Impact of atrial flow regulator implantation on survival in patients with heart failure with reduced and preserved ejection fraction: a post-hoc analysis of the PRELIEVE study

Purpose

This analysis aims to assess the theoretical impact of atrial flow regulator implantation on mortality by comparing the observed survival rate with the median predicted probability for one-year survival.

Methods

The prospective, multicentre, open-label, non-randomised PRELIEVE study assessed the safety and efficacy of the atrial flow regulator in patients with symptomatic HFrEF (left ventricular ejection fraction (LVEF) ≥15% and <40%) or HFpEF (LVEF ≥40% and <70%) and elevated PCWP (≥15mmHg at rest or ≥25mmHg during exercise). In this analysis, after the first 60 patients completed twelve months of follow-up, the theoretical impact of atrial flow regulator implantation on survival was assessed by comparing the observed mortality rate with the median predicted probability for one-year mortality. Each subject's risk of mortality was predicted from individual baseline data using the Meta-Analysis Global Group in Chronic HF (MAGGIC) prognostic model.

Results

A total of 87 patients had undergone successful device implantation for the treatment of HFrEF (53%) and HFpEF (47%). Sixty patients had a complete twelve-month follow-up. The median follow-up was 351 days (interquartile range [IQR] 202–370). A total of six (7%) patients died during follow-up (8.6 deaths per 100 patient-years; 95% confidence interval [CI] 2.7 to 15.5), all of which had HFrEF. The median predicted mortality rate for the overall study population was 12.2 deaths per 100 patient-years (95% CI 10.2 to 14.7). While the observed mortality rate (0 deaths per 100 patient-years) was significantly lower than the median predicted mortality rate (9.3 deaths per 100 patient-years; 95% CI 8.4 to 11.1) in patients with HFpEF (−9.3 deaths per 100 patient-years; 95% CI −11.1 to −8.4), there was no difference in patients with HFrEF (−3.6 deaths per 100 patient-years; 95% CI −9.5 to 3.0) (Figure 1). Four deaths were HF-related deaths (5.7 HF-related deaths per 100 patient-years; 95% CI 1.4 to 11.9; 10.8 HF-related deaths per 100 patient-years; 95% CI 2.5 to 23.1 in the HFrEF subgroup).

Conclusion

In patients with HFpEF, the mortality rate following atrial flow regulator implantation was lower than the predicted mortality rate. These findings need to be confirmed by larger randomised, controlled trials.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Occlutech International AB

CMR assessment of right ventricular remodeling after transcatheter therapy for severe tricuspid regurgitation

Funding Acknowledgements

Type of funding sources: Private hospital(s). Main funding source(s): Helios Clinical Research Institute

Background/Introduction

Patients with severe tricuspid regurgitation (TR) are characterized from severe dilatation and negative remodeling of the right heart chambers causing functional right ventricular (RV) failure and increased mortality and morbidity. The transcatheter tricuspid edge-to-edge repair (TTVR) is a new treatment option associated with symptom improvement and reduced hospitalization. The cardiac magnetic resonance imaging (CMRI) remains the gold standard for evaluating the right ventricular morphology and function and could be a useful in assessing the RV reverse remodeling after TTVR.  The Tricuspid Regurgitation REgistry (TRuE) is an ongoing national prospective register of patients with severe TR that aims to identify morphofunctional parameters of the right heart chambers related to improve outcomes after TTVR.

Purpose

The present is a subanalysis of patients with serial CMRI examinations recruited in the ongoing prospective TRuE registry.

