COVID-19 pandemic impact on heart failure epidemiology and outcomes in Poland. National database study

Background

COVID-19 pandemic negatively affected patients' will to seek urgent medical treatment as well as and health service performance.

Purpose

The aim was to evaluate the impact of COVID-19 pandemic outbreak at the beginning of 2020 on heart failure epidemiology and outcomes in Poland.

Methods

The study is based on the Nationwide Polish Ministry of Health Registry, an administrative nation-wide database covering all heart failure patients in Poland who were beneficiaries of the public health sector between 2013 and 2021.

Results

After COVID-19 outbreak in 2020, significantly fewer patients presented to health service due to HF than in previous years (Fig. 1). Compared to 2019, the number of HF hospitalisations declined by 21% and outpatient visits by 10% in 2020.

Simultaneously, for the first time in the last decade, the trend in heart failure prevalence went down dropping by 3.7% (Fig. 1). The trend was driven by the greater reduction in ischaemic vs non-ischaemic HF prevalence (4.7% vs 1.3%)

The longstanding downtrend in heart failure incidence accelerated markedly in 2020, decreasing by 20% between 2019 and 2020, compared to average fall of 8% in the previous decade (ranging between 4.1–12.9%). Likely, the drop was mainly attributable to the decline in the ischaemic HF incidence (23% vs 15.3% drop in nonischemic HF).

The average in-hospital mortality due to HF in 2020 was higher compared to 2019 (12.9% vs 11.02%). As many as 1.18% of patients died on the day of admission in 2020, contrary to 0.94% in 2019 which accounts to 25% increase. Monthly distribution of in-hospital mortality aligned with peaks of COVID-19 waves (Fig. 2).

Conclusion

The study shows unfavorable changes in HF epidemiology and outcomes due to the pandemic. The drop in prevalence and incidence seems to be associated with lower patient influx to the health service. It is unknown whether patient non-occurrence resulted from patients' actions or preoccupation of the health service with the pandemic. At the same time, a marked rise in in-hospital mortality was noted, with an over 25% increase in the number of deaths on the day of admission that could potentially reflect a more advanced disease state.

Funding Acknowledgement

Type of funding sources: None.

The relation among myocardial iron load and the severity of heart failure

 

Heart failure (HF) symptoms are related to reduced circulatory perfusion, peripheral congestion, also impaired peripheral muscle strength & oxygen utilization due to iron deficiency. Despite many premises, the correlation between myocardial iron load and failing heart function was not proved.

The purpose of this study was to assess iron itself and iron-related proteins in human failing (FH) vs non-failing (NFH) myocardium.

The study group consisted of 58 explanted FHs vs the control consisted of 31 NFHs unsuitable for transplantation. HF study group presented with LV dilatation (LVDD 67±8 mm; LVSD 59±13 mm), reduced contraction (LVEF 20±7.5%), RV enlargement (RVD 42±6.5 mm), pulmonary hypertension (2.21±0.93 Wu) and elevated NTproBNP (3955.5±2250.5pg/ml).

We assessed iron serum markers: ferritin (FR), transferrin/saturation (TSAT), transferrin receptor (soluble sTfR), sTFR/log FR; myocardial iron homeostasis assessment: M-Iron (Instrumental Neutron Activation Analysis, μg/g) and iron gathering proteins (by ELISA): divalent metal transporter (DMT-1); L-type calcium channel (L-CH), TfR-1/TfR-2; ferritins: heavy (FT-H), light (FT-L) chain, mitochondrial (FT-MT); ferroportin (FPN) and oxidative stress marker: 4-hydroxynonenal (4-HNE).

In FH vs NFH, M-Iron was reduced (164.6±25.2 vs 182.3±23.9; p=0.0358) however, did not apply to the entire group. Therefore we divvied the FH group into two subgroups (based on M-Iron concentration in NFH controls). Average iron concertation in non-iron-deficient (NIDM) subgroup was 172.5±19.1 (n=35) and in iron-deficient (IDM) subgroup wad 127.0±16.5; (n=23, p=0.0001).

