Association of Renin-Angiotensin-Aldosterone System Inhibitors With Clinical Outcomes, Hemodynamics, and Myocardial Remodeling Among Patients With Advanced Heart Failure on Left Ventricular Assist Device Support

BACKGROUND

We evaluated the potential benefits of renin-angiotensin-aldosterone system inhibitors (RAASi) in patients with left ventricular assist device support.

METHODS AND RESULTS

A total of 165 consecutive patients undergoing left ventricular assist device implant and alive at 6-month on support were studied. RAASi status after 6-month visit along with clinical reasons for nonprescription/uptitration were retrospectively assessed. The primary outcome was a composite of heart failure hospitalization or cardiovascular death between 6 and 24 months after left ventricular assist device implant. Remodeling and hemodynamic outcomes were explored by studying the association of RAASi new prescription/uptitration versus unmodified therapy at 6-month visit with the change in echocardiographic parameters and hemodynamics between 6 and 18 months. After the 6-month visit, 76% of patients were on RAASi. Patients' characteristics among those receiving and not receiving RAASi were mostly similar. Of 85 (52%) patients without RAASi new prescription/uptitration at 6-month visit, 62% had no apparent clinical reason. RAASi were independently associated with the primary outcome (adjusted hazard ratio, 0.31 [95% CI, 0.16-0.69]). The baseline rates of optimal echocardiographic profile (neutral interventricular septum, mitral regurgitation less than mild, and aortic valve opening) and hemodynamic profile (cardiac index ≥2.2 L/min per m2, wedge pressure <18 mm Hg, and right atrial pressure <12 mm Hg) were similar between groups. At 18 months, patients receiving RAASi new prescription/uptitration at 6 months had higher rates of optimal hemodynamic profile (57.5% versus 37.0%; P=0.032) and trends for higher rates of optimal echocardiographic profile (39.6% versus 22.9%; P=0.055) compared with patients with 6-month unmodified therapy. Optimal 18-month hemodynamic and echocardiographic profiles were associated with the primary outcome (log-rank=0.022 and log-rank=0.035, respectively).

CONCLUSIONS

RAASi are associated with improved outcomes and improved hemodynamics among mechanically unloaded patients.

Organ perfusion pressure at admission and clinical outcomes in patients hospitalized for acute heart failure

AIMS

Hypoperfusion portends adverse outcomes in acute heart failure (AHF). The gradient between end-organ inflow and outflow pressures may more closely reflect hypoperfusion than mean arterial pressure (MAP) alone. The aim of this study was to investigate organ perfusion pressure (OPP), calculated as MAP minus central venous pressure (CVP), as a prognostic marker in AHF.

METHODS AND RESULTS

The Sodium NItroPrusside Treatment in Acute Heart Failure (SNIP)-AHF study was a multicentre retrospective cohort study of 200 consecutive patients hospitalized for AHF treated with sodium nitroprusside. Only patients with both MAP and invasive CVP data available from the SNIP-AHF cohort were included in this analysis. The primary endpoint was to assess OPP as a predictor of worsening heart failure (WHF), defined as the worsening of signs and symptoms of heart failure leading to intensification of therapy at 48 h. One hundred and forty-six patients fulfilling the inclusion criteria were included [mean age: 61.1 ± 13.5 years, 32 (21.9%) females; mean body mass index: 26.2 ± 11.7 kg/m2; mean left ventricular ejection fraction: 23.8%±11.4%, mean MAP: 80.2 ± 13.2 mmHg, and mean CVP: 14.0 ± 6.1 mmHg]. WHF occurred in 14 (9.6%) patients. At multivariable models including hemodynamic variables (OPP, shock index, and CVP), OPP at admission was the best predictor of WHF at 48 h [OR 0.91 (95% confidence interval 0.86-0.96), P-value = 0.001] with an optimal cut-off value of 67.5 mmHg (specificity 47.3%, sensitivity 100%, and AUC 0.784 ± 0.054). In multivariable models, including univariable significant parameters available at first bedside assessment, namely New York Heart Association functional class, OPP, shock index, CVP, and left ventricular end-diastolic diameter, OPP consistently and significantly predicted WHF at 48 h.

