Impact of right ventricular reserve on exercise capacity and quality of life in patients with left ventricular assist device

Background

Right heart failure following left ventricular assist device (LVAD) implantation is a major complication which significantly impairs functional capacity and quality of life (QoL). Right ventricular (RV) reserve function may limit exercise capacity and QoL in LVAD patients; however, most patients show normal RV haemodynamics at rest.

Purpose

The aim of this study was to investigate whether RV reserve assessed by the changes of RV function during exercise is correlated with exercise capacity and QoL in patients with LVAD.

Methods

We prospectively examined 20 consecutive LVAD patients who were admitted to our university hospital between June 2020 and November 2021 after excluding those who were unable to perform exercise (n=8). All patients underwent invasive exercise right heart catheterisation with simultaneous echocardiography in the supine position. RV stroke work index (RVSWI) was calculated as 0.0136 × stroke volume index × (mean pulmonary artery pressure [mPAP] − right atrial pressure [RAP]) at rest and during exercise. Exercise capacity and QoL were assessed by 6-minute walk distance (6MWD) and peak oxygen consumption (VO2) in cardiopulmonary exercise testing, and the EuroQol visual analogue scale (EQ-VAS), respectively. The patients were divided into two groups according to the median ΔRVSWI (RVSWI change from rest to peak exercise) of 1.45 (interquartile range [IQR] −0.31 to 8.25) g/m2.

Results

Patients were predominantly male (75%) and the median age was 47 (IQR 38–60) years. Patients with lower ΔRVSWI had significantly higher change on RAP (P=0.019), but significantly lower change on mPAP (P<0.001) compared to those with higher ΔRVSWI. There were no significant differences in age, gender, primary aetiology of heart failure, type of LVAD devices, or echocardiographic parameters including tricuspid annular plane systolic excursion, and RVSWI at rest between the groups. ΔRVSWI during exercise were positively correlated with 6MWD (R=0.69, P<0.01) and peak VO2 (R=0.66, P<0.01) (Figure A). In addition, ΔRVSWI during exercise were positively correlated with the EQ-VAS (R=0.48, P=0.031). On the other hand, there was no significant correlation between RVSWI at rest and 6MWD (R=−0.11, P=0.63) and peak VO2 (R=0.13, P=0.95), and the EQ-VAS (R=0.11, P=0.61). During a median follow-up period of 312 (IQR 176–369) days, adverse events occurred in 3 patients (15%), including 1 death and 2 hospitalisations for major bleeding and right heart failure. Kaplan-Meier analysis revealed that the adverse events more frequently occurred in patients with lower ΔRVSWI compared to those with higher ΔRVSWI (Figure B).

Conclusions

ΔRVSWI was positively correlated with 6MWD, peak VO2 and EQ-VAS irrespective of RV function at rest. Our findings suggest that the assessment of RV reserve function using ΔRVSWI would be useful for risk stratification in patients with LVAD.

Funding Acknowledgement

Type of funding sources: None.

Validation of the HFA-PEFF and the H2FPEF scores for the diagnosis of heart failure with preserved ejection fraction in Japanese patients:a report from the Japanese multicentre registry

Background

The standard diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF) is based on the following: 1) symptoms of HF, 2) preserved left ventricular (LV) ejection fraction (LVEF, >50%), and 3) presence of LV diastolic dysfunction confirmed by echocardiography or cardiac catheterisation. However, there are limits to the diagnostic accuracy of individual parameters, and what cut-off values should be applied and how they should be combined remain unclear. Diagnostic algorithms for HFpEF such as the HFA-PEFF algorithm and the H2FPEF score have been proposed; however, previous validation studies were conducted in stable chronic HF and did not include an invasive haemodynamic assessment. Thus, the diagnostic accuracy for HFpEF lacked robustness. Moreover, information on their applicability in the Asian population is limited.

Purpose

The aim of this study was to investigate these scores' diagnostic validity for HFpEF in Japanese patients recently hospitalised due to acute decompensated HF.

