The Heart Failure Optimization Study (HF-OPT): rationale and design

BACKGROUND

According to the current guidelines, implantable cardioverter-defibrillators (ICD) for primary prevention in patients with heart failure and reduced ejection fraction (HFrEF) should not be considered until optimal guideline-directed medical therapy (GDMT) has been achieved for a minimum of 3 months. Optimization of GDMT often needs time beyond 3 months after diagnosis. The aim of the Heart Failure Optimization Study (HF-OPT) is to evaluate the recovery of left ventricular function beyond 3 months after diagnosis of newly diagnosed HFrEF.

METHODS

The HF-OPT multicenter study is comprised of two non-randomized phases (registry and study). During the first 90 days a wearable cardioverter-defibrillator (WCD) is prescribed and patients are enrolled in an observational pre-study registry. Registry subjects meeting inclusion criteria for the study portion at day 90 have ongoing left ventricular ejection fraction (LVEF) reassessment at 90, 180 and 360 days after the index hospital discharge, regardless of continued WCD use. Approximately 600 subjects will be enrolled in the study portion. Of those, one-third are anticipated to start the study phase at day 90 with reduced LVEF. The primary objective of this study is to observe the rate of recovery of LVEF > 35% between 90 and 180 days, while key secondary endpoints include mortality and WCD recorded arrhythmias and shocks.

DISCUSSION

The HF-OPT study will provide important information on the rate of additional recovery of LVEF > 35%, between 90 and 180 days, in newly diagnosed HF with reduced LVEF patients being titrated with GDMT. The results of the study may impact indications for primary prophylactic ICD implantation.

Automated production of specific T cells for treatment of refractory viral infections after allogeneic stem cell transplantation

Therapy resistant viral reactivations significantly contribute to mortality after hematopoietic stem cell transplantation. Adoptive cellular therapy with virus-specific T cells has shown efficacy in various single center trials. However, scalability of this therapy is hampered by laborious production methods. In this study we describe the in-house production of virus-specific T cells (VST) in a closed system (CliniMACS Prodigy® system by Miltenyi Biotec). In addition, we report the efficacy in 26 patients with viral disease post HSCT in a retrospective analysis (ADV n=7, CMV n=8, EBV n=4, multi-viral n=7). Production of VST was successful in 100% of cases. Safety profile of VST therapy was favorable (n=2 adverse event grade 3, n=1 grade 4; all three were reversible). A response was seen in 20 of 26 patients (77%). Responding patients had a significantly better OS than patients without response (p.

Pacing electrodes to ablate, not to pace: what settings to use to create lesions even deep in the septum

Funding Acknowledgements

Type of funding sources: None.

Background

Intramural septal ventricular arrhythmia remains challenging, requiring emergent technologies and experimental approaches. Although conduction system pacing (CSP) has allowed us to reach deep in the septum, ablation though pacing electrodes has not been examined yet.

Purpose

To evaluate lesion creation by radiofrequency ablation (RFA) through pacing electrodes.

Methods

A custom ex vivo swine model in a saline bath with an indifferent electrode was used to apply RFA with an 8 mm non-irrigated catheter (SJM, MN, USA) on the proximal end of pacing (CapSureFix 5086) or CSP-electrodes (SelectSecure 3830, Medtronic, MN, USA), screwed in perpendicularly to the slab. A generator (Ampere, SJM, MN, USA) applied RFA at varying settings (1-10 W, 1-20 sec). Lesion depth (D), width (W) and volume (V=3,14*W2*D/4) were assessed and analyzed (SPSS 23).

