GDF-15: a novel biomarker of heart failure predicts short-term and long-term heart-failure rehospitalization and short-term mortality in patients with acute heart failure syndrome

BACKGROUND

Acute heart failure (AHF) is a potentially life-threatening clinical syndrome, usually requiring hospital admission. Growth Differentiation Factor-15 (GDF-15) is a distant member of the transforming growth factor-β. The increased expression of GDF-15 has been observed during heart failure (HF) and is associated with worse outcomes. However, the relationship between GDF-15 and AHF is not well understood with limited evidence among Thai patients.

PURPOSE

Investigate the correlation between biomarker levels (measured upon admission and discharge) and short- and long-term adverse outcomes, encompassing all-cause mortality and heart-failure (HF) rehospitalization (at 30, 90, and 180 days, as well as throughout the entire follow-up duration) in individuals experiencing acute HF.

METHODS

This is a prospective single-center investigation involving patients admitted for AHF. Biomarkers, including GDF-15, high-sensitivity troponin T (hsTnT), and N-terminal pro-B-type natriuretic peptide (NT-proBNP), were assessed upon admission and discharge. Outcomes, including all-cause mortality and HF rehospitalization, were examined. Logarithmic transformations were applied to the biomarker variables for subsequent analysis. Univariate and multivariate analyses of cause-specific hazards were conducted using the Cox proportional hazards regression model, while subdistribution hazards were assessed using the Fine-Gray regression model to evaluate outcomes.

RESULTS

A total of 84 patients were enrolled (mean age of 69 years, 52% females). The GDF-15 level significantly decreased during admission (median at the time of admission 6,346 pg/mL, median at the time of discharge 5,711 pg/mL; p < 0.01). All-cause mortality at 30 days and 180 days were 6.0% and 16.7%, respectively. HF rehospitalization at 30 days and 180 days were 15.5% and 28.6%, respectively. Univariate analysis showed that total orthoedema congestion score (p = 0.02) and admission GDF-15 level (p = 0.01) were associated with 30-day all-cause mortality, whereas hsTnT or NT-proBNP levels did not show significant associations. However, higher levels of NT-proBNP upon admission were associated with all-cause mortality when considering the entire follow-up period (p < 0.01). Both univariate and multivariate analyses demonstrated that lower discharge GDF-15 levels and a greater reduction in GDF-15 levels from admission to discharge were associated with a lower risk of 30-day rehospitalization. Similarly, univariate analysis revealed that a greater reduction in NT-proBNP levels from admission to discharge was associated with lower 30-day rehospitalization rates. At 180 days, a greater reduction in GDF-15 levels remained associated with lower hazards and incidence of rehospitalization.

CONCLUSION

The significant decrease in Growth Differentiation Factor-15 (GDF-15) levels during hospitalization suggests its potential as a dynamic marker reflecting the course of AHF. Importantly, higher GDF-15 levels at admission were associated with an increased risk of 30-day all-cause mortality, highlighting its prognostic value in this patient population. Moreover, lower discharge GDF-15 levels, reductions in GDF-15 from admission to discharge, and decreases in NT-proBNP from admission to discharge were associated with a reduced risk of 30-day rehospitalization.

The decline in kidney function after heart transplantation and its impact on survival

BACKGROUND

Evidence of decline in native renal function after heart transplantation (HTx) in the Asian population is limited. This study determined the incidence and risk factors associated with declining kidney function after HTx and its impact on survival.

METHODS

A retrospective study of consecutive adult heart transplant patients was conducted in a single center between 2010 and 2020. The decline in kidney function was defined as the presence of one of the following criteria, including a ≥ 40% decline in eGFR, absolute value <15 mL/min/1.73 m2 (calculated by the CKD-EPI method), doubling of serum creatinine, or dialysis.

RESULTS

A total of 79 patients (77% male, mean age 44.5 ± 11.53 years, with a mean eGFR at discharge from the heart transplant admission of 87.9 ± 25.48 mL/min/1.73 m2 ) were included. During the median follow-up of 42 months, the rate of decline in eGFR was 3.9 mL/min/1.73 m2 per year, with a cumulative probability of decline in kidney function of 22% at 1 year and 43% at 5 years. The need for dialysis was 2.5% at 1 year and 5% at 5 years. The decline in kidney function within 1 year after discharge (hazard ratio (HR), 22.24; p = .007) and pre-HTx diabetes mellitus (DM) (HR, 8.99; p = .034) were independently associated with the need for dialysis. Post-HTx dialysis predicted all-cause mortality (HR, 4.47; p = .017).

CONCLUSIONS

Approximately 20% of HTx patients developed a decline in kidney function within 1 year after discharge. These individuals and pre-HTx DM patients needed preventive measures to prevent progression to chronic dialysis, which impacted survival. (thaiclinicaltrials.org number, TCTR20230620004).

Role of β-blockers in the cardiovascular disease continuum: a collaborative Delphi survey-based consensus from Asia-Pacific

OBJECTIVE

This Delphi method of consensus was designed to develop scientific statements for β-blockers in the continuum of cardiovascular diseases with a special focus on the role of bisoprolol.

METHODS

Eleven experienced cardiologists from across the Asia-Pacific countries participated in two rounds of the survey. In the first round, experts were asked to rate agreement/disagreement with 35 statements across seven domains regarding the use of β-blockers for treating hypertension, heart failure, coronary artery diseases, co-morbidities, as well as their safety profile, usage pattern, and pharmacokinetic variability. A consensus for a statement could be reached with >70% agreement.