Methods

We examined patients with HFpEF recently hospitalised with acute decompensated HF whose HFA-PEFF and H2FPEF scores could be calculated at discharge from a nationwide HFpEF-specific multicentre registry (HFpEF group) and control patients who underwent echocardiography to investigate the cause of dyspnoea in our hospital (Non-HFpEF group). We calculated the HFA-PEFF and the H2FPEF scores among the studied population. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were computed to compare the diagnostic accuracy of these scores.

Results

The studied population included 372 consecutive patients (194 HFpEF group and 178 Non-HFpEF group; HFpEF prevalence, 52%). The HFA-PEFF score classified 155 (42%) of all patients into the high likelihood category (5–6 points) and only 19 (5%) into the low likelihood category (0–1 point). A high HFA-PEFF score could diagnose HFpEF with a high specificity of 84% and a positive predictive value (PPV) of 82%, and a low HFA-PEFF score could rule out HFpEF with a high sensitivity of 99% and a negative predictive value (NPV) of 89%. The H2FPEF score classified 86 (23%) of all patients into the high likelihood category (6–9 points) and 84 (23%) into the low likelihood category (0–1 point). HFpEF could be diagnosed with a high H2FPEF score (specificity, 97%; PPV, 94%) or ruled out with a low H2FPEF score (sensitivity, 97%; NPV, 93%). The diagnostic accuracy for the HFA-PEFF and H2FPEF scores was 0.82 (95% confidence interval [CI] 0.78–0.86) and 0.89 (95% CI 0.86–0.93), respectively, by the AUC of the ROC curve (P=0.004) (Figure 1A). In the HFA-PEFF sub-scores, the functional score showed little diagnostic value, while the morphological and biomarker scores showed moderate diagnostic value (Figure 1B).

Conclusions

The H2FPEF score may be more useful than the HFA-PEFF score in diagnosing HFpEF in Japanese patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): a Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (JSPS KAKENHI) Figure 1

Applicability of the AHA/ACC/HRS guideline for implantable cardioverter defibrillator implantation in Japanese patients with cardiac sarcoidosis

Background

Sarcoidosis is a systemic granulomatous disease that affects multiple organs. Cardiac involvement is a key determinant of poor clinical outcomes in the patients with sarcoidosis, as it causes congestive heart failure, conduction abnormalities, ventricular tachycardia and fibrillation (VT/VF), and sudden cardiac death (SCD). Although implantable cardioverter defibrillators (ICDs) are used to prevent SCD from VT/VF in patients with cardiac sarcoidosis (CS), the generalizability of the AHA/ACC/HRS guidelines for the Japanese CS patients remains unclear.

Purpose

We aimed to assess, among Japanese patients with CS, the ICD recommendations from the 2017 AHA/ACC/HRS Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death.

Methods

We examined 188 consecutive patients with CS in two tertiary hospitals between 1979 and 2020. The primary outcome was defined as a composite outcome involving SCD or ventricular arrhythmic events. Ventricular arrhythmic events were defined as either emergency treatment for VF or sustained VT, which included appropriate ICD therapy.

Results

During a median follow-up period of 5.68 (IQR: 4.87–6.70) years, the primary outcome occurred in 44 patients (23%), which included 6 cases of SCD and 38 cases of VT/VF. ICD implant was indicated based on left ventricular ejection fraction (LVEF) of ≤35% (class I recommendation) in 62 patients, with an annualized event rate of 3.93%. A LVEF of >35% with a need for a permanent pacemaker (class IIa recommendation) was observed for 53 patients, with an annualized event rate of 2.54%. A LVEF of >35% with late gadolinium enhancement (LGE) during cardiovascular magnetic resonance (class IIa recommendation) was observed for 62 patients, with an annualized event rate of 2.38% (Figure A). Kaplan-Meier analyses revealed that patients with a class I recommendation for ICD implantation had a significant higher incidence of the primary outcome, compared to patients with a class IIa recommendation and patients with no indication for ICD implantation (P=0.03). However, there were no significant differences in the incidence of the primary outcome between patients with a LVEF of >35% and a need for a permanent pacemaker and patients with a class I recommendation (P=0.08) or patients with a LVEF of ≤35% (P=0.31). Moreover, there was no significant difference in the incidence of the primary outcome between patients with a LVEF of >35% and LGE on cardiovascular magnetic resonance and patients with a class I recommendation (P=0.054) or patients with a LVEF of ≤35% (P=0.22) (Figure B).