CONCLUSION

In this retrospective analysis on patients hospitalized for AHF treated with sodium nitroprusside, on-admission OPP significantly predicted WHF at 48 h with high sensitivity.

Transthyretin cardiac amyloidosis in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement: experience of a single center

BACKGROUND

Even if prevalent among patients with severe aortic stenosis (AS), the clinical suspicion for transthyretin cardiac amyloidosis (ATTR-CA) remains difficult in this subset. We report our single center experience on ATTR-CA detection among TAVR candidates to provide insights on the prevalence and clinical features of dual pathology as compared to lone AS.

METHODS

Consecutive severe AS patients undergoing transcatheter aortic valve replacement (TAVR) evaluation at a single center were prospectively included. Those with suspected ATTR-CA based on clinical assessment underwent 99m Tc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy. The RAISE score, a novel screening tool with high sensitivity for ATTR-CA in AS, was retrospectively calculated to rule-out ATTR-CA in the remaining patients. Patients were categorized as follow: "ATTR-CA+": patients with confirmed ATTR-CA at DPD bone scintigraphy; "ATTR-CA-": patients with negative DPD bone scintigraphy or a negative RAISE score; "ATTR-CA indeterminate": patients not undergoing ATTR-CA assessment with a positive RAISE score. The characteristics of ATTR-CA+ and ATTR-CA- patients were compared.

RESULTS

Of 107 included patients, ATTR-CA suspicion was posed in 13 patients and confirmed in six. Patients were categorized as follow: 6 (5.6%) ATTR-CA+, 79 (73.8%) ATTR-CA-, 22 (20.6%) ATTR-CA indeterminate. Excluding ATTR-CA indeterminate patients, the prevalence of ATTR-CA was 7.1% (95% CI 2.6-14.7%). As compared to ATTR-CA - patients, ATTR-CA + patients were older, had higher procedural risk and more extensive myocardial and renal damage. They had higher left ventricle mass index and lower ECG voltages, translating into a lower voltage to mass ratio. Moreover, we describe for the first time bifascicular block as an ECG feature highly specific of patients with dual pathology (50.0% vs. 2.7%, P<0.001). Of note, pericardial effusion was rarely found in patients with lone AS (16.7% vs. 1.2%, P=0.027). No difference in procedural outcomes was observed between groups.

CONCLUSIONS

Among severe AS patients, ATTR-CA is prevalent and presents with phenotypic features that may aid to differentiate it from lone AS. A clinical approach based on routine search of amyloidosis features might lead to selective DPD bone scintigraphy with a satisfactory positive predictive value.

Adults living with Duchenne muscular dystrophy: old and new challenges in a cohort of 19 patients in their third to fifth decade

BACKGROUND AND PURPOSE

Advances in multidisciplinary care are extending overall survival in Duchenne muscular dystrophy (DMD) patients. Our research objective was to delineate the clinical characteristics of this particular cohort and identify novel challenges associated with the disease.

METHODS

Nineteen individuals aged 25-48 years (median 34 years) with a confirmed diagnosis of out-of-frame DMD gene mutation were selected.

RESULTS

All patients were mechanically ventilated (5/19 via tracheostomy), with different patterns of cardiomyopathy. Swallowing and nutritional issues were frequent (median body mass index 18.95), with six cases requiring artificial enteral feeding (median age at start 29 years), as well as bone density alterations (11/19, 58%). Only 2/19 had been on long-term prednisone therapy. Issues requiring at-home/hospital assistance were respiratory infections (15/19, 79%), gastroenterological symptoms (9/19, 47%, including toxic megacolon and rectal perforation after repeated enemas), metabolic acidosis (2/19, 11%) and recurrent ischaemic strokes (1/19, 5%). From a social perspective, augmented-alternative communication devices were necessary for 7/19 (37%), with most of the patients being assisted at home and 2/19 institutionalized. Eight/19 (42%) patients experienced psychiatric symptoms (median age at presentation 16 years) and 9/19 (47%) chronic pain (median age at onset 23 years), in both cases treated with psychoactive/analgesic drugs without major adverse events. The patients' subjective perception of physical health resulted in unfavourable scores, whilst the subjective assessment of mental health unexpectedly showed more positive values compared to other chronic neurological conditions.