RESULTS

Except for seven statements, all attained consensus in the first round. In the second round that was conducted virtually, the experts re-appraised their ratings for the seven statements along with a critical appraisal of two additional statements that were suggested by experts in the preceding round. At the end of the second round, the final version included 36 statements (34 original statements, two statements suggested by experts, and the omission of one statement that did not attain consensus). The final version of statements in the second round was disseminated among experts for their approval followed by manuscript development.

CONCLUSION

Attainment of consensus for almost all statements reconfirms the clinical benefits of β-blockers, particularly β1-selective blockers for the entire spectrum of cardiovascular diseases.

An unusual cause of high-output heart failure from the iliac arteriovenous fistula after lumbar discectomy: A case report

A minority of patients with heart failure present in a high-output state. We described an uncommon case of high-output heart failure caused by an iliac arteriovenous fistula (IAVF), a rare but serious complication after lumbar discectomy surgery (LDS). A 44-year-old man with no notable medical condition except a history of herniated nucleus pulposus necessitating the L4-L5 LDS 5 years ago presented with clinical signs of progressive high-output heart failure. Physical examination revealed wide pulse pressure with bruit and systolic thrill at the right inguinal region. Computed tomographic angiography confirmed the IAVF from the right common iliac artery to the left common iliac vein. There was a significant shunting to the venous system, causing severe dilatation of the inferior vena cava. Notably, the preoperative lumbar magnetic resonance imaging performed 5 years ago demonstrated that the herniated disc was located at the L4-L5 level, which corresponded to the location of IAVF. The patient successfully underwent endovascular closure by covered stent leading to the gradual resolution of symptoms and hemodynamic parameters. Although vascular complications from the LDS are very uncommon, most patients develop severe symptoms from worsening high-output heart failure. This case highlights the essence of careful history taking, physical examinations, and appropriate investigations in guiding the diagnosis and contemplating the treatment strategy.

Proenkephalin as a Novel Prognostic Marker in Heart Failure Patients: A Systematic Review and Meta-Analysis

Over the last several years, the use of biomarkers in the diagnosis of patients with heart failure (HF) has skyrocketed. Natriuretic peptides are currently the most widely used biomarker in the diagnosis and prognosis of individuals with HF. Proenkephalin (PENK) activates delta-opioid receptors in cardiac tissue, resulting in a decreased myocardial contractility and heart rate. However, the goal of this meta-analysis is to evaluate the association between the PENK level at the time of admission and prognosis in patients with HF, such as all-cause mortality, rehospitalization, and decreasing renal function. High PENK levels have been associated with a worsened prognosis in patients with HF.

Primary isolated right ventricular failure after heart transplantation: prevalence, right ventricular characteristics, and outcomes

To determine the prevalence, right ventricular (RV) characteristics, and outcomes of primary isolated RV failure (PI-RVF) after heart transplant (HTX). PI-RVF was defined as (1) the need for mechanical circulatory support post-transplant, or (2) evidence of RVF post-transplant as measured by right atrial pressure (RAP) > 15 mmHg, cardiac index of < 2.0 L/min/m² or inotrope support for < 72 h, pulmonary capillary wedge pressure < 18 mmHg, and transpulmonary gradient < 15 mmHg with pulmonary systolic pressure < 50 mmHg. PI-RVF can be diagnosed from the first 24-72 h after completion of heart transplantation. A total of 122 consecutive patients who underwent HTX were reviewed. Of these, 11 were excluded because of secondary causes of graft dysfunction (GD). PI-RVF was present in 65 of 111 patients (59%) and 31 (48%) met the criteria for PGD-RV. Severity of patients with PI-RVF included 41(37%) mild, 14 (13%) moderate, and 10 (9%) severe. The median onset of PI-RVF was 14 (0-49) h and RV recovery occurred 5 (3-14) days after HTX. Severe RV failure was a predictor of 30-day mortality (HR 13.2, 95% CI 1.6-124.5%, p < 0.001) and post-transplant dialysis (HR 6.9, 95% CI 2.0-257.4%, p = 0.001). Patients with moderate PI-RVF had a higher rate of 30-day mortality (14% vs. 0%, p = 0.014) and post-operative dialysis (21% vs. 2%, p = 0.016) than those with mild PI-RVF. Among patients with mild and moderate PI-RVF, patients who did not meet the criteria of PGD-RV had worsening BUN/creatinine than those who met the PGD-RV criteria (p < 0.05 for all). PI-RVF was common and can occur after 24 h post-HTX. The median RV recovery time was 5 (2-14) days after HTX. Severe PI-RVF was associated with increased rates of 30-day mortality and post-operative dialysis. Moderate PI-RVF was also associated with post-operative dialysis. A revised definition of PGD-RV may be needed since patients who had adverse outcomes did not meet the criteria of PGD-RV.

Outcomes and predictors of one-year mortality in patients hospitalized with Acute Heart Failure

BACKGROUND

Registries of patients hospitalized with acute heart failure (AHF) provided useful description of characteristics and outcomes. However, a contemporary registry which provides sufficient evidence on outcomes after discharge is needed.