Results

A total of 80 lesions were used for analysis. Median RFA with 3 W over 6 sec resulted in an impedance drop from 200 to 140 Ω and a lesion of 2x3 mm or 9.4 mm3 (Figure 1). Higher energy settings caused impedance rise with abort (n=3, 4%) or charring (n=3, 4%). Compared to conventional electrodes, lesions with CSP-electrodes had similar volume (9.3±7 vs. 10.8±9 mm3, p=0.45) and width (2±0.8 vs. 2±0.7, p=0.58), but more depth (2.6±0.5 vs. 3±0.6, p=0.0.01). Regression analysis showed final-impedance (FI), power and duration (WS=W*Sec) as independent predictors of lesion volume (V=4.7WS-4.1WS2+4.5FI-4, p<0.001).

Conclusions

Effective ablation through pacing electrodes is possible, but lesion size is limited and low-power settings are necessary. Using CSP-electrodes for effective intramural lesions is possibly a new tool for septal arrhythmias. Further in vivo studies are warranted and bailout use should be considered.

Prevalence and clinical impact of major incidental findings detected on routine cardiovascular resonance imaging prior to catheter ablation of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Preprocedural contrast-enhanced cardiovascular magnetic resonance (CMR) or computed tomography (CT) imaging of the left atrium (LA) and pulmonary veins (PVs) is usually employed to facilitate catheter mapping and ablation of atrial fibrillation (AF). Incidental findings (IFs) are common on cardiac imaging prior to AF catheter ablation (AFCA). However, previous studies were of small size and have mainly focused on radiological extracardiac IFs detected on preprocedural CT scan.

Purpose

To assess the prevalence of major cardiac and extracardiac IFs on routine preprocedural CMR in a large cohort of consecutive patients scheduled for first-time AFCA, and to report its impact on clinical decision-making and management.

Methods

All consecutive patients who underwent routine preprocedural CMR prior to first-time AFCA between April 2015 and March 2019 were considered for analysis. Main exclusion criteria were referral for repeat AFCA; prior cardiac CT or CMR imaging; and general contraindication to CMR or AFCA. All CMR examinations consisted of survey images with full thoracic coverage, cardiac cine and late-gadolinium enhancement imaging, and three-dimensional contrast-enhanced CMR angiography of the LA/PVs. An IF was defined as major when any newly detected finding either resulted in cancellation of the AFCA procedure or intentional deviation from the standard AFCA protocol. In patients with accessory or anomalous PVs the ablation strategy was individually tailored aiming at isolation of all PVs.

Results

Two thousand consecutive patients (62±10 years; 59% male) with paroxysmal (48%) or persistent (52%) AF were included. Among the entire study cohort 172 patients (8.6%) had a total of 184 cardiac (75%) and extracardiac (25%) major IFs (Fig. A+B). Preprocedural detection of a major IF resulted in cancellation of the scheduled AFCA procedure in 88 patients (4.4%). Forty-two patients (2.1%) have thereupon never been ablated, 46 patients (2.3%) underwent postponed AFCA after a median time from CMR imaging of 83 (32-213) days. The remaining 84 patients with major IF (4.2%) underwent an individualized approach to AFCA (Fig. A). The most common major IFs were accessory or anomalous PVs in 76 (3.8%), extracardiac abnormalities suspicious of malignancy in 29 (1.5%), and positive stress perfusion imaging in 19 (1.0% overall; 7.2% of 261 tested) patients. In 19 patients (1.0%) preprocedural CMR detected a previously unknown intracardiac thrombus or structural cardiac disease.

Conclusion

Unexpected major IFs on routine preprocedural CMR affected clinical decision-making and therapeutic management in 8.6% of patients scheduled for first-time AFCA at our institution. Whether preprocedural CMR imaging may improve safety and outcome of AFCA needs to be addressed in future research.

Closed loop stimulation in heart failure patients with severe chronotropic incompetence: responder versus non-responders

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Biotronik SE & Co. KG Woermannkehre 1 12359 Berlin

Background

The prevalence of chronotropic incompetence (CI) in heart failure (HF) population is high and negatively impacts prognosis. Rate-adaptive pacing (RAP) is an important treatment option for CI. However, only a proportion of HF patients treated with cardiac resynchronisation therapy (CRT) devices benefit from accelerometer-based RAP in terms of exercise tolerance, functional capacity, and quality of life (QoL). Further research is needed to identify patient characteristics predicting positive response to RAP, and to evaluate performance of alternative sensors such as closed loop stimulation (CLS) driven by cardiac impedance measurements. An optimal outcome measure is represented by ventilatory efficiency (VE) slope during cardio-pulmonary exercise test (CPX) because of superior prognostic value.