Methods

After excluding patients with intracardiac RV leads, seven patients (age 70 ±12 years) with completed thirty-day follow up were included in the present analysis. Retrospective gated steady state free precession cine images were acquired in the long and short-axis views covering the entirety of both ventricles. Aortic and pulmonary flow data were acquired with a flow-sensitive gradient echo sequence. Assessment of left ventricular (LV) and RV volumes was performed manually in the short-axis cine images (Circle Cardiovascular Imaging, Calgary, Alberta, Canada). The TR fraction was calculated as: ({total RV stroke volume (SV) – total pulmonary forward flow}/total RVSV) × 100. All volumes and flow measurements were indexed for body surface area and expressed in ml/m2. The ratio between the diameter of pulmonary artery (PA) and ascending aorta (AA) was used as indirect measurement of pulmonary arterial hypertension (PAH). CMRI parameters assessing TR quantification, RV morphology and function were analyzed at baseline and follow-up with Fisher´s test or paired t-test.

Results

At thirty days there was a significant reduction of the TR fraction (45% to 20%, p < 0.001), RV dilatation (RV-end diastolic volume (EDV): 106 ± 12ml/m2 to 86 ± 9.4ml/m2, p = 0.002, RV- end sistolic volume (ESV):55 ± 6.5 to 43 ± 6.6ml, p = 0.003) and improvement of function (RVEF: 47 ± 3.6 to 53 ± 2.4 %, p = 0.006). On the left heart side, there was an improvement of LV filling, with increased LVEDV and LVESV and of the LVSV (36 ± 5.3 to 41 ± 3.7ml/m2, p = 0.040), causing an improvement of the cardiac index (2.2 ± 0.9 l/min/m2 to 2.9 ± 0.7 l/min/m2; p = 0.019. Furthermore, the PA/AA ratio improved significantly (0.91 ± 0.15 to 0.81 ± 0.14, p = 0.006).

Conclusion

TTVR is associated with positive reverse remodeling of the RV with reduction of dilatation, PAH and function improvement.

Low-gradient aortic stenosis in patients with concomitant mitral regurgitation - a subgroup analysis from the German aortic valve registry (GARY)

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by German Cardiac Society, German Society for Thoracic and Cardiovascular Surgery, and German Heart Foundation. Statistical funding support by the German Center for Cardiovascular Research/Deutsches Zentrum für Herz-Kreislauf Forschung (DZHK).

Background

Patients with severe aortic stenosis (AS) frequently present concomitant mitral regurgitation (MR), which may interfere with echocardiographic measurement of mean pressure gradient (MPG), maximal flow velocity and aortic valve area (AVA).

Purpose

We therefore, aimed to investigate the impact of different grades of MR on parameters of AS severity in a large cohort of all-comer patients with severe AS, prospectively included in the national German Aortic Registry (GARY).

Methods

 All patients undergoing transcatheter or surgical aortic valve replacement for severe AS enrolled in GARY between 2011 and 2017 were considered for this analysis. After excluding cases with mitral stenosis and unknown causes of MR, 119,641 patients were considered for the present study. Based on LVEF, the study population was divided into the following subgroups: group 1 (LVEF < 30%, n = 7545), group 2 (LVEF 30-50%, n = 30,116), and group 3 (LVEF > 50%, n = 81,980). Differences in the values of the mPG were explored in each group and in relation to the decremental values of aortic valve area (AVA).

Results

Overall, 37,489 (31.3%) patients had no MR, 77,890 (65.1%) had MR grade I-II, and 4262 (3.6%) had MR grade III-IV. 

In group 1, 2 and 3, no MR was reported in 1339 (17.7%), 7612 (25.3%) and 28,538 (34.8%) patients respectively. MR grade I-II was more frequently observed (group 1 5621 [74.5%] vs. group 2 20,972 [69.6%] vs. group 3 51,297 [62.6%]), whereas MR grade III-IV was observed less frequently and present only in 585 (7.7%), 1532 (5.1%) and 2145 (2.6%) patients in subgroups 1, 2 and 3, respectively.

The aortic mPG was significantly lower in subgroup 1 compared to 2 and 3 (33.74 ± 14.93 versus 41.4 ± 16.47 and 46 ± 16.19mmHg respectively, p < 0.001). With increasing severity of MR, there was a significant reduction of the aortic mPG in each LVEF subgroup (Figure 1). This pattern was maintained irrespective of the AVA value.