Regardless M-Iron load in FH vs NFH myocardial proteins expressions were reduced: L-CH (NIDM vs IDM vs NFH: 49.2±9.2; 42.5±4.2; 67.3±23.0, p=0.0022); FT-L (16.4±7.3; 11.6±4.8; 26.3±7.5, p= <0.0001, respectively); FT-MT (41.2±7.6; 38.7±4.1; 59.3±10.4 p≤0,0001, respectively). With regard to M-Iron load, only in DMT-1 expression was changed (NIDM vs IDM vs NFH 4.8±0.7; 4.0±0.5; 5.8±0.8; p≤0.0001). 4-HNE levels in FH vs NFH were increased, regardless M-Iron load (NIDM-Iron vs IDM-Iron vs NFH; 55.7±29.2; 57.2±47.8; 9.9±8.1 p≤0.0001).

Interestingly, the iron load (NIDM-Iron vs IDM-Iron) did not modify the assessed clinical parameters.

With regard to commonly used systemic iron markers only sTFR/log FR proved M-Iron load difference (NIDM-Iron vs IDM-Iron 0.6±0.2; 0.7±0.3; p=0.047910)

In FH, we observed, the subgroup with the reduced M-Iron load. The observed reduction of iron gathering proteins were independent on M-Iron load, except DMT-1 the main iron transportation protein into the cell. The results showed that the HF degree and concertation of iron proteins are unlikely to be affected by the M-Iron load, except DMT-1 protein. The oxidative stress was also regardless from M-Iron load, and increased in the whole FH group. Commonly used systemic iron markers except sTFR/log FR did not define M-Iron load.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Cardinal Stefan Wyszyński National Institute of Cardiology

Circular RNAs dysregulation in ischemic heart failure

Introduction

Circular RNAs (circRNAs) are an emerging class of non-coding RNAs originating from the splicing and circularization of pre-mRNAs and long non-coding RNAs. CircRNAs can regulate transcription and splicing, sequester microRNAs acting as “sponge” and inducing the respective targets, and bind to RNA binding proteins. CircRNAs have been found deregulated in several cardiovascular diseases, including heart failure (HF). However, incomplete and sometimes contradictory results have been reported on their regulation and function in HF, possibly for the heterogeneity of patients analyzed, indicating that our understanding of the regulation and role of cardiac circRNAs is still very limited.

Purpose

We aim to identify novel circRNA candidates deregulated in ischemic HF and to functionally characterize them in HF.

Methods

To define the circRNA expression pattern in ischemic HF, a high-depth RNA-seq was performed on the remote zone of left ventricle (LV) samples of 20 non end-stage ischemic HF patients with reduced LV ejection fraction and 20 matched controls. Differentially expressed circRNAs identified using CIRIquant tool were validated by qRT-PCR. Samples from the border zone of non end-stage HF patients and LV biopsies from end-stage HF patients were also used to measure circRNAs expression.

Results

By RNA-seq, we identified 17 circRNAs as differentially expressed with FDR<0.1. qRT-PCR results confirmed the differential expression of 4 circRNAs, cSLC6A6, cNAA16, cMLIP and cHDCA9, which were upregulated in HF samples (t-test, p-value <0.001). To evaluate circRNAs deregulated independently of their linear counterparts, we also estimated the ratio between circular and linear isoforms. cSLC6A6, cMLIP and cHDCA9 showed also a statistically significant (t-test, p-value <0.002) increase of the circular-to-linear ratio between HF and control patients.

To complement the unbiased strategy of RNA-seq, we evaluated the modulation of 18 candidate circRNAs identified by a literature analysis as dysregulated in ischemic or not-ischemic cardiomyopathies or in biological mechanisms relevant for ischemic HF. cPVT1, cANKRD17, cBPTF, displaying a concordant deregulation in different stages of the disease (non end-stage and end-stage HF) and in different regions of LV myocardium (remote and border zone), were chosen for further analysis.

Using siRNAs targeting the backsplice junction, cPVT1 was specifically knockdown in a human cardiomyocyte cell line. RNA-seq analysis of cPVT1 knockdown samples identified 3577 significantly differentially expressed genes (FDR<0.01). Gene ontology and pathway analysis showed that these genes were mainly involved in the formation of extracellular matrix, fibrosis and in cellular senescence, suggesting the involvement of cPVT1 in these HF-related disease mechanisms.