Conclusions

The American guideline recommendations for ICD implantation might be applicable to Japanese patients with CS. Implantation of an ICD may need to be considered in these patients if they require a permanent pacemaker or have LGE, regardless of LVEF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science

Circular dichroism and resonance Raman spectroscopies of bacteriochlorophyll b-containing LH1-RC complexes

The core light-harvesting complexes (LH1) in bacteriochlorophyll (BChl) b-containing purple phototrophic bacteria are characterized by a near-infrared absorption maximum around 1010 nm. The determinative cause for this ultra-redshift remains unclear. Here, we present results of circular dichroism (CD) and resonance Raman measurements on the purified LH1 complexes in a reaction center-associated form from a mesophilic and a thermophilic Blastochloris species. Both the LH1 complexes displayed purely positive CD signals for their Q_y transitions, in contrast to those of BChl a-containing LH1 complexes. This may reflect differences in the conjugation system of the bacteriochlorin between BChl b and BChl a and/or the differences in the pigment organization between the BChl b- and BChl a-containing LH1 complexes. Resonance Raman spectroscopy revealed remarkably large redshifts of the Raman bands for the BChl b C3-acetyl group, indicating unusually strong hydrogen bonds formed with LH1 polypeptides, results that were verified by a published structure. A linear correlation was found between the redshift of the Raman band for the BChl C3-acetyl group and the change in LH1-Q_y transition for all native BChl a- and BChl b-containing LH1 complexes examined. The strong hydrogen bonding and π-π interactions between BChl b and nearby aromatic residues in the LH1 polypeptides, along with the CD results, provide crucial insights into the spectral and structural origins for the ultra-redshift of the long-wavelength absorption maximum of BChl b-containing phototrophs.

AB1123 PROGRESSION OF FINGER JOINT CARTILAGE DAMAGE EVALUATED BY ULTRASOUND IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Cartilage damage in rheumatoid arthritis (RA) has been evaluated by joint space narrowing (JSN) in X-ray, despite the fact that it is not a direct evaluation of cartilage. We have recently reported that direct evaluation of finger joint cartilage thickness evaluated by ultrasound (US) is valid and useful for patients with RA1).

Objectives:

In this study, we aimed to examine the progression of cartilage damage in RA patients.

Methods:

Forty-six patients with RA who had completed the US evaluation of finger joint cartilage thickness at baseline and after 1 year were included in this study. The cartilage thickness of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of 2nd to 5th fingers were bilaterally visualized and measured at the middle portion of MCP and PIP joints from a longitudinal dorsal view, with approximately 90 degrees flexion. Cartilage thickness was measured from the base of the cartilage to the interface artefact at the cartilage surface by calculating the pixel counts on DICOM images.

Results:

In patients, 78% were female, the median age was 68 years and the median disease duration of the patients was 6 years. The median DAS28-CRP at baseline was 2.6. The sum of total cartilage thickness from 16 joints per patient ranged from 3.1 to 9.1 mm (median 6.4 mm) at baseline, and it was significantly correlated with disease duration (ρ=-0.423, p=0.003). A significant decrease from the baseline in the cartilage thickness (median -1.6%) was observed after 1 year (p=0.041). Furthermore, patients with persistently moderate/high disease activity for 1 year by DAS28-CRP (n=9) showed a greater decrease in the cartilage thickness than the remaining patients with controlled disease activity (n=37) (median -5.9% versus -1.5%, respectively, p=0.029).

Conclusion:

This study further supported the validity and usefulness of joint cartilage thickness evaluation by US in patients with RA.

References:

[1]Ogura T, et al. Arthritis Care Res 2019 Oct 25.