Conclusions

 In patients with severe AS, concomitant MR may potentially affect diagnostic accuracy of echocardiographic AS evaluation. In this first GARY analysis of patients with severe AS and concomitant MR, we observed that increasing MR severity affects transvalvular aortic mPG and results in a low-gradient AS pattern. In contrast, AVA is a robust diagnostic parameter for the diagnosis of true severe AS that maintains its validity independently of LVEF and severity of concomitant MR.

Abstract Figure 1

TLR2 signalling orchestrates neutrophil activation in acute coronary syndrome with intact fibrous cap – results from the OPTICO-ACS study

Background

Neutrophil granulocytes are key players of the innate immunity, participating in the initiation and progression of atherosclerosis. However, the exact mechanisms of neutrophil activation after acute coronary syndrome (ACS) are poorly understood, especially in the context of the two predominant ACS-causing pathophysiologies - ACS with intact fibrous cap (IFC-ACS) and ACS with ruptured fibrous cap (RFC-ACS). Therefore, the current study focuses on immunophenotyping and ex-vivo functional characterization of neutrophils with regard to the molecular differences between IFC-ACS and RFC-ACS.

Methods

Using high-resolution optical coherence tomography (OCT) of the ACS-causing culprit lesion and re-evaluation by a second OCT-core lab, thirty-two IFC-ACS-patients were matched to thirty-two RFC-ACS-patients by gender, age and diabetes. Local and systemic blood samples were obtained from the site of the ACS-causing culprit lesion (LOC) and from the arterial sheath (SYS), respectively. Neutrophil abundance and surface marker expression were quantified by flow cytometry. Fresh neutrophils were isolated for functional analysis and ex-vivo assessment of cell-toxicity in a co-culture with human aortic endothelial cells (HAECs). Neutrophil secretion of active MMP9 was evaluated by fluorescence-based zymography in supernatants of isolated neutrophils and in patients' plasma samples.

Results

Neutrophils of patients with IFC-ACS show significantly higher expression of the toll-like receptor 2 (TLR2) in comparison to RFC-ACS-derived neutrophils (LOC: 1991±492.8 vs. 1615±440.2; p=0.01; SYS: 2062±464.4 vs. 1670±525.1; p=0.0056). Ex-vivo TLR2-stimulation of local neutrophils in patients with IFC-ACS led to increased toxicity of their secretome and aggravated endothelial cell death in co-culture, as compared to neutrophils from RFC-ACS patients (+59% dead HAECs, IFC-LOC vs. RFC-LOC; p=0.0078). Furthermore, TLR2-stimulation using Pam3CSK4 triggered higher activity rates of MMP9 exclusively in local neutrophils of IFC-ACS-patients (+38.9%±6.1% in IFC-LOC vs. RFC-LOC; p=0.0154). This effect was reversed in IFC-ACS-derived neutrophils being pre-treated with an anti-TLR2 neutralizing antibody (−58.4% ±5.2%, IFC-LOC-anti-TLR2 vs. IFC-LOC-vehicle; p=0.0069). Additionally, MMP9 activity was higher in plasma obtained from the culprit site of IFC-ACS patients (74.1 U/ml ±4.1 vs. 70.0 U/ml ±5.1, IFC-LOC vs. RFC-LOC; p=0.01).

Conclusion

The current study demonstrates novel TLR2-dependant neutrophil activation patterns at the coronary culprit lesion of IFC-ACS, leading to higher endothelial cell toxicity and MMP9 activity. Further studies need to assess whether a temporary blockade of TLR2 activation could be a possible therapeutic target in the era of personalized medicine.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Berlin Institute of Health (BIH), German Center for Cardiovascular Research

Impact of pre-hospital resuscitation on short-and long-term mortality in patients with cardiogenic shock and multivessel disease. Results of the CULPRIT trial

Background

There are only a few prospective data on the outcome of patients with cardio-pulmonary resuscitation (CPR) admitted with acute myocardial infarction (AMI) complicated by cardiogenic shock and an invasive strategy including primary percutaneous coronary intervention (PCI). Therefore, we evaluated the impact of pre-hospital CPR on outcomes in a large group of patients with AMI complicated by cardiogenic shock.