OBJECTIVE

The study aims to identify 1-year clinical outcomes and prognostic predictors of patients hospitalized with AHF.

METHOD

This is a retrospective registry which enrolled patients who were hospitalized due to a principal diagnosis of AHF in a tertiary care center in Thailand between July 2017 and June 2019. Baseline characteristics and hospital courses between the deceased patients and the survivors at 1 year were compared. Prognostic predictors for 1-year mortality were analyzed using Cox regression model.

RESULTS

A total of 759 patients were enrolled (mean age of 68.9 ± 15 years, 49.8% men, mean ejection fraction of 47.1 ± 19.2%, 55.7% heart failure reduced ejection fraction (HFrEF)). Among these, 40.7% had no history of heart failure. The in-hospital and 1-year mortality was 5.8% and 21.5%, respectively. Patients with HFrEF had lower 1-year mortality compared to those without (HR = 0.57, p = 0.04). Age ≥ 70 years, the history of heart failure, prior heart failure hospitalization, cerebrovascular accident (CVA), reactive airway disease, cancer, length of stay > 10 days and NT-proBNP ≥ 10,000 pg/mL were associated with higher 1-year mortality (p < 0.05). The multivariate analysis showed age, CVA and NT-proBNP were independent predictors.

CONCLUSION

Patients with AHF had high mortality after discharge. Patients with poor prognostic predictors, such as elderly, may benefit from continuous care. The study is the most recent registry of patients with AHF in Thailand.

Proenkephalin as a novel prognostic marker in heart failure patients: a meta-analysis

Background

Proenkephalin (PENK), a novel biomarker, sequentially activates delta-opioid receptors in heart tissue causing reduced myocardial contractility, blood pressure, and heart rate. PENK has several prognostic abilities for patients with myocardial infarction, stroke, and impaired renal function. However, its prognostic value in heart failure patients is still inconclusive.

Purpose

To evaluate the association between plasma PENK level at the time of admission and all-cause mortality in patients with heart failure.

Methods

We collected studies from MEDLINE and EMBASE databases until January 2022 to perform a meta-analysis. High level of PENK is defined as plasma PENK level more than 99th percentile of the general population. Separated pooling hazard ratio (HR) for all-cause mortality among high and normal levels of PENK was performed using a random-effect model, generic inverse variance method of DerSimonian and Laird. Sources of heterogeneity including clinical and methodological variations were explored using a meta regression and subsequent subgroup analysis.

Results

A total of six observational studies composed of 6,929 patients with either acute heart failure or chronic heart failure were included in this analysis. There are five studies involving heart failure patients with both reduced ejection fraction and preserved ejection fraction and another one concerning those with only preserved ejection fraction. High level of PENK was found in 70.9% of patients. The high level of PENK compared with normal levels was associated with a higher prevalence of all-cause mortality with pooled HRs of 1.72 (95% CI, 1.62–1.84; I2=84%). The analyzed data were shown in the Figure 1.

Conclusions

This study demonstrates the association between high levels of PENK and all-cause mortality in heart failure patients. These findings suggest that the opioid system might be involved in deteriorating cardiovascular function in heart failure.

Funding Acknowledgement

Type of funding sources: None.

Infective Endocarditis Complicated With Septic Embolic Stroke After Transcatheter Aortic Valve Implantation: A Case Report

Transcatheter aortic valve implantation (TAVI) is a relatively novel procedure developed for aortic stenosis (AS) management in patients with moderate to high surgical risk, especially the elderly with multiple comorbidities. Infective endocarditis following transcatheter aortic valve implantation (post-TAVI-IE) is an uncommon complication that contributes to very high morbidity and mortality. Further complications from post-TAVI-IE include ischemic stroke from septic emboli. Here, we report a case of an 82-year-old man with severe symptomatic AS who underwent TAVI, presenting with fever and alteration of consciousness, which was diagnosed as post-TAVI-IE per Duke criteria complicated by acute hemiparesis from septic emboli stroke. He was treated successfully conservatively using antibiotics. We have reviewed the options of treatment and outcomes for post-TAVI-IE.

Acute Coronary Syndrome After Inactivated SARS-COV-2 Vaccine

CoronaVac is an inactivated coronavirus disease (COVID-19) vaccine that was granted an emergency authorization by the World Health Organization in June 2021. We present the two cases of patients presenting with chest pain, abnormal electrocardiography, and elevated troponin consistent with non-ST-elevation myocardial infarction within 24 hours after receiving the CoronaVac COVID-19 vaccine.

In-hospital outcomes of acute heart failure according to left ventricular ejection fraction: a single-center retrospective cohort study

Funding Acknowledgements

Type of funding sources: None.

Background

Acute heart failure (AHF) is a common cause of hospitalization and associated with high mortality rate. However, the study on outcomes of AHF patients classified by left ventricular ejection fraction (LVEF) in Thailand remains limited.

Purpose

To compared outcomes of AHF patients across LVEF categories.

Methods

We retrospectively analyzed all consecutive AHF patients who admitted during Jan 2018 to Dec 2019 and had been evaluated for LVEF during hospitalization or within the last 12 months prior to admission. Baseline characteristics, management and outcomes were compared between AHF with reduced LVEF (HFrEF; LVEF &lt; 40%), mid-ranged LVEF (HFmrEF; LVEF 40–49%), and preserved LVEF (HFpEF; LVEF≥50%). Primary outcome was in-hospital mortality. Secondary outcomes were length of stay (LOS), 1-year all-cause mortality and 1-year heart failure (HF) readmission rate. Statistical differences with a p-value &lt;0.05 were considered to be significant.