Disclosure of Interests:

Takehisa Ogura: None declared, Ayako Hirata: None declared, Sayaka Takenaka: None declared, Yuki Inoue: None declared, Takaharu Kagtagiri: None declared, Yuto Takakura: None declared, Hideki Ito: None declared, Hideto Kameda Grant/research support from: Abbvie, Asahi-Kasei, Chugai, Eisai, Mitsubishi-Tanabe and Novartis, Consultant of: Abbvie, Boehringer, Celgene, Eli Lilly, Janssen, Novartis, Sanofi, UCB, Speakers bureau: Abbvie, Asahi-Kasei, BMS, Chugai, Eisai, Eli Lilly, Janssen, Mitsubishi-Tanabe, Novartis and Pfizer

Continuity and efficacy of real-world use of azacitidine

Long-term azacitidine (AZA) treatment is necessary for its maximal therapeutic effect. This study examined the continuity and efficacy of AZA treatment in real-world use. We conducted a retrospective study in 38 patients who had completed AZA treatment at the Ogaki Municipal Hospital between April 2011 and August 2019. The median number of AZA received cycles was 4. The number of AZA treatment cycles received was 1-3 cycles in 15 (39.5%), 4-6 cycles in 15 (39.5%), and ≥ 7 cycles in 8 (21.1%). The most common reason for discontinued AZA treatment was infection. Overall response rate was 33.3% in patients with discontinued AZA use (< 4 cycles) and 56.5% in patients with continued AZA (≥ 4). Median overall survival (OS) was 124 (15-529) days and 391 (132-2,825) days in the respective groups (p<0.01). The presence of peripheral blood blasts (PBs) was a prognostic factor for continuation of treatment (p =0.03). Discontinued AZA treatment due to infection (p <0.01), and PBs (p =0.03) were unfavourable prognostic factors for OS. Long-term AZA use is beneficial for improvement and survival. Infection control and presence of PBs were important factors for continuing AZA. These data support the idea of long-term continued treatment with AZA for optimal benefit to patients.

Comparison of ultrasonographic joint and tendon findings in hands between early, treatment-naïve patients with systemic lupus erythematosus and rheumatoid arthritis

Although both systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) may lead to joint deformity, SLE arthritis is typically non-erosive and often accompanied by Jaccoud's deformity. Therefore, we examined characteristics of joint and tendon lesions in patients with SLE and RA by ultrasonography. Fifteen treatment-naïve SLE patients and 40 treatment-naïve RA patients with joint symptoms were included in this study. The hand joints and related tendons were ultrasonographically examined using grey-scale (GS) and power Doppler (PD). Joint involvement was comparably observed in patients with SLE and RA (80% versus 95%, p = 0.119). However, tendon involvement was more frequent in SLE than in RA (93% versus 65%, p = 0.045), especially in the wrist joints (73% versus 40%, p = 0.037). When we investigated the intensity of US findings, the joint synovitis score (GS + PD) per affected joint was lower in SLE than RA (2.0 versus 2.6, p = 0.019), while tendon inflammation score was not significantly different (2.1 versus 2.2, p = 0.738). Finally, the examination of concordance between joint and tendon involvement in the same finger revealed that joint lesion appeared in only 49% of fingers having tendon involvement in the SLE group, which was significantly less than 74% in the RA group ( p = 0.010). Thus, as compared with RA, SLE arthropathy is characterized by the predominance of tenosynovitis/periextensor tendon inflammation, which is likely to develop independently from joint synovitis.

Significant reduction in the incidence of C5 palsy after cervical laminoplasty using chilled irrigation water

Aims

The aim of this study was to determine whether chilled irrigation saline decreases the incidence of clinical upper limb palsy (ULP; a reduction of one grade or more on manual muscle testing; MMT), based on the idea that ULP results from thermal damage to the nerve roots by heat generated by friction during bone drilling.

Methods

Irrigation saline for drilling was used at room temperature (RT, 25.6°C) in open-door laminoplasty in 400 patients (RT group) and chilled to a mean temperature of 12.1°C during operations for 400 patients (low-temperature (LT) group). We assessed deltoid, biceps, and triceps brachii muscle strength by MMT. ULP occurring within two days post-operatively was categorised as early-onset palsy.