Methods

We used the data of the prospective CULPRIT-Shock trial and registry and including patients with acute myocardial infarction complicated by cardiogenic shock. The primary endpoint was 30-day mortality or renal replacement therapy.

Results

Between 2013 and 2017, a total of 1055 patients were included in the randomized trial (n=686) and in the registry (n=369), 550 (54%) had CPR, 40 had no information regarding CPR. Baseline characteristics, procedural features and outcomes in the two groups with and without CPR are given in the table.

Conclusion

Patients with pre-hospital CPR represent more than half of the population with AMI complicated by cardiogenic shock. They are younger, have less risk factors and more often LAD as infarct vessel. Despite the younger age and a high success rate of PCI patients with CPR have a high 30-day mortality.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Deutsches Zentrum fuer Herz-Kreislauf-Forschung - DZHK

P6394Neutrophil activation patterns in acute coronary syndrome with intact fibrous cap - results from the OPTICO-ACS study

Background

In up to one third of all cases, acute coronary syndrome occurs without signs of plaque rupture. Instead endothelial cell erosion is considered to be the hallmark of acute coronary syndrome with intact fibrous cap (IFC-ACS), with matrix metalloproteinase 9 (MMP9) directly linked to this pathology. The main source of MMP9 immediately after ACS are the neutrophil granulocytes. Therefore, their molecular activation patterns and subsequent MMP9 production are the objectives of the ongoing, translational OPTICO-ACS-Study, aiming to compare the mechanisms and prognosis of IFC-ACS and ACS with ruptured fibrous cap (RFC-ACS).

Methods

Local and systemic blood samples were simultaneously obtained from the site of the ACS-causing culprit lesion (LOC) using an aspiration catheter and from the systemic circulation (SYS). Using optical coherence tomography (OCT) the ACS-causing culprit lesion was characterized and two patient groups, patients with ACS caused by intact (IFC-ACS) and by ruptured fibrous cap (RFC-ACS) were compared. Each group consists of twenty patients (n=20) matched by age, gender and diabetes. Neutrophil counts and expression of activation markers were immediately quantified by whole-blood flow cytometry. Release of active MMP9 into the plasma was assessed by fluorescence-based zymography. Activation profiles of freshly isolated neutrophils, including MMP9 activity and effect on endothelial cell death, in response to toll-like receptor 2 (TLR2) stimulation was studied.

Results

Local neutrophils of patients with IFC-ACS show significantly higher expression of TLR2 in comparison to RFC-ACS neutrophils (LOC: 1866±382.1 vs. 1498±426.9; IFC-ACS vs. RFC-ACS, p=0.03). MMP9 activity is significant higher (p=0.01) in plasma obtained from the culprit site of IFC-ACS (74.1 U/ml±4.1) compared to those of RFC-ACS patients (70.0 U/ml±5.1) indicating secretion and activation of the enzyme during IFC-ACS. Importantly, in patients with IFC-ACS, TLR2-stimulation using Pam3CSK4 triggers higher activity rates of MMP9 only in neutrophils isolated directly from the culprit site (LOC), but not systemically (+27%±17.2% IFC-LOC vs. IFC-SYS; p=0.003). This effect was not observed in RFC-derived neutrophils. Inhibiting TLR2 by a monoclonal antibody, strongly reduced secretion of activated MMP9 only in the local neutrophils from IFC-ACS-patients (−54.6%±6.5% in IFC-LOC-anti-TLR2 vs. IFC-LOC-vehicle; p=0.008), but not from systemic IFC-neutrophils, nor from RFC-neutrophils. Furthermore, LOC IFC-ACS neutrophils aggravate endothelial cell death upon TLR2-activation in comparison to LOC RFC-ACS neutrophils (58.4±4.96% vs. 20±1.89%, IFC-ACS vs. RFC-ACS; p=0.0023).