CONCLUSIONS

The analysis of adults living with DMD reveals several new health-related issues, such as the management of emergencies and safety of pharmacological treatments for psychiatric symptoms, chronic pain management, as well as an increasing caregivers burden.

Cardiac imaging for the prediction of sudden cardiac arrest in patients with heart failure

The identification of heart failure (HF) patients at risk for arrhythmic sudden cardiac arrest (SCA) is a major challenge in the cardiovascular field. In addition to optimal medical treatment for HF, implantable cardioverter defibrillator (ICD) is currently recommended to prevent SCA in patients with reduced left ventricular ejection fraction (LVEF). The indication for an ICD implantation, in addition to HF etiology, New York Health Association (NYHA) class and life expectancy, mainly depends on LVEF value at echocardiography. However, the actual role of LVEF in the prediction of SCA has recently been debated, while newer multimodality imaging techniques with increased prognostic accuracy have been developed. Speckle tracking imaging allows the quantification of mechanical dispersion, a marker of electrophysiological heterogeneity predisposing to malignant arrhythmias, while advanced cardiac magnetic resonance techniques such as myocardial T1-mapping and extracellular volume fraction assessment allow the evaluation of interstitial diffuse fibrosis. Nuclear imaging is helpful for the appraisal of sympathetic nervous system dysfunction, while newer computed tomography techniques assessing myocardial delayed enhancement allow the identification of focal myocardial scar. This review will focus on the most modern advances in the field of cardiovascular imaging along with its applications for the prediction of SCA in patients with HF. Modern artificial intelligence applications in cardiovascular imaging will also be discussed.

Acute Reduction in Left Ventricular Function Following Transcatheter Mitral Edge-to-Edge Repair

Background Little is known about the impact of transcatheter mitral valve edge-to-edge repair on changes in left ventricular ejection fraction (LVEF) and the effect of an acute reduction in LVEF on prognosis. We aimed to assess changes in LVEF after transcatheter mitral valve edge-to-edge repair for both primary and secondary mitral regurgitation (PMR and SMR, respectively), identify rates and predictors of LVEF reduction, and estimate its impact on prognosis. Methods and Results In this international multicenter registry, patients with both PMR and SMR undergoing transcatheter mitral valve edge-to-edge repair were included. We assessed rates of acute LVEF reduction (LVEFR), defined as an acute relative decrease of >15% in LVEF, its impact on all-cause mortality, major adverse cardiac event (composite end point of all-cause death, mitral valve surgery, and residual mitral regurgitation grade ≥2), and LVEF at 12 months, as well as predictors for LVEFR. Of 2534 patients included (727 with PMR, and 1807 with SMR), 469 (18.5%) developed LVEFR. Patients with PMR were older (79.0±9.2 versus 71.8±8.9 years; P<0.001) and had higher mean LVEF (54.8±14.0% versus 32.7±10.4%; P<0.001) at baseline. After 6 to 12 months (median, 9.9 months; interquartile range, 7.8-11.9 months), LVEF was significantly lower in patients with PMR (53.0% versus 56.0%; P<0.001) but not in patients with SMR. The 1-year mortality was higher in patients with PMR with LVEFR (16.9% versus 9.7%; P<0.001) but not in those with SMR (P=0.236). LVEF at baseline (odds ratio, 1.03 [95% CI, 1.01-1.05]; P=0.002) was predictive of LVEFR for patients with PMR, but not those with SMR (P=0.092). Conclusions Reduction in LVEF is not uncommon after transcatheter mitral valve edge-to-edge repair and is correlated with worsened prognosis in patients with PMR but not patients with SMR. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT05311163.