Purpose

The purpose of the BIO|Create pilot study was to assess the benefit of CLS in CRT patients with CI. In this predefined subanalysis, we identify predictors of positive response to CLS (reduction of VE slope by ≥5%) and compare study outcomes in responders vs non-responders.

Methods

The study enrolled CRT patients with NYHA class II or III and severe CI (<75% of age-predicted maximum heart rate [HR] or <50% of HR reserve utilised at end-exercise). Patients were randomised to DDD-CLS mode or to DDD pacing at 40 beats/min for 1 month, followed by crossover for another month. At 1- and 2-month follow-ups, exercise tolerance was assessed by treadmill CPX, functional capacity by 6-min walk test, and QoL by the EQ-5D-5L and Minnesota Living with HF (MLHFQ) questionnaires.

Results

Among 17 patients with full follow-up datasets, 8 (47%) were responders to CLS. Compared to non-responders, responders had larger left ventricular (LV) ejection fraction at baseline (46 ± 3 vs 36 ± 9 %; p = 0.0070), smaller end-diastolic (121 ± 34 vs 181 ± 41 ml; p = 0.0085) and end-systolic (65 ± 23 vs 114 ± 39 ml; p = 0.0076) LV volumes, and were predominantly in NYHA class II (p = 0.0498). For study outcomes, the mean difference between DDD-CLS and DDD-40 modes in responders vs non-responders was - 6.1 (-16.4%) vs +2.7 (+6.8%) for VE slope (both p < 0.05), +0.5 vs -0.2 ml/min (O2 uptake efficiency slope), +1.3 vs -0.3 ml/kg/min (peak O2 uptake), +1.4 vs -0.75 mmHg (end-exercise end-tidal CO2), 16 vs 7 m (6-min walk distance), 0.08 vs 0.06 (EQ-5D-5L index), 1.9 vs 0 (EQ-5D-5L scale), and -2.5 vs +1.75 (MLHFQ).

Conclusions

For the first time, predictors for positive outcome of RAP in CRT patients have been identified. Patients with less advanced HF were responders to RAP driven by CLS principle. In addition, a consistent increase in exercise and functional capacity and QoL in these patients could be achieved. In contrast, patients with advanced HF experienced worse exercise capacity and QoL during RAP, suggesting caution if RAP is desirable due to CI. Further clinical research is needed to evaluate if positive response to RAP can improve hard clinical outcomes.

Correction to: Allogeneic hematopoietic stem cell transplantation in two brothers with DNA ligase IV deficiency: a case report and review of the literature

After publication of the original article (1), it was brought to our attention that references 24 and 31 are inappropriately cited in the article.

Allogeneic hematopoietic stem cell transplantation in two brothers with DNA ligase IV deficiency: a case report and review of the literature

BACKGROUND

DNA ligase IV deficiency is a rare autosomal recessive disorder caused by hypomorphic mutations in the DNA ligase IV (LIG4) gene. DNA ligase IV is an essential protein for the development of a healthy immune system as well as for the protection of genomic integrity. Apart from typical stigmata, patients with DNA ligase IV deficiency are characterized by progressive bone marrow failure and a predisposition to malignancy. To our knowledge this reported case is the first description of two brothers with ligase IV deficiency who are treated with different hematopoietic stem cell transplantation (HSCT) regimens resulting in vastly divergent outcomes.