Conclusion

We newly describe differential kinetics of MMP9 release by neutrophils in ACS patients with IFC versus RFC. Our data support a role of a TLR-2 activated and neutrophil-MMP9-mediated mechanism leading to endothelial cell erosion in patients with IFC-ACS.

Acknowledgement/Funding

DZHK (German Centre for Cardiovascular Research); BIH (Berlin Institute of Health)

P3668In non-critically ill patients suffering from endocarditis partial oral antibiotic therapy is non-inferior to intravenous therapy

Introduction

Antibiotic treatment for infective endocarditis is paramount typically consisting of intravenous therapy for up to eight weeks leading to long hospital stays. This often is associated with reduced quality of life for patients and might heighten complication rates. Recently, several trials evaluating the efficacy of partial oral treatment (switching to an oral antibiotic after an initial intravenous therapy for stabilization) versus an intravenous therapy were published. We here meta-analyze all available data.

Methods and results

Overall after screening 1848 studies at title and abstract level four studies including a total of 788 patients were included. Heterogeneity was assessed using the I2 statistic. Primary endpoint was all-cause mortality, secondary endpoint endocarditis relapse. Pooled event rates were obtained for each subset of studies and combined in a fixed-effect meta-analysis, and odds ratios were calculated using a fixed-effects model (Mantel-Haenszel).

A total of 765 patients suffered from primary left-sided endocarditis. From right-sided endocarditis suffered 72 patients. All treatment regimes were adjusted to susceptibility testing. Included patients were evaluated clinically and non-critically ill.

Rate of mortality was lower in partial oral versus intravenous strategy (OR 0.34 95% CI 0.17–0.68; p=0.003; I2 30%): In partial oral group, 11 of 379 patients died, whereas in the intravenous group, 33 of 409 patients died. Endocarditis relapse rates were not dissimilar between intravenous versus oral group (OR 0.55 95% CI 0.26–1.20; p=0.13; I2 0%) with, 10 of 459 patients in the partial oral group and 18 of 456 patients in the intravenous group evidencing a relapse.

Conclusion

Partial oral therapy is non-inferior to intravenous therapy with regards to endocarditis relapse in non-critically-ill patients suffering from both left- and right-sided endocarditis. In this meta-analysis, partial oral therapy was associated with lower mortality rates. This finding certainly needs validation in further future randomized trials comparing partial oral versus intravenous antibiotic treatment in non-critically-ill patients. As partial oral therapy allows shorter hospitalization it might be preferable and improve both quality of care and patients quality of life.

5938Mortality risk stratification in patients with severe tricuspid regurgitation - Insights from the Tricuspid Regurgitation REgistry (TRuE)

Background/Introduction

Severe tricuspid regurgitation (TR) is associated with progressive right atrial (RA) and ventricular (RV) dilation, dysfunction and increased mortality. Risk factors impacting the long-term prognosis in patients with severe TR are largely undetermined.

Purpose

Herein, we aimed to identify risk factors associated with long-term mortality in patients with severe TR and implement a novel risk stratification strategy based on an individual five-year mortality prediction score.

Methods

From January 2013 to December 2017, 1238 patients with severe functional TR were enrolled in the TRuE-registry, of which 914 with a complete dataset were included in the present study. Echocardiographic quantification of RV-function and size included measurements of tricuspid annular plane systolic excursion (TAPSE), the end-diastolic basal (RVDbasal) and longitudinal diameters (RVDlong) and the RA-volume index (RAVI). The cohort was randomly divided into a development (n=610) and validation (n=304) sample. A risk stratification model was developed using a multivariable Cox regression.