Results

A total of 614 patients were enrolled in the study (mean age 68.6 years, 52% male, 81% history of heart failure). Of those, there were 43%, 12%, and 45% of HFpEF, HFmrEF and HFrEF, respectively. The in-hospital mortality of HFpEF and HFmrEF were not significantly different from HFrEF (6.1% vs 4% vs 10.1%, respectively, p = 0.10). Similarly, there were no differences in LOS (the median LOS was 7 days, IQR 4-12, p= 0.34), 1-year all-cause mortality and 1-year heart failure (HF) readmission rate among these group (p &gt; 0.05).

Conclusion

The outcomes of HFpEF and HFmrEF were as poor as that of HFrEF. These findings highlight the need for effective therapeutic strategies to improve prognosis of HFpEF and HFmrEF patients. Abstract Figure.

GDF-15: a novel biomarker of heart failure predicts 30-day all-cause mortality and 30-day HF rehospitalization in patients with acute heart failure syndrome

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Ratchadapiseksomphotch Fund, Faculty of Medicine, Chulalongkorn University

Background

Growth Differentiation Factor-15 (GDF-15) is a distant member of the transforming growth factor-β (TGF-β) cytokine super family. The increased expression of GDF-15 has been observed during various cardiac diseases include heart failure (HF) and may associated with worse outcomes. However, the relationship is still not well understood, and evidences are not existed in Thai patients.

Purpose

To study association between biomarker (GDF-15, NT-proBNP and hs-Troponin T) at the time of admission and discharge in patient with AFHS and their association with 30-day all-cause mortality and 30-day heart failure rehospitalization

Methods

This is a prospective, single center study of patients admitted for acute HF syndrome regardless of ejection fraction between December 2018 to June 2019. GDF-15 were measured within 24 hours after admission and at the time of discharge. Patient characteristics, orthoedema congestion score, biomarkers, treatment and outcome including 30-day, all-cause mortality and rehospitalization were collected. Logistic regression analysis was used to evaluate the relationship between GDF-15 level and outcomes.

Results

Total of 103 patients were screened and 84 patients were enrolled (mean age of 69 ± 14 years, 52.4% females). Ischemic heart diseases were reported in 38.1% and 23.1% of patients had history of HF with reduced ejection fraction. The orthoedema congestion score at the time of admission and discharge were 2.29 ± 0.1 and 0.38 ± 0.8, respectively (score from 0 to 4, with lower scores are less congestion). The GDF-15 level was significantly decrease during admission (at the time of admission 9118 ± 6010 pg/mL, at time of discharge 7107 ± 4787 pg/mL, mean differences 1528 ± 4469; p = 0.006). The 30-day all-cause mortality was 5.95%. The 30-day rehospitalization occurred in 22 (26.1%) patients (13 HF rehospitalization and 9 non-HF rehospitalization). Univariate analysis showed that the admission GDF-15 level, but not troponin or NT-proBNP, was associated with 30-days all-cause mortality (p = 0.029) and multivariate analysis showed reduction in GDF-15 level from admission to discharge was associated with lower 30-days rehospitalization (p = 0.023).

Conclusion

In this single center study, the rate of mortality and rehospitalization is very high in patient discharge after acute HF hospitalization. the GDF-15 levels were elevated during acute HF and improving by the time of discharge. This novel biomarker may offer additional value in predicting the risk of outcomes in patient with acute HF.

Thyrotoxicosis-Induced Cardiomyopathy Complicated by Refractory Cardiogenic Shock Rescued by Extracorporeal Membrane Oxygenation

Patient: Male 53-year-old

Final Diagnosis: Thyrotoxicosis-induced cardiomyopathy

Symptoms: Dyspnea

Medication:—

Clinical Procedure: —

Specialty: Cardiology • Critical Care Medicine

A Premature Ventricular Contraction Associated With Transient Worsening Pulsus Alternans: A Case Report

Pulsus alternans is a rare condition characterized by alternation between strong and weak pulses during regular heart rhythm. Although pulsus alternans occurs mostly in severe heart failure, it can also be seen in other conditions that alternate ventricular contraction such as rapid tachycardia and extrasystole. Here, we report the case of a patient with peripartum cardiomyopathy who developed worsening pulsus alternans after a premature ventricular contraction.

Acute coronary syndrome with non-obstructive coronary arteries (ACS-NOCA) in patients with hypertrophic cardiomyopathy

Objectives

Our study aimed to determine the prevalence and prognosis of acute coronary syndrome with non-obstructive coronary artery (ACS-NOCA) in patients with hypertrophic cardiomyopathy (HCM).

Methods and results

We enrolled a total of 200 consecutive patients with HCM over a 139-month period from 2002 to 2013. The study found that 28 patients (14% of overall patients, 51% of patients with ACS) had ACS-NOCA, and 18 patients (9% of overall patients, 86% of patients with acute MI) had MINOCA as initial clinical presentations. The highest prevalence of non-obstructive coronary artery disease (NOCA) in patients with HCM was found in acute ST-elevation myocardial infarction (STEMI) (100%), followed by non-STEMI (82%), and unstable angina (29%). Patients with ACS-NOCA had more frequent ventricular tachycardia and lower resting left ventricular (LV) outflow tract gradients than those with no ACS-NOCA (p < 0.05 for all). The ACS-NOCA group had a lower probability of HCM-related death compared with the no ACS-NOCA group and the significant coronary artery disease (CAD) group (p-log-rank = 0.0018).