1078 RECURRENT FLARES OF MYOCARDITIS: A CHALLENGING CASE

A 38-year-old woman with curly hair was admitted at the Emergency Department of our Hospital for typical thoracic pain associated with dyspnea and palpitations. Electrocardiogram showed sinus rhythm, 65 bpm, low voltages in the peripheral leads with fragmented QRS complex in the inferior leads and negative T-waves in anterior leads. Initial high-sensitivity cardiac troponin level was 46326 ng/L (n.v. &lt; 16 ng/L). At presentation the patient was treated with Anakinra (anti-interleukin 1) and Metoprolol 200 mg/die because of a past medical history characterized by multiple myocarditis recurrences since 2012. Various therapies had been tested (Aspirin, Ibuprofen, Colchicine, Prednisone, Azathioprine), with a good efficacy of Mycophenolic acid, recently stopped to plan a pregnancy.

Transthoracic echocardiography documented normal left ventricle (LV) ejection fraction and no alteration wall motion abnormalities; cardiac-MRI demonstrated LV late gadolinium enhancement with a non-ischemic subepicardial “ring-like” pattern. Endomyocardial biopsy was performed, and the ultrastructural analysis showed mitochondrial hyperplasia with focal swelling and marked alterations of intercalated disks. A high ventricular extrasystolic burden was registered at EKG monitoring.

Gene sequencing revealed a pathogenetic variant of the gene coding for Desmoplakin. This is involved in the anchoring of intermediate filaments to desmosomal plaques and its pathogenetic variants are associated with an inflammatory and fibrotic LV predominant cardiomyopathy with an arrhythmogenic evolution (see Padua criteria).

In the absence of approved therapies, in agreement with the limited available data and considering patient's history, Micofenolic acid was restarted. At 1-, 3- and 6-month follow-up the patient has remained asymptomatic with progressive declining in troponin levels after discharge.

Evolution of tricuspid regurgitation after transcatheter edge-to-edge mitral valve repair for secondary mitral regurgitation and its impact on mortality

AIM

To evaluate short-term changes in tricuspid regurgitation (TR) after transcatheter edge-to-edge mitral valve repair (M-TEER) in secondary mitral regurgitation (SMR), their predictors and impact on mortality.

METHODS AND RESULTS

This is a retrospective analysis of SMR patients undergoing successful M-TEER (post-procedural mitral regurgitation ≤2+) at 13 European centres. Among 503 patients evaluated 79 (interquartile range [IQR] 40-152) days after M-TEER, 173 (35%) showed ≥1 degree of TR improvement, 97 (19%) had worsening of TR, and 233 (46%) remained unchanged. Smaller baseline left atrial diameter and residual mitral regurgitation 0/1+ were independent predictors of TR ≤2+ after M-TEER. There was a significant association between TR changes and New York Heart Association class and pulmonary artery systolic pressure decrease at echocardiographic re-assessment. At a median follow-up of 590 (IQR 209-1103) days from short-term echocardiographic re-assessment, all-cause mortality was lower in patients with improved compared to those with unchanged/worsened TR (29.6% vs. 42.3% at 3 years; log-rank p = 0.034). Baseline TR severity was not associated with mortality, whereas TR 0/1+ and 2+ at short-term follow-up was associated with lower all-cause mortality compared to TR 3/4+ (30.6% and 35.6% vs. 55.6% at 3 years; p < 0.001). A TR ≤2+ after M-TEER was independently associated with a 42% decreased risk of mortality (p = 0.011).