CASE PRESENTATION

The cases of two brothers suffering from severe recurrent infections and growth retardation are described. The laboratory findings showed pancytopenia with significant lymphopenia. The two boys were diagnosed with DNA ligase IV deficiency, associated with severe combined immunodeficiency (SCID). Both patients received HSCT from two different matched unrelated donors (MUD) at the age of 33 and 18 months. The older brother succumbed post-transplant due to fatal side-effects 143 days after allogeneic HSCT. The younger brother - conditioned with a different regimen - received a T cell depleted graft 4 months later. No severe side-effects occurred, neither post-transplant nor in the following years. Ten years after HSCT the patient is well off, living a normal life and attending a regular high school. His immune system is fully reconstituted, resulting in a maximum of T cell receptor (TCR) diversity, which is a prerequisite for immune competence. However, he still suffers from microcephaly, dwarfism and dystrophy.

CONCLUSIONS

This case report gives an example of a successful HSCT as a treatment option in a genetic disorder such as ligase IV deficiency, using a rather mild conditioning regimen. Further studies are required to determine the viability and efficacy of this treatment option.

[Atrioventricular block and left ventricular wall mobility disorder in a 44-year-old female patient : A case report of a rarity with pitfalls]

Eosinophilic myocarditis is a rare condition with good treatment options, which can be difficult to diagnose. The clinical presentation can vary from asymptomatic to life-threatening forms. This article describes the case of a 44-year-old woman who suffered from vertigo, chest pain and dyspnea. The woman presented with an intermittent atrioventricular (AV) block II Mobitz type II° and mild impairment of left ventricular ejection fraction. Hypereosinophilia in the peripheral blood, cardiac magnetic resonance imaging (MRI) and endomyocardial biopsy led to the diagnosis of eosinophilic myocarditis, most likely as a result of an allergic reaction to Aspergillus fumigatus. A general treatment recommendation cannot be made due to the lack of evidence-based guidelines; however, recent scientific studies confirmed timely, high-dose steroid administration over several months to be the mainstay of treatment of eosinophilic myocarditis. The following article may be helpful in the early diagnosis and treatment of this underdiagnosed and insidious disease.

Chiral Extrapolations of the ρ(770) Meson in Nf = 2 + 1 Lattice QCD Simulations

Several lattice QCD simulations of meson-meson scattering in p-wave and Isospin = 1 in Nf = 2 + 1 flavours have been carried out recently. Unitarized Chiral Perturbation Theory is used to perform extrapolations to the physical point. In contrast to previous findings on the analyses of Nf = 2 lattice data, where most of the data seems to be in agreement, some discrepancies are detected in the Nf = 2 + 1 lattice data analyses, which could be due to different masses of the strange quark, meson decay constants, initial constraints in the simulation, or other lattice artifacts. In addition, the low-energy constants are compared to the ones from a recent analysis of Nf = 2 lattice data.

Mesenchymal stromal cells for treatment of steroid-refractory GvHD: a review of the literature and two pediatric cases

Severe acute graft versus host disease (GvHD) is a life-threatening complication after allogeneic hematopoietic stem cell transplantation. Human mesenchymal stromal cells (MSCs) play an important role in endogenous tissue repair and possess strong immune-modulatory properties making them a promising tool for the treatment of steroid-refractory GvHD. To date, a few reports exist on the use of MSCs in treatment of GvHD in children indicating that children tend to respond better than adults, albeit with heterogeneous results.

We here present a review of the literature and the clinical course of two instructive pediatric patients with acute steroid-refractory GvHD after haploidentical stem cell transplantation, which exemplify the beneficial effects of third-party transplanted MSCs in treatment of acute steroid-refractory GvHD. Moreover, we provide a meta-analysis of clinical studies addressing the outcome of patients with steroid-refractory GvHD and treatment with MSCs in adults and in children (n = 183; 122 adults, 61 children). Our meta-analysis demonstrates that the overall response-rate is high (73.8%) and confirms, for the first time, that children indeed respond better to treatment of GvHD with MSCs than adults (complete response 57.4% vs. 45.1%, respectively).