Results

The variables statistically significant to predict five-year-mortality, included in the final model and used as score parameters were: age, COPD, dialysis, pulmonary artery systolic pressure, RAVI, TAPSE RVDbasal, RVDlong and systolic hepatic vein flow reversal (sHVFR). Progressive enlargement of RV and RA and concomitant sHVFR was associated with higher values of hazard ratios (HR, Figure A). Based on the HR values, a risk score with 3 categories was developed (Figure B): low (0–2), intermediate (3–5), high (6–16). Among the risk groups, Kaplan Meier estimates of all-cause mortality at 5 years were 18%, 52% and 84% respectively (p<0.001; https://thetruerisk.com). The score showed good discrimination, with a concordance index of 0.75. At internal validation, a good agreement between the derivation and validation datasets indicated a good calibration of the survival curves.

Implementation of a long term risk score

Conclusion

The present study demonstrates the prognostic impact of comorbidities and right heart remodeling on long-term mortality in patients with severe TR. The presented risk score provides an easy and accurate estimation of long-term mortality and may thus help to guide therapeutic decision-making in this difficult group of patients.

P5249Comprehensive invasive and non-invasive assessment of coronary artery lesions with and without hemodynamic significance

Background

There is limited knowledge about specific morphological parameters beyond the degree of stenosis to further characterize hemodynamically relevant coronary lesions.

Objective

The goal of this study was to identify certain morphological or molecular characteristics that distinguish hemodynamically significant from non-significant coronary lesions using various invasive and non-invasive measures.

Methods

This clinical study included patients with symptoms suggestive of CAD who underwent native T1-weighted CMR and gadofosveset-enhanced CMR as well as invasive coronary angiography between 2015 and 2016. OCT of the culprit vessel to determine the plaque type was performed in a subset of patients. Functional relevance of all lesions was examined using quantitative flow reserve (QFR-Angio). Hemodynamically significant lesions were defined as lesions with a QFR <0.8. Signal intensity (contrast-to-noise ratios; CNRs) on native T1-weighted CMR and gadofosveset-enhanced CMR was defined as a measure for intraplaque hemorrhage and endothelial permeability respectively.

Results

Overall 13 patients (n=28 coronary segments) were included, whose invasive coronary angiograms projections were eligible for QFR analysis. Segments containing lesions with a QFR <0.8 (n=9) were associated with significantly higher signal enhancement on Gadofosveset-enhanced CMR as compared to segments containing a hemodynamically non-relevant lesions (lesion-QFR>0.8; n=19) (7.0±4.9 vs. 3.0±2.6; p=0.02). No differences in signal enhancement were seen on native T1-weighted CMR (2.1±4.3 vs. 3.3±4.1; p=0.24). 66,7% (4 out of 6) of all vulnerable plaque and 33.3% (2 out of 6) of all non-vulnerable plaque (fibroatheroma) as assessed by OCT were hemodynamically significant lesions.

Conclusion

The findings of this small feasibility study suggest that hemodynamically significant lesions are more advanced and associated with a higher grade of endothelial permeability while the presence of intraplaque hemorrhage may not be associated with hemodynamically relevant coronary lesions.

[Interventional therapy of heart valve diseases: future perspectives]

Transcatheter procedures have been adopted as novel treatment strategy for patients with valvular heart disease, particularly for those who are inoperable or at high risk for surgical valve procedures. Significant technological advances have resulted in an improvement of devices for transcatheter aortic valve replacement (TAVI) with downsizing of crossing profiles, reduction in the rate of paravalvular leakage and conduction abnormalities as well as a lower short- and mid-term mortality and a higher patient acceptance. In the near future, TAVI may potentially develop as first-line treatment for the majority of patients with aortic valve disease. For patients with mitral and pulmonary stenosis, balloon valvuloplasty is effective and well established and should be preferred over valve replacement, last but not least also for economic reasons. For treatment of mitral regurgitation, several transcatheter devices aiming to restore or replace mitral valve function are currently under investigation. This review summarizes the current state of interventional treatment of valvular heart disease along with implications for the future.