CONCLUSION

More than one third of patients with SMR undergoing successful M-TEER experienced an improvement in TR. Pre-procedural TR was not associated with outcome, but a TR ≤2+ at short-term follow-up was independently associated with long-term mortality. Optimal M-TEER result and a small left atrium were associated with a higher likelihood of TR ≤2+ after M-TEER.

Determinants and prognostic impact of afterload mismatch after MitraClip implantation

Introduction

Mitral transcatheter edge-to-edge repair (TEER) is a widespread option to treat mitral regurgitation in high-risk patients. The sudden reduction of mitral regurgitation (MR) following TEER abruptly eliminates the low-impedance regurgitant flow into the left atrium, leading to an increase in left ventricle (LV) afterload with possible impairment of LV systolic function, defined afterload mismatch (AM).

Purpose

To explore a new definition of AM and to analyze the determinants and prognostic role of AM in patients with functional MR (FMR) undergoing TEER.

Methods

This was an international multicenter case-control study including adult patients with severe FMR and LVEF ≤35% undergoing TEER between 2012 and 2020. AM was defined as the acute need to initiate or increase inotropic support by a vasoactive inotropic score ≥3 or the need for a mechanical circulatory support following TEER.

Results

80 patients with AM were compared to 80 consecutive patients undergoing TEER not meeting the criteria for AM. Median age was 67 years, 79% of patients were male, had a median LVEDV of 240 ml with severely reduced LVEF (median 26%) and pulmonary hypertension (median 48 mmHg). Median EROA/LVEDV ratio was 0.17 (IQR 0.12–0.24) based on which 37% of the total population presented with proportionate MR. Levosimendan was administered before TEER in 42% of patients while intravenous vasodilators in 43%. In most patients more than 1 clip were needed (2 clips in 88 patients, 3 clips in 11). Patients presenting AM more commonly had a lower EROA/LVEDV ratio (0.14 vs. 0.18, p&lt;0.001) leading to a higher percentage of patients with proportionate MR (55% vs. 22%, p&lt;0.001; Figure 1) and had more clips implanted (p=0.008). AM was graded as mild in 74% of patients, moderate in 15% and severe in 11%. At multivariate analysis, patients with proportionate MR were more likely to develop AM after TEER (OR 2.95, 95% CI: 1.32–6.60, p=0.008), while those treated with levosimendan (OR 0.32, 95% CI: 0.15–0.71, p=0.005) and/or IV vasodilators (OR 0.44, 95% CI: 0.21–0.96, p=0.040) before TEER were less likely to suffer from AM. In-hospital death occurred in 7 cases, all being part of AM group. Patients were more likely to die in-hospital if AM was more severe (OR 2.56, 95% CI: 1.19–5.54, p=0.017), and for higher grades of residual MR (OR 3.35, 95% CI: 1.27–8.79, p=0.014). The 2-year survival rate did not differ significantly between groups (66% vs 75%, HR 1.51, 95% CI: 0.73–3.12, p=0.270; Figure 2). At 2 years 51 patients (32%) were re-hospitalized for HF, independently from post-procedural AM (HR 1.36, 95% CI: 0.70–2.67, p=0.363).

Conclusions

In patients with LVEF ≤35% and severe FMR undergoing TEER, the development of AM predicted in-hospital mortality, while long-term outcomes were not affected by acute AM. The use of levosimendan or intravenous vasodilators during the pre-procedural phase reduced the risk of acute AM.

Funding Acknowledgement

Type of funding sources: None.

P227 DOES NITROPRUSSIDE TEST BEHAVE AD AN INCREMENTAL PROGNOSTIC FACTOR IN SELECTION OF PATIENTS CANDIDATE TO LVAD IMPLANTATION?

Background

Left ventricular assist device in the last two decades has been used to improve survival and quality of life of patients suffering from heart failure, regardless presence of concomitant pulmonary hypertension. Most patients showed improvement in pulmonary pressure. Current clinical practice lacks a reliable method for prediction of reverse remodelling and prognosis.