Conclusions

MINOCA or ACS-NOCA is not an uncommon initial presentation (prevalence rate 9–14%) in patients with HCM. NOCA was highly prevalent (51–86%) in patients with HCM presenting with ACS and had a favorable prognosis. Our findings highlight as a reminder that in an era of rapid reperfusion therapy, ACS in patients with HCM is not only a result of obstructive epicardial CAD, but also stems from the complex cellular mechanisms of myocardial necrosis.

Acute coronary syndrome with non-obstructive coronary arteries (ACS-NOCA in patients with hypertrophic cardiomyopathy

Background

Previous case reports have described myocardial ischemia and/or infarction in hypertrophic cardiomyopathy (HCM); however, prevalence and prognosis are little known. Thus, our study aimed to determine the prevalence and prognosis of acute coronary syndrome with non-obstructive coronary artery (ACS-NOCA) in patients with hypertrophic cardiomyopathy (HCM).

Methods

We prospectively enrolled 200 consecutive HCM patients (mean age 66±16 years, 42% males) from 2002 to 2013 attending a tertiary referral center, King Chulalongkorn Memorial Hospital, Thailand. The median follow-up time was 13 years. ACS-NOCA was diagnosed by a clinical syndrome of acute myocardial ischemia or MI with &lt;50% angiographically luminal stenosis in the major epicardial coronary branch by coronary angiogram.

Results

Of 200 HCM patients, 28 patients (14% of overall patients, 51% of patients with ACS) had ACS-NOCA, and 18 patients (9% of overall patients, 86% of patients with acute MI) had myocardial infarction with nonobstructive coronary artery (MINOCA) as initial clinical presentations. Of the 28 patients, 4 (14%) were STEMI, 14 (50%) were NSTEMI and 10 (36%) were UA. ACS-NOCA group had more frequent ventricular tachycardia and lower resting left ventricular (LV) outflow tract gradients than no ACS-NOCA group (p&lt;0.05). The ACS-NOCA group tended to have a lower rate of HCM-related death compared with the no ACS-NOCA group and the significant coronary artery disease (CAD) group (p-log-rank = 0.0018). As shown in Figure 1.

Conclusions

ACS-NOCA is not an uncommon initial presentation (prevalence rate 9–14%) in patients with HCM. More than half of HCM patients presenting with ACS were found to have NOCA. ACS-NOCA was not associated with an increased mortality, but had a more favorable prognosis.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Circulating growth differentiation factor-15 as a novel biomarker in heart transplant

Aims

This study aimed to examine (i) whether circulating growth differentiation factor‐15 (GDF‐15) is associated with acute cellular cardiac allograft rejection (ACR); (ii) a longitudinal trend of GDF‐15 after heart transplantation; and (iii) the prognostic value of GDF‐15 in predicting a composite outcome of severe primary graft dysfunction (PGD) and 30 day mortality post‐transplant.

Methods and results

Serum samples were collected before heart transplantation and at every endomyocardial biopsy (EMB) post‐heart transplantation in de novo transplant patients. A total of 60 post‐transplant serum samples were matched to the corresponding EMBs. Seven (12%) were considered International Society for Heart Lung Transplantation Grade 1R ACR, and one (2%) was identified as Grade 2R ACR. GDF‐15 levels in patients with ACR were not different from those in the non‐rejection group (6230 vs. 6125 pg/mL, P = 0.27). GDF‐15 concentration gradually decreased from 8757 pg/mL pre‐transplant to 5203 pg/mL at 4 weeks post‐transplant. The composite adverse outcome of PGD and 30 day mortality was significantly associated with increased post‐operative GDF‐15 (odds ratio: 40; 95% confidence interval: 2.01–794.27; P = 0.005) and high inotrope score post‐transplant (odds ratio: 18; 95% confidence interval: 1.22–250.35; P = 0.01).

Conclusions

Circulating GDF‐15 concentration was markedly elevated in patients with end‐stage heart failure and decreased after heart transplantation. GDF‐15 was significantly associated with post‐transplant PGD and mortality. A lack of association between ACR and GDF‐15 did not support routine use of GDF‐15 as a biomarker to detect ACR. However, GDF‐15 may be potentially useful to determine heart transplant recipients at high risk for adverse post‐transplant outcomes. We suggest that GDF‐15 levels in recipient serum can provide risk stratification for severe PGD including death during post‐operative period. This novel biomarker may serve to inform and guide timely interventions against severe PGD and adverse outcomes during the first 4 weeks after transplantation. Further studies to support the utility of GDF‐15 in heart transplantation are required.

The impact of the coronavirus disease and Tele-Heart Failure Clinic on cardiovascular mortality and heart failure hospitalization in ambulatory patients with heart failure

Background

We sought to investigate the impact of the COVID-19 pandemic and the Tele-HF Clinic (Tele-HFC) program on cardiovascular death, heart failure (HF) rehospitalization, and heart transplantation rates in a cohort of ambulatory HF patients during and after the peak of the pandemic.

