) was related with the changes in central SBP (r=0.40) and PWV (r=0.35) (p<0.05).

N=120 Insulin GLP-1A SGLT-2 GLP-1A + SGLT-2 P 3-months N=30 N=30 N=30 N=30 PBR, μm 2.27±0.3 2.17±0.3 2.17±0.3 1.99±0.2 <0.05 Central SBP, mmHg 136±20 127±16 126±11 124±10 <0.05 PWV, m/sec 11.7±0.5 9.5±0.5 9.3±0.5 9.2±0.5 <0.05 HbA1 7.1±1.5 6.6±0.3 6.7±0.6 6.2±0.6 0.8 Myocardial work index (GWI), mmHg% 1343±394 1579±245 1364±431 1784±593 <0.05 LV untwisting velocity, deg/sec −116±36 −123±36 −122±36 −130±36 <0.05 PWV/GLS ratio −0.77±0.2 −0.57±0.2 −0.66±0.3 −0.55±0.3 <0.05

Conclusion

Three-month treatment with GLP-1A, SGLT-2 and their combination showed a greater improvement of vascular markers, ventricular-arterial coupling and effective cardiac work than insulin treatment in type 2 diabetes.

The association of hematological indices with the response to cardiac resynchronization therapy: a single-center study

BACKGROUND

Cardiac resynchronization therapy (CRT) is an established therapeutic option for patients with heart failure (HF) and left ventricular ejection fraction (LVEF) ≤35 % who meet specific criteria according to current guidelines. However, up to 40 % of patients have no response to CRT. Our study aimed to investigate the association between different hematological and biochemical indices and response to CRT.

METHODS

Patients with HF due to ischemic or dilated cardiomyopathy referred to our hospital for CRT implantation from January 2013 to November 2017 were included in the study. Response to CRT was defined as an increase in LVEF ≥10 % or a decrease in left ventricular end-systolic volume (LVESV) ≥15 % at six months of follow-up.

RESULTS

A total of 48 patients (mean age: 66.2 ± 9.5 years, 81.3 % males) were included in the study. Of these HF patients, 29 (60.4 %) had ischemic cardiomyopathy, and 19 (39.6 %) had dilated cardiomyopathy. At six months of follow-up, 37 patients (77.1 %) had responded to CRT. Ten patients (20.8 %) had ventricular tachycardia (VT), 24 (50 %) patients were hospitalized, and two patients (4.2 %) died during the follow-up period. Multivariate analysis demonstrated that age (p =0.03) and creatinine levels (p =0.02) were independent predictors of the response to CRT. No significant associations between hematological markers (white blood cells, neutrophils, lymphocytes, platelets, neutrophil to lymphocyte ratio, red blood cells distribution width) and CRT response were observed.

CONCLUSIONS

A smaller increase in LVEF and a smaller decrease in LVESV were predictive for VT occurrence and hospitalizations in patients receiving CRT. No significant association between hematological markers and response to CRT was found. HIPPOKRATIA 2019, 23(3): 118-125.

Intermuscular implantation technique for subcutaneous cardioverter-defibrillators

BACKGROUND

The conventional technique for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation has been associated with pocket complications. The aim of this study was to evaluate the efficacy and safety of an alternative intermuscular technique for S‑ICD implantation.

METHODS

S-ICDs were implanted in ten consecutive patients (ten males, mean age: 46.8 ± 14.7 years). The pocket for the pulse generator was made above the serratus anterior muscular fascia and beneath the latissimus dorsi muscle by detaching the fibrous tissue between the muscles. Electrode implantation was performed using the three- (n = 4) or the two-incision technique (n = 6).

RESULTS

All S‑ICDs were successfully implanted in the absence of any procedure-related complications with a successful 65-J standard polarity defibrillation threshold testing, apart from one patient with Brugada syndrome who needed device repositioning more dorsally. During a mean follow-up of 16.5 ± 7.3 months, no major complications requiring surgical repair were encountered, while patients demonstrated high levels of comfort and satisfaction with the cosmetic result. One patient experienced an inappropriate shock due to noise detection, which was resolved after reprogramming to a different sensing vector.

CONCLUSION

The intermuscular technique is a safe and efficacious approach for S‑ICD implantation. This technique could lead to fewer pocket-related complications and better cosmetic results.