Conclusion

We identified new deregulated circRNAs in ischemic HF patients that might play a pathogenic role in HF.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Italian Ministry of Health, Ricerca Corrente 2021-2023 “CircularRNAs in heart failure: regulation, function and interaction with the transcriptome”

Investigation of cardiotoxicity by dipeptidyl-peptidase-4 inhibitors in a human cardiomyocyte cell line as well as in samples from chronic heart failure patients

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Horizon 2020 research and innovation programme, Ministry for Innovation and Technology

Background

Dipeptidyl-peptidase-4 (DPP4) inhibitors are relatively new therapeutic tools for type 2 diabetes. The SAVOR-TIMI-53 clinical trial has revealed an increased heart failure (HF)-associated hospitalization rate in saxagliptin treated patients. Although this critical side effect could limit the therapeutic use considerably, the mechanism by which DPP4 inhibitors damage the heart is still unclear.

Aims

We aimed to set up a relevant cellular platform to investigate mechanistically DPP4 inhibition, and the role of its potentially important neuropeptide substrates (e.g. Substance P and Neuropeptide Y). Moreover, we aim to determine the expression of DDP4 and its neuropeptide substrates in human and cellular samples.

Methods

Western blot, ELISA, and radioimmunoassay experiments were performed to investigate the expression of DPP4 and its neuropeptide substrates in human hearts and in AC16 cells. Viability measurements with calcein staining and scratch assay experiments were used to test the potentially toxic effect of DPP4 inhibitors. The localization of DPP4 mRNA was determined with RNA Scope in situ hybridization.

Results

Expression of DPP4 and NPY proteins decreased in interventricular septum samples of patients with HF compared to healthy controls. In human hearts DPP4 mRNA is detectable in cardiomyocytes, while other cell types (endothelial cells, fibroblasts, and macrophages) show negligible expression. AC16 human cardiomyocyte cell line expresses DPP4 enzyme.  Treatment with various DPP4 inhibitors administered alone or in combination with neuropeptides don’t affect cellular survival; although, in scratch assay experiments treatments with neuropeptides decreased cell migration speed in the isolated neonatal rat cardiomyocyte-fibroblast co-culture. The migration speed reducing effect of NPY was revered by the administration of saxagliptin at the highest concentration of NPY.

Conclusions

Decreased activity of DPP4 may play a role in the pathomechanism of end-stage congestive heart failure. The DPP4 enzyme could be important as a compensating mechanism against the elevated sympathetic activity in HF and for the altered neuropeptide tone. Inhibition of DPP4 could decrease this adaptive mechanism thereby exacerbating myocardial damage.

Transcriptomic analysis and comparative characterization of rat H9C2, human AC16 and murine HL-1 cardiac cell lines

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 research and innovation programme

National Research, Development and Innovation Fund of Hungary

Background

Cardiac cell lines and primary cell cultures are widely used to model various cardiovascular diseases in vitro. Despite the increasing number of publications using these models, limitations of these cell lines are still undetermined.

Purpose

The aim of our study was to compare the most commonly used cardiac cell lines to primary cultures and to mature cardiac tissues by transcriptomic analysis and morphological characterization.

Methods

H9C2 (rat), AC16 (human) and HL-1 (mouse) cardiac cell lines were differentiated towards a phenotype more resembling cardiomyocytes, by methods most widely used in the literature, and cells were harvested at stages of proliferation and differentiation. Whole left ventricular tissue, neonatal primary cardiac myocytes isolated from mice and rats, or human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CM) were applied as references. Transcriptome analysis and immunocytochemical detection of cardiac structural proteins were performed on all cell models.

Results

RNA expression of cardiac markers (e.g. Tnnt2, Ryr2, Tnni3) was markedly lower in cell lines compared to primary cells or hiPSC-CM and adult tissue controls. Differentiation procedures induced a significant increase in cardiac- and decrease in embryonic markers in AC16 and H9C2 lines; however, the overall expression pattern of investigated genes in all cell lines showed significant differences in comparison to corresponding myocardium or primary cultures. Immunocytochemistry confirmed low expressions of structural protein alpha-actinin and troponin I in cell lines.

Conclusion

Expression patterns of cardiomyocyte markers and mRNA profile indicates low-to-moderate similarity of cell lines to primary cells/cardiac tissues regardless the differentiation protocol used. These limitations should be taken into account while choosing cells as in vitro platforms to model cardiomyocytes and cardiovascular diseases.