Methods

Using the HF clinic database, we compared data of patients with HF before, during, and after the peak of the pandemic (January 1 to March 17 [pre-COVID], March 17 to May 31 [peak-COVID], and June 1 to October 1 [post-COVID]). During peak-COVID, all patients were managed by Tele-HFC or hospitalization. After June 1, patients chose either a face-to-face clinic visit or a continuous tele-clinic visit.

Results

Cardiovascular death and medical titration rates were similar in peak-COVID compared with all other periods. HF readmission rates were significantly lower in peak-COVID (8.7% vs. 2.5%, p<0.001) and slightly increased (3.5%) post-COVID. Heart transplant rates were substantially increased in post-COVID (4.5% vs. peak-COVID [0%], p = 0.002). After June 1, 38% of patients continued with the Tele-HFC program. Patients managed by the Tele-HFC program for <6 months were less likely to have HF with reduced ejection fraction (73% vs. 54%, p = 0.005) and stage-D HF (33% vs. 14%, p = 0.001), and more likely to achieve the target neurohormonal blockade dose (p<0.01), compared with the ≥6-month Tele-HFC group.

Conclusions

HF rehospitalization and transplant rates significantly declined during the pandemic in ambulatory care of HF. However, reduction in these rates did not affect subsequent 5-month hospitalization and cardiovascular mortality in the setting of Tele-HFC program and continuum of advanced HF therapies.

Endomyocardial Biopsy and Prevalence of Acute Cellular Rejection in Heart Transplantation

BACKGROUND

Percutaneous endomyocardial biopsy (EMB) remains the criterion standard method for surveillance of allograft rejection after heart transplant (HT). However, data regarding utility of EMBs and prevalence of acute cellular rejection (ACR) in Asian populations are still limited. We aimed to report our experience in the use of EMBs and prevalence of ACR in HT recipients.

METHODS

We retrospectively evaluated all EMBs from consecutive HT recipients between January 2008 and December 2018. EMB pathology results were according to International Society for Heart and Lung Transplantation 2004 revision of biopsy grading. We also divided patients into previous era and current era group (underwent HT before and after 2015) to compare prevalence of ACR and survival outcome.

RESULTS

A total of 832 EMBs from 81 HT recipients were included. Pathologic reports revealed ACR grade 1R 22.8%, 2R 4.2%, and 3R 0.6%. At patient level, at least 1 episode of ACR grade 1R, 2R, and 3R were found in 70.6%, 24.7%, and 3.5% of the patients, respectively. When compared between era, frequency of EMB during the first year after HT in current era was significantly higher (9.74 ± 3.38 vs 4.93 ± 3.29, P < .001), but lower frequency of rejection grade ≥ 2R were found (2.3% vs 8.1%, P < .001). However, 1-year survival was not statistically different (76% in previous era vs 80% in current era, P = .37).

CONCLUSIONS

From our study, prevalence of grade ≥ 2R rejection was approximately 5%, which is comparable with previous studies. Further studies are needed to evaluate proper interval and number of EMBs in HT recipients.

P182 Implantable cardioverter defibrillator in old age patients with cardiomyopathy : a meta-analysis and systematic review

Introduction

Implantable cardioverter defibrillator (AICD) showed benefit for primary prevention of death in cardiomyopathy, but still controversy in elderly.

We performed a systematic review and meta analysis to the benefit of AICD for primary prevention of death in patients age ≥ 65 with cardiomyopathy according to 2017 ACC/AHA guideline for the Management Ventricular Arrhythmias and 2015 ESC guideline for Management of Ventricular Arrythmias.

Method

We comprehensively searched the databases of MEDLINE, EMBASE and SCOPUS from inception to October 2018. Included studies with prospective and retrospective cohort design. Studies those compared all-cause mortality in elderly patients who has been implanted with AICD versus none. Data of each studies were combined with random effects model, subgroup analysis for each types of studies were done. All the results were reported in hazard ration (HR) and 95% confidence intervals.

Result

Nine studies from March 2002 to October 2018 were included in meta-analysis (Five randomized controlled trial and Four cohort studies) involving 20,656  patients. AICD implantation showed benefit in reduction of all-cause mortality in patients older than 65 years.( pooled hazard ratio =  0.72, 95% confidence interval: 0.64 – 0.81, I2 = 56.3%),however pool hazard ratio from subgroup analysis with only randomized controlled trial did not demonstrate effectiveness of this intervention. (pooled hazard ratio 0.78, 95% confidence interval: 0.61 – 1, I2= 49.5%)

Conclusion

 AICD could benefit in reduction of all-cause mortality in aged patients. However randomized controlled trial with larger population in this group is needed.