Results

The incidence of ULP (4.0% vs 9.5%, p = 0.003), especially early-onset palsy (1.0% vs 5.5%, p < 0.001), was significantly lower for the LT group than for the RT group. Multivariate analysis indicated that RT irrigation saline use, concomitant foraminotomy, and opened side were significant predictors for ULP.

Discussion

Using chilled irrigation saline during bone drilling significantly decreased the ULP incidence, particularly the early-onset type, and shortened the recovery period for ULP. Chilled irrigation saline can thus be recommended as a simple method for preventing ULP. Take home message: Chilled irrigation during laminoplasty reduces C5 palsy. Cite this article: Bone Joint J 2016;98-B:117–24.

Metabolomic investigation of pathogenesis of myxosporean emaciation disease of tiger puffer fish Takifugu rubripes

Serum biochemical analysis was undertaken to study the pathophysiological details of emaciation disease of the tiger puffer fish Takifugu rubripes (Temminck and Schlegel). Serum parameters were measured by biochemical analysis using automated dry chemistry and gas chromatography/mass spectrometry (GC/MS). Serum concentrations of albumin, amylase, calcium, creatinine, glucose and total protein were significantly lower in the emaciated fish when compared with those of normal fish. Regression analyses found close correlation between concentrations of total protein, albumin, amylase, glucose and progress of the disease. In contrast, serum alanine aminotransferase increased significantly in emaciated fish indicating liver function disorder. Further, GC/MS metabolic profiling of the puffer serum showed that the profile of the emaciated fish was distinct to that of non-infected control. The serum content of amino acids including glycine, 5-oxo-proline and proline, and ascorbic acid, fumaric acid and glycerol increased significantly in serum in moderately emaciated fish. The serum glucose, linolenic acid and tyrosine level decreased significantly in the late phase of the disease. Our results clearly show that prolonged intestinal damage caused by myxosporean infection impairs absorption of nutrients, resulting in extreme emaciation.

Evaluation of a lattice Boltzmann method in a complex nanoflow

In order to establish a cost-effective strategy to simulate complex flows in continuum to slip and transitional regimes, the present study assesses the performance of a lattice Boltzmann method (LBM) formerly discussed by the present authors' group [Niu, Phys. Rev. E 76, 036711 (2007)]. This LBM is based on a diffuse scattering wall boundary condition, a regularization procedure, and an effective relaxation time associated with the Knudsen number. The present assessment is on its regularization procedure and third-order truncated system based on the two-dimensional twenty-one discrete velocity (D2Q21) model for the Cartesian lattices. The test flow cases are force-driven Poiseuille flows, the Couette flows and a flow around a square cylinder situated in a nanochannel. For producing the reference data of the square cylinder flow, the molecular dynamics simulation using Lennard-Jones potential is also performed. Although the flow profiles and the slip velocities of the Poiseuille flows and the Couette flows are more accurately predicted by the third-order truncated system, the general velocity profiles around the square cylinder are also well predicted by the second-order truncated system based on the two-dimensional nine discrete velocity (D2Q9) model. It is also confirmed that without the regularization process, the entire flow field prediction suffers unphysical momentum oscillations around the square cylinder.

Potential risk of thermal damage to cervical nerve roots by a high-speed drill

Using the transverse processes of fresh porcine lumbar spines as an experimental model we evaluated the heat generated by a rotating burr of a high-speed drill in cutting the bone. The temperature at the drilled site reached 174 degrees C with a diamond burr and 77 degrees C with a steel burr. With water irrigation at a flow rate of 540 ml/hr an effective reduction in the temperature was achieved whereas irrigation with water at 180 ml/hr was much less effective. There was a significant negative correlation between the thickness of the residual bone and the temperature measured at its undersurface adjacent to the drilling site (p < 0.001). Our data suggest that tissues neighbouring the drilled bone, especially nerve roots, can be damaged by the heat generated from the tip of a high-speed drill. Nerve-root palsy, one of the most common complications of cervical spinal surgery, may be caused by thermal damage to nerve roots arising in this manner.