Rehospitalization as a predictor of mortality in Polish population of heart failure patients-national registry

Background

High mortality risk in heart failure (HF) is related to repeat HF hospitalizations but also individual patient characteristics.

Purpose

To evaluate the impact of HF re-/hospitalizations and patient-related factors (sex, HF etiology, age, comorbidity) on all-cause mortality.

Methods

Our study represents one of the most extensive retrospective cohort analyses consisting of 1,686,861 adult Polish HF patients who presented into public health system in years 2013–2018. It is a part of a nationwide National Health Fund registry covering out- and in-patient data for the entire Polish population (38,495,659 in 2013) since 2009. HF hospitalizations were extracted using ICD-10 coding, whereas the comorbidity was evaluated by means of Charlson Comorbidity Index (CCI).

Results

In years 2013–2018 the absolute number of HF hospitalizations in Poland grew by 33% to 264,808 in 2018, whereas the number of rehospitalizations increased 1.5-fold to reach 137,708 in 2018.

In fact, nearly half of HF patients (n=817,432; 48.5%) experienced at least one hospitalization, while 15.4% (n=259,868) were rehospitalized during the study period. After initial hospitalization the readmission rate due to HF/all circulatory diseases at 30, 60, 180, 360, and 720 days was 10.4%/15.1%, 21.2%/28.3%, 43.9%/52.8%, 62%/70.4%, and 81%/87%, respectively.

As compared to patients who were hospitalized just once, those who underwent at least one rehospitalization were more often female (p<0.001), slightly older (p<0.001), and with higher burden of comorbidities based on CCI (p<0.001).

Patient survival was highly dependent on hospitalization frequency (Fig. 1). Mean survival rate at day 720 was 66.4%, 59.8%, 54.9%, 51%, and 43.9% for 1st, 2nd, 3rd, 4th, and ≥5th hospitalization, respectively.

After adjusting for age, sex, etiology (ischemic/non-ischemic) and CCI using a multivariate stratified Cox regression model, the estimated hazard ratios (HR) for all-cause mortality amounted to 1.22 (95% CI: 1.21–1.23, p<0.001) for 2nd, 1.4 (95% CI: 1.39–1.42, p<0.001) for 3rd, 1.58 (95% CI: 1.56–1.6, p<0.001) for 4th, and 1.97 (95% CI: 1.95–1.98 p<0.001) for 5th and subsequent hospitalizations, as compared to the first hospitalization.

Conclusions

Hospitalization rate in Poland is alarmingly high. Repeat HF hospitalizations strongly predict mortality rate for HF patients even after adjustment for age, sex, etiology, and comorbidity burden.

Figure 1. Kaplan-Meier for survival post hosp.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): The project is co-financed by the European Union from the European Social Fund under the Operational Programme Knowledge Education Development and it is being carried out by the Analyses and Strategies Department of the Polish Ministry of Health.

Cardiac rehabilitation effectively reduces the number of deaths in the heart failure population (propensity score matched analysis)

Background

Numerous cardiac rehabilitation (CR) studies have demonstrated functional benefits, improvement in quality of life and clinical outcomes from exercise training in patients with heart failure (HF), so CR is consistently recommend for HF patients. However its influence on survival in HF population is unknown.

Purpose

To assess the influence of CR on survival rate in HF patients.

Methods

It is a retrospective analysis of 1 620 686 HF patients in Poland in years 2013–2018, based on nationwide Polish Ministry of Health registry, that provides public universal healthcare coverage to all residents and collects detailed information for the entire Polish population (38,495,659 in 2013) since 2009. Within registry, we identified the experimental group of 11 512 HF patients ≥18 years old who underwent CR in 2013–2018.

From entire HF population we identified a 1:1 propensity score matched cohort of HF patients, who did not get CR.

Results

After propensity-score matching, we identified 11,512 patient pairs who underwent/not CR. Average age was approximately 66 years (18–39: 2.1 vs 2.0%; 40–49: 491 – 4.3 vs 4.2%; 50–59: 17.0 vs 17.1%; 60–69: 34.9 vs 35.2%; 70–79: 31.3 vs 31.4%; 80+: 10.4 vs 10.3% respectively), 61% of the participants were males, mainly urban residence nearly 70%, with HF diagnose put during hospitalization 74.5%. Both groups were similar also by comorbidities evaluated by Charlson Comorbidity Index.