Aim

of this study is to investigate the possible role of nitroprusside test as prognostic factor in candidates to LVAD implantation.

Methods

We conducted a monocentric prospective observational study analysing 31 consecutive patients implanted with LVAD between July 2013 and October 2021 that underwent right heart catheterization and nitroprusside test before implantation. Basal and nitroprusside–obtained hemodynamic parameters were subsequently correlated with the primary outcome, defined as the composite of death and episodes of right ventricular failure.

Results

Mean age of study population was 58,6 ± 7,97 years, 12,9% were female. Most prevalent INTERMACS class was 3 and mean EF was 18 ± 4,92 %. Mean follow–up was 31,3 ± 20,4 months, during which 11 death and 14 episodes of RVF occurred. At basal hemodynamic assessment, patients with pulmonary vascular resistance above 3 WU had a significant higher rate of events (50% vs 9%, Likelihood ratio 5.7, p = 0.029). No hemodynamic parameter measured after nitroprusside infusion was found to predict survival or episode of RVF.

Conclusion

In this exploratory study we have shown that nitroprusside infusion does not add further prognostic information when compared with basal hemodynamic parameters.

P316 TRANSTHYRETIN CARDIAC AMYLOIDOSIS IN PATIENTS WITH SEVERE AORTIC STENOSIS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT: A SINGLE CENTER EXPERIENCE

Background

Even if prevalent among patients with severe aortic stenosis (AS), the clinical suspicion for transthyretin cardiac amyloidosis (ATTR–CA) remains difficult in this subset.

Methods

Consecutive severe AS patients undergoing transcatheter aortic valve replacement (TAVR) evaluation at a single center were prospectively included. Those with suspected ATTR–CA based on clinical assessment underwent 99mTc–DPD cardiac scintigraphy. The RAISE score, a novel screening tool with high sensitivity for ATTR–CA in AS, was retrospectively calculated to rule–out ATTR–CA in the remaining patients. Patients were categorized as follow: “ATTR–CA +”: patients with confirmed ATTR–CA at 99mTc–DPD cardiac scintigraphy; “ATTR–CA –”: patients with negative 99mTc–DPD cardiac scintigraphy or a negative RAISE score; c) “ATTR–CA indeterminate”: patients not undergoing ATTR–CA assessment with a positive RAISE score. The characteristics and outcomes of ATTR–CA + and ATTR–CA – patients were compared.

Results

Of 107 included patients, ATTR–CA suspicion was posed in 13 patients and confirmed in 6. Patients were categorized as follow: 6 (5.6%) ATTR–CA +, 79 (73.8%) ATTR–CA –, 22 (20.6%) ATTR–CA indeterminate. Excluding ATTR–CA indeterminate patients, the prevalence of ATTR–CA was 7.1%. As compared to ATTR–CA – patients, ATTR–CA + patients were older, had higher procedural risk and more extensive myocardial and renal damage. They had higher left ventricle mass index and lower ECG voltages, translating into a lower voltage to mass ratio. Moreover, bifascicular block was more common. No difference in procedural outcomes and 1–year mortality was observed between groups.

Conclusions

Among severe AS patients, ATTR–CA is prevalent and presents with phenotypic features that may aid to differentiate it from lone AS. The procedural and mid–term outcomes following TAVR seems unaffected by ATTR–CA status.

Prognostic implications of pulmonary artery catheter monitoring in patients with cardiogenic shock: A systematic review and meta-analysis of observational studies

PURPOSE

To investigate the impact of pulmonary artery catheter (PAC) monitoring on survival of cardiogenic shock(CS), in the light of the controversies in available evidence.

MATERIALS AND METHODS

MEDLINE, EMBASE, Cochrane library and Web of Science were systematically screened to identify most relevant studies on patients with CS comparing PAC use to non-use during hospital stay. Short-term mortality was the primary endpoint and the use of Mechanical Circulatory Support (MCS) devices was the secondary one.