Clinical characteristics of studies Author Year Study type Total population Age of participant (year) Type of cardiomyopathy NYHA FC Median follow up ( months) Outcome definition Quality assessment Bias for RCT Mezu 2011 Prospective cohort 485 ≥ 80 Ischemic and non-ischemic cardiomyopathy II - III 12 All-cause mortality Newcastle - ottawa : Fair Kober (DANISH) 2016 Randomize controlled trial 393 ≥ 68 Non ischemic cardiomyopathy II - III 67.6 All-cause mortality Performance bias Chan 2009 Prospective cohort 852 ≥ 65 Ischemic and non-ischemic cardiomyopathy N/A 34 ± 16 All-cause mortality Newcastle - ottawa : Fair Kadish (DEFINITE) 2004 Randomize controlled trial 157 ≥ 65 Non ischemic cardiomyopathy I - III 29 ± 14.4 All-cause mortality Performance bias Bristow (COMPANION) 2004 Randomize controlled trial 853 ≥ 65 Ischemic and non-ischemic cardiomyopathy III - IV 16.5 All-cause mortality Performance bias Moss ( MADIT II) 2002 Randomize controlled trial 436 ≥ 70 Ischemic cardiomyopathy I - III 20 All-cause mortality Performance bias Groeneveld 2008 Prospective cohort 14250 ≥ 65 Ischemic and non-ischemic cardiomyopathy I - IV 24 All-cause mortality Newcastle - ottawa : Fair Bardy ( SCD HEFT) 2005 Randomize controlled trial 578 ≥ 65 Ischemic and non-ischemic cardiomyopathy II - III 45.5 All-cause mortality Performance bias Pokorney 2015 Retrospective cohort 852 ≥ 65 Ischemic and non-ischemic cardiomyopathy IV 36 All-cause mortality Newcastle - ottawa : Fair

Abstract P182 Figure. Forest plot of elderly with AICD vs none

The role of N-terminal pro-B-type natriuretic peptide in prognostic evaluation of heart failure

Heart failure (HF) is a growing challenge in the Asia Pacific region. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a well-established tool for diagnosis of HF; however, it is relatively underutilized in predicting adverse outcomes in HF. Multiple studies have demonstrated the prognostic role of NT-proBNP in HF. A single value of NT-proBNP >5000 pg/mL predicts a worse outcome in hospitalized patients with HF with reduced ejection fraction (HFrEF). In stable outpatients with HFrEF, NT-proBNP > 1000 pg/mL predicts a poorer prognosis. NT-proBNP provides the same prognostic information in patients with HF with preserved ejection fraction (HFpEF) as in those with HFrEF. An expert panel composed of cardiologists mainly from Asia Pacific region was convened to discuss the utility of NT-proBNP in HF prognostication. This article summarizes available scientific evidence and consensus recommendations from the meeting.

Real-World Effectiveness of High- Versus Moderate-Intensity Statin Therapy in Thai Patients With Acute Coronary Syndrome and Who Had Undergone Primary Percutaneous Coronary Intervention

Although high-intensity statins are recommended for atherosclerotic cardiovascular disease, evidence has shown that Asians may need lower dose statins to achieve similar effect when compared to Caucasians. Moreover, awareness of adverse effects leads physicians to initiate moderate-intensity statins. Comparative of high versus moderate-intensive statins on LDL-C among patients who had undergone primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) are less established in Thailand. We conducted a retrospective cohort study to identify pattern of statins prescribing and explored the effectiveness on lipid profiles, including LDL-C goal achievement (<70 mg/dL) in STEMI patients underwent PPCI. A total of 983 patients with STEMI who had undergone PPCI were identified during 2005-2015. At 3-month follow-up, 31.9% patients were investigated for their lipid profile. There was 26.11% of patients who received high-intensity statins. When compared to baseline, we found more LDL-C reduction (38.22% ± 26.75% vs 22.36% ± 35.05%, P < .01) in the high-intensity group. Eighty-one patients achieved the target LDL-C, the high-intensity group were able to achieve the LDL-C goal than moderate-intensity group, but did not reach statistical significance (24.1% vs 30.5%, P = .26). This study confirmed that high-intensity statins have superior for LDL-C reduction and tend to achieve LDL-C goal more than moderate-intensity statins.

Cardiac MRI-Proven Myocarditis Mimicking ST-Elevation Myocardial Infarction after a Cobra Bite

Cardiac complications following snake envenomation occur infrequently. Myocarditis, as a consequence of the toxic effect of the snake venom, is rare, and only a few cases have been reported. We present a case of an 84-year-old man who was envenomed by a cobra. In addition to respiratory failure due to neurotoxicity of the venom, cardiac abnormalities including elevated cardiac markers and abnormal electrocardiogram were found. The findings on cardiac magnetic resonance imaging confirmed the diagnosis of acute myocarditis. The patient spontaneously recovered without any momentous events. To our knowledge, this is the first reported case of myocarditis associated with cobra envenomation. Physicians should be familiar with potential life-threatening cardiac effects of these toxins.

Low-dose basiliximab induction therapy in heart transplantation

We prospectively studied efficacy and safety outcomes of two 10-mg doses of intravenous basiliximab on day 0 and day 4 for induction therapy in 17 consecutive de novo heart transplant recipients. By the 2-week assessment post-transplant, there were no deaths, graft failures, or acute cellular rejections (ACRs) ISHLT grade ≥ 2R. By the 1-year assessment post-transplant, there were 1 (6%) infectious death, no graft failures, 2 (12%) grade 2R ACRs, 6 (35%) asymptomatic cytomegalovirus (CMV) infections, and 4 (25%) treated infections. Our study was the first to show that low-dose basiliximab induction in heart transplant resulted in favorable efficacy and safety outcomes. Additionally, calcineurin inhibitor (CNI) initiation in a low-risk population could be safely delayed using the strategy of modified low-dose postoperative basiliximab. This strategy also appears to allow subsequent early corticosteroid wean, although with the concomitant maintenance of higher CNI levels and higher dosing of mycophenolate.