Patients subjected to CR compared CR negative significantly increased survival risk at 1st, 2nd, 3rd, 4th and 5th year (CR vs CR negative 97.4% vs. 84.9%; 93.9% vs. 77.9%; 89.9% vs. 71.9%; 85.2% vs 66.0%; 81.8% vs 62.1% respectively) – Figure 1.

Conclusion

Our analysis showed that in heart failure patients, CR was associated with an increased survival rate among HF patients as treated in routine health care system.

Figure1

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): European Union from the European Social Fund

Real world heart failure epidemiology and outcome: a population-based analysis of 1,990,162 heart failure patients

Background

Heart failure (HF) is the leading cause of death and hospitalization in developed countries. Most of the information about HF is based on selected cohorts, the real epidemiology of HF is scarce.

Purpose

To assess trends in the real world incidence, prevalence and mortality of all in-and outpatients with HF who presented in public health system in 2009–2018 in Poland.

Methods

It is a retrospective analysis of 1,990,162 patients who presented with HF in Poland in years 2009–2018. It is a part of nationwide Polish Ministry of Health registry that collects detailed information for the entire Polish population (38,495,659 in 2013) since 2009. Detailed data within the registry were collected since 2013. HF was recorded if HF diagnosis was coded (ICD-10).

Results

The incidence of HF in Poland fell down from 2013 to reach 127,036 newly diagnosed cases (330 per 100,000 population) in 2018 that equals to 43.6% drop. This decrease was mainly driven by marked reduction in females (p<0.001; Fig. 1A) and HF of ischaemic etiology (HF-IE vs HF-nonIE, Fig. 1B. p<0.001). The HF incidence per 100,000 population decreased across all age groups with the greatest drop in the youngest (Table 1).

The prevalence rose by 11.6% to reach 1,242,129 (3233 per 100,000 population) in 2018 with significantly greater increase in females and HF-IE (both p<0.0001, Fig. 1C and D, respectively). The HF prevalence per 100,000 population increased across all age groups except for the 70–79 years old. (Table 1).

Mortality increased by 28.5% to reach 142,379 cases (370 per 100,000 population) in 2018. The rise was more pronounced among females (p=0.015, Fig. 1E) and in HF-IE (p<0.001, Fig. 1F). The HF mortality per 100 000 population increased across all age groups, except for the 50–59 subgroup (Table 1).

Conclusions

Heart failure incidence plummeted in years 2013–2018 in Poland due to drop in newly diagnosed HF-IE. Despite that fact, the prevalence and mortality increased with rising trends in HF-IE.

Figure 1. Incidence, prevalence, mortality trends

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): The project is co-financed by the European Union from the European Social Fund under the Operational Programme Knowledge Education Development and it is being carried out by the Analyses and Strategies Department of the Polish Ministry of Health

P6333Therapy-induced weight gain is associated with higher appendicular muscle mass in patients with heart failure

Background

The catabolic predominance in acute heart failure (HF) leads to significant weight loss. The low body weight before HF (preHF) and the loss during its natural course, both are risk factors of sarcopenia and worse clinical outcome in HF. Modern therapy can inhibit or even reverse catabolism resulting in oedema-free weight gain. It is unknown if therapy-induced weight gain can protect against low appendicular skeletal muscle mass (ASM) – the key prerequisite of sarcopenia.

Aims

We intended to assess whether therapy-induced oedema-free weight gain protects against low ASM.

Material and methods

In 802 patients with HF (age: 52±10 years 13% women, LVEF: 24±7%, NYHA: 2.6±0.7), we analysed weight changes from preHF to minimal oedema-free weight during HF (minHF), and then weight occurring after removal of all reversible factors aggravating HF with optimisation of therapy (indexHF). At index date we performed dual X-ray densitometry (DXA) calculating ASM as the sum of lean mass within the legs and arms adjusted to body size. The low ASM was defined as ≤7 and 6 kg/m2 in men and women respectively. The catabolic (C) and anabolic (A) components of weight change ware calculated based of formulas: C=100*(minHF-preHF)/preHF, A=100*(indexHF-minHF)/minHF. Using logistic regression we estimated the risk of low ASM after adjustment for potential confounders.

Results

The median C and A were −11.7% and 3.3% respectively. The low ASM was found in 230 (28.7%) patients. In multivariable model comprising age, gender, weight preHF, C and A, the odds for low as compared to normal ASM are shown in table 1.