RESULTS

Six observational studies including 1,166,762 patients were selected. The most frequent etiology of CS was post-myocardial infarction (75% [95% CI 55-89%] in PAC-group and 81%[95% CI 47-95%] in non-PAC group). Overall, PAC was used in 33%(95% CI 24-44%) of cases. Pooling data adjusted for confounders, a significant association between the PAC-group and a reduction in short-term mortality emerged when compared to the non-PAC group (36%[95% CI 27-45%] vs 47%[95% CI 35-59%];AdjustedOR 0.71, 95% CI 0.59-0.87, p < 0.01). MCS use was significantly higher in PAC vs non-PAC group (59% [95% CI 54-65%]) vs 48% [95% CI 43-53%]);OR 1.60 [95% CI 1.27-2.02, p < 0.01]).

CONCLUSIONS

PAC was associated with lower incidence of short-term mortality in CS pooling adjusted observational studies. Prospective studies are needed to confirm our hypothesis and better clarify the mechanisms of this potential prognostic benefit.

Echocardiographic-derived Pulmonary Artery Pulsatility Index: towards non-invasive evaluation of right ventricular function

Funding Acknowledgements

Type of funding sources: None.

Background. Pulmonary artery pulsatility index (PAPi)(1) is a powerful predictor of right ventricular failure in patients with acute inferior myocardial infarction(2) and in patients with heart failure undergoing LVAD implantation(3). PAPi derivation requires invasive right heart catheterism (RHC), thus limiting availability and seriate assessment of right ventricular function.

Purpose. Aim of the study was to evaluate accuracy and agreement of echocardiographic derived PAPi (ePAPi) compared to right heart catheterism derived PAPi in heart failure with reduced ejection fraction (HFrEF) patients.

Methods. ePAPi was defined as the ratio of pulmonary artery pulse pressure (sPAP – dPAP) to right atrial pressure (RAP). Systolic pulmonary artery pressure (sPAP) was determined from tricuspid regurgitation (TR) velocity using the simplified Bernoulli equation(4): sPAP = 4 x (peak TR jet velocity)2 + RA pressure. Diastolic pulmonary artery pressure (dPAP) was calculated as: dPAP = 4 x (end-diastolic pulmonary regurgitant velocity)2 + RA pressure. Simplified ePAPi, defined as peak TR pressure to RA pressure ratio was also investigated. Pearson and Spearman correlation tests were performed. A Bland-Altman plot analysis was performed to assess agreement between ePAPi and invasive PAPi. ROC curves were made to assess ePAPi accuracy in identifying patients with low PAPi (defined as PAPi &lt; 2 and PAPi &lt; 3.65).

Results. 66 HFrEF patients (age 59 ± 10 years, 63% males, mean EF: 35 ± 9%) underwent RHC and blinded echocardiogram in a single center Cardiology Departement. Mean invasive derived PAPi was 4.4 ± 3.6, while ePAPi was 3.9 ± 2.3. ePAPi showed an excellent correlation with invasive PAPi (Pearson r: 0.80, p &lt; 0.001; Spearman rho: 0.83, p &lt; 0.001) and good agreement as shown in Bland Altman plot (figure 1). In ROC analysis, ePAPi accurately identified patients with low hemodynamic PAPi &lt; 2 (Sensibility: 100%; Specificity: 87.2%; AUC: 0.97; Youden criterion: ePAPi &lt; 2.3) and PAPi &lt; 3.65 (Sensibility: 81.8%; Specificity: 84%; AUC: 0.89; Youden criterion: ePAPi &lt; 3.6)(figure 2). Simplified ePAPi also showed good correlation and agreement (Pearson r: 0.58, p &lt; 0.001; Spearman rho: 0.81, p &lt; 0.001).