Heart Transplant in Asia

The prevalence of heart failure has increased in Asia. A significant proportion of patients with heart failure and left ventricular dysfunction end up with advanced heart failure or end-stage heart disease. These patients may be placed on the waiting list for heart transplant. There are more than 10 countries in Asia that have an active heart transplant program. The number of heart transplants performed is limited despite an increase in the number of patients with end-stage heart failure mainly because of donor shortage, which may be related to religious belief and inefficient allocation policy.

Prevention of ventricular fibrillation episodes in Brugada syndrome by catheter ablation over the anterior right ventricular outflow tract epicardium

BACKGROUND

The underlying electrophysiological mechanism that causes an abnormal ECG pattern and ventricular tachycardia/ventricular fibrillation (Vt/VF) in patients with the Brugada syndrome (BrS) remains unelucidated. However, several studies have indicated that the right ventricular outflow tract (RVOT) is likely to be the site of electrophysiological substrate. We hypothesized that in patients with BrS who have frequent recurrent VF episodes, the substrate site is the RVOT, either over the epicardium or endocardium; abnormal electrograms would be identified at this location, which would serve as the target site for catheter ablation.

METHODS AND RESULTS

We studied 9 symptomatic patients with the BrS (all men; median age 38 years) who had recurrent VF episodes (median 4 episodes) per month, necessitating implantable cardioverter defibrillator discharge. Electroanatomic mapping of the right ventricle, both endocardially and epicardially, and epicardial mapping of the left ventricle were performed in all patients during sinus rhythm. All patients had typical type 1 Brugada ECG pattern and inducible Vt/VF; they were found to have unique abnormal low voltage (0.94±0.79 mV), prolonged duration (132±48 ms), and fractionated late potentials (96±47 ms beyond QRS complex) clustering exclusively in the anterior aspect of the RVOT epicardium. Ablation at these sites rendered Vt/VF noninducible (7 of 9 patients [78%]; 95% confidence interval, 0.40 to 0.97, P=0.015) and normalization of the Brugada ECG pattern in 89% (95% confidence interval, 0.52 to 0.99; P=0.008). Long-term outcomes (20±6 months) were excellent, with no recurrent Vt/VF in all patients off medication (except 1 patient on amiodarone).

CONCLUSIONS

The underlying electrophysiological mechanism in patients with BrS is delayed depolarization over the anterior aspect of the RVOT epicardium. Catheter ablation over this abnormal area results in normalization of the Brugada ECG pattern and prevents Vt/VF, both during electrophysiological studies as well as spontaneous recurrent Vt/VF episodes in patients with BrS.

Prevention of ventricular fibrillation episodes in Brugada syndrome by catheter ablation over the anterior right ventricular outflow tract epicardium

BACKGROUND

The underlying electrophysiological mechanism that causes an abnormal ECG pattern and ventricular tachycardia/ventricular fibrillation (Vt/VF) in patients with the Brugada syndrome (BrS) remains unelucidated. However, several studies have indicated that the right ventricular outflow tract (RVOT) is likely to be the site of electrophysiological substrate. We hypothesized that in patients with BrS who have frequent recurrent VF episodes, the substrate site is the RVOT, either over the epicardium or endocardium; abnormal electrograms would be identified at this location, which would serve as the target site for catheter ablation.

METHODS AND RESULTS

We studied 9 symptomatic patients with the BrS (all men; median age 38 years) who had recurrent VF episodes (median 4 episodes) per month, necessitating implantable cardioverter defibrillator discharge. Electroanatomic mapping of the right ventricle, both endocardially and epicardially, and epicardial mapping of the left ventricle were performed in all patients during sinus rhythm. All patients had typical type 1 Brugada ECG pattern and inducible Vt/VF; they were found to have unique abnormal low voltage (0.94±0.79 mV), prolonged duration (132±48 ms), and fractionated late potentials (96±47 ms beyond QRS complex) clustering exclusively in the anterior aspect of the RVOT epicardium. Ablation at these sites rendered Vt/VF noninducible (7 of 9 patients [78%]; 95% confidence interval, 0.40 to 0.97, P=0.015) and normalization of the Brugada ECG pattern in 89% (95% confidence interval, 0.52 to 0.99; P=0.008). Long-term outcomes (20±6 months) were excellent, with no recurrent Vt/VF in all patients off medication (except 1 patient on amiodarone).

CONCLUSIONS

The underlying electrophysiological mechanism in patients with BrS is delayed depolarization over the anterior aspect of the RVOT epicardium. Catheter ablation over this abnormal area results in normalization of the Brugada ECG pattern and prevents Vt/VF, both during electrophysiological studies as well as spontaneous recurrent Vt/VF episodes in patients with BrS.

Anomalous origin of right coronary artery from pulmonary artery and severe mitral regurgitation due to myxomatous mitral valve disease: a case report and literature review

Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is an uncommon congenital coronary artery anomaly. In contrast to anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), most of the patients with ARCAPA remain asymptomatic. However, few cases of angina, heart failure and sudden cardiac death depicting the malignant nature of the disease are described in the literature. We report an unusual case of ARCAPA with severe mitral valve regurgitation and pulmonary hypertension. Echocardiography and angiography were utilized for the diagnosis. Surgical correction was provided to our patient and should be considered for all patients with this potentially fatal disease.