Odds ratio ± 95% CI Normal ASM Low ASM Gender (man v. women) 1.0 0.87 (0.81–0.94), p=0.0002 Weight preHF (per 1 kg/m2 increase) 1.0 0.85 (0.83–0.87), p<0.0001 Age (per 5 years increase) 1.0 1.05 (1.02–1.08), p=0.0003 C (per 1% increment) 1.0 1.05 (1.04–1.06), p<0.0001 A (per 1% increment) 1.0 0.98 (0.97–0.99), p<0.0001

Conclusions

In HF higher body weight preHF and oedema-free weight gain decreases the risk of low ASM independently of age, gender and weight loss.

P750Role of circulating endothelial cells post-heart transplantation

Background

The role of endothelial progenitor cells (EPC) in heart transplantation (HT) is not well defined. Thus, the aim of this study was to evaluate prospectively the dynamic changes of circulating EPC levels in relation to post-HT rejection risk.

Methods

There were 27 HT recipients who had EPC from peripheral blood quantified during 6 months follow-up after HT. Patients were monitored regularly, by right ventricular endomyocardial biopsy assessment, for cellular rejection (ACR) defined as grade ≥2 or an antibody-mediated rejection (AMR) characterized by histopathological changes recorded as AMR1H. The primary end-point was acute rejection, either AMR or ACR.

Results

ACR and AMR were observed in 7 (25.9%) and 6 (22.2%) subjects respectively. EPC levels, after logarithmic transformation, immediately post-HT were alike regardless of ACR status, however patients with lower EPC were at risk of AMR at 1 month (Table 1). On the other hand patients with a significant reduction of EPC at 1 month post-HT compared with HT were less likely to have either ACR or AMR (p=0.0003). During longer post-HT observation (12 months) patients had similar EPC levels regardless of the rejection events. Dynamic changes in EPC levels are presented in figure. Nonetheless, greater changes in EPC expressed by coefficient of variation were associated with the risk of either AMR or ACR compared to the participants without rejection (mean [lower–upper quartile]) 15 [13–18] vs 8 [5–13]; p=0.02) and (22 [14–26] vs 8 [5–13]; p=0.01) respectively.

EPC by rejection – 1st month following HT ACR (+) AMR (+) ACR (−) and AMR (−) p^ p p N=3 (mean± SD) N=4 (mean± SD) N=20 (mean± SD) ACR (+) vs ACR (−) and AMR (−) AMR (+) vs ACR (−) and AMR (−) EPC log HT 5.14±1.55 3.81±1.01 5.30±0.88 0.0325 0.97 0.025 EPC log M1 4.97±0.59 3.69±1.33 4.15±1.29 0.4160 0.55 0.78 Delta EPC log M1-HT -0.17±1.98* −0.12±1.30* −1.15±1.18# 0.2195 0.44 0.32 ACR – acute cellular rejection; AMR or – acute antibody-mediated rejection; EPC log – endothelial progenitor cells after logarithmic transformation; HT – within 24 hours post-transplantation; M1 – at 1-month post-transplantation; Delta EPC log M1-HT – difference in EPC log between M1 and HT. #p=0.0003 for the difference between M1 vs HT; *p=ns for the difference between M1 vs HT; ^pP – for the difference among the groups.

Changes in EPC level post-HT

Conclusions

Early reduction of EPC levels was predictive of a lower risk of ACR or AMR. Greater dynamic changes of EPC during 6 months of observation were associated with a higher risk of rejection suggesting an important role of EPC in the pathological processes post-HT. Thus our findings suggest significant role of EPC post-HT with respect to rejection status.

Acknowledgement/Funding

Intramural research grant from the Institute of Cardiology

Traumatic tricuspid valve insufficiency: case report

A 30-year old man underwent a head-on motor accident and was admitted to hospital, where he was successfully treated for several injuries. He was discharged home with slight tricuspid regurgitation, without signs of hemodynamic decompensation, and required no further treatment. Five years later he was admitted to the National Institute of Cardiology due to overt right ventricular failure secondary to tricuspid valve regurgitation. After several unsuccessful attempts at papillary muscle and chordal repair, a 33-mm SJM Biocor valve was implanted. This case history underlines the value of echocardiography, even after blunt chest trauma without cardiac symptoms. A good functional result can be achieved years after onset of traumatic valve insufficiency, but early diagnosis and surgical treatment increases the feasibility of tricuspid valve repair rather than replacement, and also prevents progressive deterioration of right ventricular function.