These data emphasize the significance of this therapeutic approach especially in children and indicate that future prospective studies are needed to assess the reasons for the observed differential response-rates in pediatric and adult patients.

The organotelluride catalyst LAB027 prevents colon cancer growth in the mice

Organotellurides are newly described redox-catalyst molecules with original pro-oxidative properties. We have investigated the in vitro and in vivo antitumoral effects of the organotelluride catalyst LAB027 in a mouse model of colon cancer and determined its profile of toxicity in vivo. LAB027 induced an overproduction of H(2)O(2) by both human HT29 and murine CT26 colon cancer cell lines in vitro. This oxidative stress was associated with a decrease in proliferation and survival rates of the two cell lines. LAB027 triggered a caspase-independent, ROS-mediated cell death by necrosis associated with mitochondrial damages and autophagy. LAB027 also synergized with the cytotoxic drug oxaliplatin to augment its cytostatic and cytotoxic effects on colon cancer cell lines but not on normal fibroblasts. The opposite effects of LAB027 on tumor and on non-transformed cells were linked to differences in the modulation of reduced glutathione metabolism between the two types of cells. In mice grafted with CT26 tumor cells, LAB027 alone decreased tumor growth compared with untreated mice, and synergized with oxaliplatin to further decrease tumor development compared with mice treated with oxaliplatin alone. LAB027 an organotelluride catalyst compound synergized with oxaliplatin to prevent both in vitro and in vivo colon cancer cell proliferation while decreasing the in vivo toxicity of oxaliplatin. No in vivo adverse effect of LAB027 was observed in this model.

Apolipoprotein E polymorphism and response to electroconvulsive therapy

The aim of this study was to determine whether the apolipoprotein E genotype differs in patients who respond or do not respond to electroconvulsive therapy (ECT). Inpatients, out-patients, and day-treatment patients who had received ECT comprised the study group. The 34 patients included met DSM-III-R criteria for affective or schizoaffective disorder. Responder or nonresponder status was assessed using the Clinical Global Inventory and Montgomery Asberg Depression Rating Scale. Blood samples were taken and coded when the patients entered the study. DNA extraction and apolipoprotein E genotyping were performed with no knowledge of the clinical classification of the patients. A significant difference in E4 genotype distribution was found between ECT responders and nonresponders (p < 0.02); psychosis was significantly less frequent in this group (p = 0.046), and there was a trend toward older onset of depression among these persons (p = 0.10). Only the E3/3 genotype was found in the patients with early-onset depression. The E4 genotype appears to define a subgroup of patients with late-onset depression who respond to ECT. If confirmed in prospective studies, this may provide a useful marker in the treatment decision-making process for late-onset depression.

Planned reoperation for generalized intraabdominal infection

Intraabdominal infection remains a common cause of death in surgical patients. Progress in this area with improved survival rates is difficult to demonstrate despite the use of antibiotics, nutritional support, and aggressive maintenance of function of failed organs. This report documents our experience with planned reoperation to cleanse the abdominal cavity in 77 patients with generalized intraabdominal infection. In 34 of the patients, reoperation to cleanse the abdominal cavity was performed every 24 to 48 hours after the first operation until the abdominal cavity was judged to be clean. Forty-three patients underwent a single operation for intraabdominal contamination and were treated expectantly, only undergoing reoperation for signs of recurrent infection. In all patients, the hole in the intestinal tract was controlled primarily by stoma formation at the initial operation to treat intraabdominal infection. Patients with appendiceal disease were excluded. The severity of illness in the two patient groups was compared by a modified acute physiologic score. Planned reoperation was not associated with improvement in survival when compared with patients managed expectantly. Patients managed by planned reoperation had significantly more laparotomies than patients managed expectantly without improving survival. The results of this study disclosed that empiric reoperation to clean the abdominal cavity in patients with generalized intraabdominal infection produced no improvement in survival when compared with observation and reoperation when indicated.