Mutation screening of the CARD15 gene in sarcoidosis

CARD15 was first identified as a susceptibility gene for Crohn's disease. More recently, CARD15 mutations were shown to be associated with the pediatric granulomatous inflammatory diseases, Blau syndrome and early-onset sarcoidosis (EOS). The aim of the present study was to evaluate whether CARD15 variants also play a role in patients with ordinary sarcoidosis other than EOS. We enrolled 135 Japanese sarcoidosis patients with uveitis as well as 95 healthy individuals and performed mutation analysis by direct sequencing of CARD15 exon 4. Direct DNA sequencing in the sarcoidosis patients showed eight CARD15 variants, including five novel mutations (13402C>T, 13543C>T, 13775C>A, 13937G>A, and 14079C>T). Compared with healthy individuals, CARD15 mutations are not common in the Japanese patients with sarcoidosis. Based on the results, we examined the clinical manifestations in patients with sarcoidosis according to their CARD15 mutations. Sarcoidosis patients with these mutations have no specific clinical features with regard to course of the disease or disease severity. Our results indicate that in general, CARD15 mutations may not contribute to the risk of sarcoidosis.

Distribution pattern of inhaled ultrafine gold particles in the rat lung

The role of alveolar macrophages in the fate of ultrafine particles in the lung was investigated. Male Wistar-Kyoto rats were exposed to ultrafine gold particles, generated by a spark generator, for 6 h at a concentration of 88 microg/m3 (4 x 10(6)/cm3, 16 nm modal mobility diameter). Up to 7 days, the animals were serially sacrificed, and lavaged cells and lung tissues were examined by transmission electron microscopy. The gold concentration/content in the lung, lavage fluid, and blood was estimated by inductively coupled plasma-mass spectrometry. Gold particles used were spherical and electron dense with diameters of 5-8 nm. The particles were individual or slightly agglomerated. By inductively coupled plasma-mass spectrometry analysis of the lung, 1945 +/- 57 ng (mean +/- SD) and 1512 +/- 184 ng of gold were detected on day 0 and on day 7, respectively, indicating that a large portion of the deposited gold particles was retained in the lung tissue. In the lavage fluid, 573 +/- 67 ng and 96 +/- 29 ng were found on day 0 and day 7, respectively, which means that 29% and 6% of the retained gold particles were lavageable on these days. A low but significant increase of gold (0.03 to 0.06% of lung concentration) was found in the blood. Small vesicles containing gold particles were found in the cytoplasm of alveolar macrophages. In the alveolar septum, the gold particles were enclosed in vesicles observed in the cytoplasm of alveolar type I epithelial cells. These results indicate that inhaled ultrafine gold particles in alveolar macrophages and type I epithelial cells are processed by endocytotic pathways, though the uptake of the gold particles by alveolar macrophages is limited. To a low degree, systemic particle translocation took place.

Inhalation of ultrafine carbon particles triggers biphasic pro-inflammatory response in the mouse lung

High levels of particulate matter in ambient air are associated with increased respiratory and cardiovascular health problems. It has been hypothesised that it is the ultrafine particle fraction (diameter <100 nm) that is largely responsible for these effects. To evaluate the associated mechanisms on a molecular level, the current authors applied an expression profiling approach. Healthy mice were exposed to either ultrafine carbon particles (UFCPs; mass concentration 380 microg x m(-3)) or filtered air for 4 and 24 h. Histology of the lungs did not indicate any pathomorphological changes after inhalation. Examination of the bronchoalveolar lavage fluid revealed a small increase in polymorphonuclear cell number (ranging 0.6-1%) after UFCP inhalation, compared with clean air controls, suggesting a minor inflammatory response. However, DNA microarray profile analysis revealed a clearly biphasic response to particle exposure. After 4 h of inhalation, mainly heat shock proteins were induced, whereas after 24 h, different immunomodulatory proteins (osteopontin, galectin-3 and lipocalin-2) were upregulated in alveolar macrophages and septal cells. In conclusion, these data indicate that inhalation of ultrafine carbon particles triggers a biphasic pro-inflammatory process in the lung, involving the activation of macrophages and the upregulation of immunomodulatory proteins.