A randomized crossover trial of levodopa in congestive heart failure

BACKGROUND

The short- and long-term effects of levodopa (L-dopa), an oral dopaminergic prodrug, were assessed in patients with severe left ventricular dysfunction.

METHODS AND RESULTS

Initially, 26 patients were included in the study group. After clinical, radiographic, and radionuclide examination, each patient underwent right heart catheterization (Swan-Ganz thermodilution catheter). Plasma noradrenaline levels were measured. In two patients, a favorable hemodynamic response to L-dopa was not observed, another two required permanent pacemaker implantation. These four patients were excluded from the study. Two patients required permanent pacemaker implantation. The remaining 22 patients with favorable hemodynamic response to L-dopa (increase in cardiac index, stroke volume index, reduction in total systemic resistance) were randomized in a nonblinded fashion to the conventional (11 patients) or conventional plus L-dopa (11 patients) treatment groups. During the study period, two patients, one from each group, died. They were excluded from the analysis. The final analyzed study group consisted of 20 men, aged 33-69, in New York Heart Association functional class IV (9 patients) and III (11 patients). The cause of congestive heart failure was primary dilated cardiomyopathy in 11 patients and ischemic heart disease in 9 patients. After 3 months' treatment, all patients were crossed over. Clinical, radiographic, radionuclide, and hemodynamic evaluation was repeated at the end of the 3-month treatment period. After 3 months of therapy with L-dopa in each group (covariance analysis), there was improvement in clinical, radiographic (relative heart volume, -128 mL/m2), radionuclide (left ventricular ejection fraction, +4.6; right ventricular ejection fraction, +4.8%), hemodynamic (mean pulmonary wedge pressure, -8 mmHg; total systemic resistance, -1.8 Wu; total pulmonary resistance, -3.5 Wu), and neurohumoral (noradrenaline, -218 pg/mL) measures.

CONCLUSIONS

The addition of L-dopa to conventional therapy has beneficial short- and long-term effects in patients with severe left ventricular dysfunction.

[Surgical treatment for mitral valve defects with preponderance of mitral stenosis and high pulmonary vascular resistance. Clinical and hemodynamic observations 6 months after valve replacement]

10 patients with isolated or predominant mitral stenosis (mean mitral valve area 0.9 cm) and high preoperative values of pulmonary vascular resistance (mean 7.2 Wood units) were chosen for further hemodynamic postoperation evaluation. The patients had normal function of the aortic valve and no significant stenosis of coronary arteries. Hemodynamic evaluation was done by floating Swan-Ganz catheter preoperatively at rest and 6 months after mitral valve replacement at rest and during bicycle cycloergometer test in the supine position. Significant improvement in NYHA class was noted. Preoperatively 6 patients were in NYHA III class, 4 in NYHA IV class. After mitral valve replacement 4 patients were in class III and 6 in class II. Before mitral valve replacement only 3 patients were able to perform 25 Watt test. After surgery all except one performed at least 25 W. There was a significant decrease of pulmonary vascular resistance from 7.2 +/- 2.2 preoperatively to 3.1 +/- 1.9 Wood units at rest after the operation. Post operation during exercise pulmonary vascular resistance attained 4.2 +/- 1.9 Wood units. These changes were due to a fall in mean pulmonary artery pressure 49 +/- 13 at rest preoperatively to 25 +/- 6 mm Hg (rest) and 43 +/- 14 mm Hg (23 W) postoperatively and a rise in stroke volume index from 24 +/- 7 ml (m2) beat preoperatively to 32 +/- 9 at rest and 33 +/- 6 (25 W) postoperatively. Despite clinical and hemodynamic improvement there was no full recovery of pulmonary hemodynamics.

[Hemodynamic effects of one administration of l-dopa in patients with left ventricular heart failure (introductory remarks)]

The study group consisted of 8 men with congestive heart failure. They ranged in age from 33 do 63 years (mean 48). Three patients were in class III NYHA, five in class IV. Idiopathic cardiomyopathy was diagnosed in 6 patients, one individual displayed ischemic heart disease and one patient was after mitral and aortic-valve replacement despite a normally functioning prosthetic valve. L-dopa was given orally beginning with 250 mg every six hours until a total daily dose of 4.0 g was achieved with no side effects (patients additionally received 50 mg of pyridoxine hydrochloride). Afterwards L-dopa was withheld for 24-36 hours. Having completed this washout period, patients underwent right heart catheterization, with placement of a balloon-tipped thermodilution catheter in a pulmonary artery, so that balloon inflation allowed recording of the pulmonary capillary wedge pressure. Right atrial and pulmonary arterial pressures were monitored continuously. Systemic arterial pressure was measured by mercury manometer. Cardiac output was determined by the thermodilution technique. Rest and effort hemodynamic measurements were repeated before and one, three hours after administration of 1-dopa. The base-line hemodynamic values were consistent with the clinical presentation of severe congestive heart failure. The average cardiac index (CI-1/min/m2--rest--1.93; 25 Watt-3.1) and stroke volume index (SVI-m1/m2--rest--22.2; 25 Watt-32.0) were markedly lowered. Left ventricular filling pressure and pulmonary artery pressure were elevated. The systemic vascular resistance was significantly increased (SVR -j.W.--rest--22.7; 25 Watt-14.2). Administration of 1-dopa resulted in the increase in cardiac index and stroke volume index accompanied by a substantial reduction in systemic vascular resistance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Factors influencing survival in patients with coronary disease. I. Characteristics of examined patients and survival curves]

The group of 683 patients with the significant narrowing (> 70%) of at least one coronary vessel diagnosed by coronarography performed between 1976-1988 in the Institute of Cardiology in Warsaw was followed during one to seven years. The number of patients with a poor left ventricular function was high in the group treated surgically and non surgically. Ejection fraction < 50% was found in 27% and 43% respectively, LVEDP > 12 mmHg (66% and 69%), EDVI > 100 ml/m2 (58% and 70%). Survival curves were calculated in the two different subsets of patients treated surgically and non surgically. Despite some favorite trend toward a better outcome for patients treated surgically the differences were not statistically significant for a whole group. However we showed a significantly higher probability of survival in the subgroup of the three vessel disease treated surgically compared to other treatment. There were no significant differences in survival in patients with one, two, or three vessel disease treated surgically (survival probability of 0.82; 0.78; 0.84 respectively after 7 years). In patients treated non surgically the growing number of diseased vessels worsened the prognosis (survival probability of 0.84; 0.78; 056 respectively). In our observation the differences for better outcome in patients with poor left ventricular function treated surgically did not reach a statistical significance.

[Factors influencing survival in patients with coronary heart disease. II. Multivariate logistic function analysis]

A group of 683 patients with the significant narrowing (> 70%) of at least one coronary vessel diagnosed by coronarography performed between 1976-1988 in the Institute of Cardiology in Warsaw was followed during one to seven years. Two hundred ninety of them were treated surgically, 393 non surgically. A multivariate logistic function (MLF) analysis of 10 variables is presented obtained from anamnesis and hemodynamic data and their significance upon survival after 2, 4 and 6 years. In the group treated non surgically the number of narrowed vessels was a factor independently significant after 2, 4 and 6 years. After 4 and 6 years the ejection fraction and the left ventricle end diastolic volume index were also significant. In the group treated surgically none of those were significant after 2 years. After 4 and 6 years anamnesis of arterial hypertonia was significant after 6 years also left ventricle end diastolic volume index. Coefficients calculated from multivariate logistic function analysis allow the calculation of probability of survival for an individual patient.

[Functional and morphologic changes of left ventricular myocardium in the course of aortic valve disease]

The mortality of patients with aortic valve disease is growing significantly from the time of manifestation of features of left ventricular heart failure. Probably, the causes of that situation are the irreversible changes in the myocardium. During the first, asymptomatic stage of aortic valve disease, the increase of preload and afterload is compensated by myocardial hypertrophy, concentric or eccentric respectively. The global heart function as a pump remains normal, in spite of decreased contractility of individual sarcomeres. Valve replacement at that stage of the disease gives the best effects, being the causal treatment. After having used up the compensation possibilities, of the myocardium, the features develop of left ventricular heart failure. The mortality of patients operated on in that stage of the disease is high. Valve replacement is often a palliative method.