Conclusions. In patients with HFrEF, echocardiographic derived PAPi showed a good agreement and correlation with invasive derived PAPi. ePAPi was also accurate in identifying patients with low PAPi values associated with poor outcomes and may be of interest for non-invasive right ventricular function seriate assessment. Further studies are needed to investigate prognostic implications. Abstract Figure.  Abstract Figure 2

Clinical Outcomes Following Isolated Transcatheter Tricuspid Valve Repair: A Meta-Analysis and Meta-Regression Study

OBJECTIVES

The aim of this study was to assess the pooled clinical and echocardiographic outcomes of different isolated transcatheter tricuspid valve repair (ITTVR) strategies for significant (moderate or greater) tricuspid regurgitation (TR).

BACKGROUND

Significant TR is a common valvular heart disease worldwide.

METHODS

Published research was systematically searched for studies evaluating the efficacy and safety of ITTVR for significant TR in adults. The primary outcomes were improvement in New York Heart Association (NYHA) functional class and 6-minute walking distance and the presence of severe or greater TR at the last available follow-up of each individual study. Random-effect meta-analysis was performed comparing outcomes before and after ITTVR.

RESULTS

Fourteen studies with 771 patients were included. The mean age was 77 ± 8 years, and the mean European System for Cardiac Operative Risk Evaluation II score was 6.8% ± 5.4%. At a weighted mean follow-up of 212 days, 209 patients (35%) were in NYHA functional class III or IV compared with 586 patients (84%) at baseline (risk ratio: 0.23; 95% CI: 0.13-0.40; P < 0.001). Six-minute walking distance significantly improved from 237 ± 113 m to 294 ± 105 m (mean difference +50 m; 95% CI: +34 to +66 m; P < 0.001). One hundred forty-seven patients (24%) showed severe or greater TR after ITTVR compared with 616 (96%) at baseline (risk ratio: 0.29; 95% CI: 0.20-0.42; P < 0.001).

CONCLUSIONS

Patients undergoing ITTVR for significant TR experienced significant improvements in NYHA functional status and 6-minute walking distance and a significant reduction in TR severity at mid-term follow-up.

Clinical outcomes following isolated transcatheter tricuspid valve repair: a meta-analysis and meta-regression study

Background

Significant tricuspid regurgitation (TR) is a common valvular heart disease worldwide.

Purpose

We aimed to assess the pooled clinical and echocardiographic outcomes of different isolated transcatheter tricuspid valve repair (ITTVR) strategies for significant (≥ moderate) TR.

Methods

We systematically searched the literature for studies evaluating the efficacy and safety of ITTVR for significant TR in adult. The primary outcomes were the improvement of New York Heart Association (NYHA) functional class and 6-minutes walking distance (6MWD) and the presence of severe or greater TR at the last available follow-up of each individual study. Random-effect meta-analysis was performed comparing outcomes before and after ITTVR.

Results

14 studies with 771 patients were included. Mean age was 77±8 years and mean EuroScore II was 6.8%±5.4%. At a weighted mean follow-up of 212 days, 209 (35%) patients had a NYHA III to IV functional class compared to 586 (84%) patients at baseline (risk ratio: 0.23, 95% CI 0.13 to 0.40, P-value&lt;0.001). 6MWD significantly improved from 237±113 meters to 294±105 meters (mean difference: +50 meters, 95% CI +34 to +66 meters, P-value&lt;0.001). 147 (24%) patients showed severe or greater TR after ITTVR compared to 616 (96%) at baseline (risk ratio: 0.29, 95% CI 0.20 to 0.42, P-value&lt;0.001).

Conclusion

Patients undergoing ITTVR for significant TR experienced a significant improvement in NYHA functional status and 6MWD and a significant reduction in TR severity at mid-term follow-up.

Funding Acknowledgement

Type of funding sources: None.

Interventricular Septal Rupture in a 62-Year-Old Man With Familial Amyloid Polyneuropathy

Cardiac involvement in familial amyloid polyneuropathy consists of arrhythmias, conduction disturbances, and heart failure. To our knowledge, heart rupture has never been described in association with this condition. We report the case of a 62-year-old man with a 6-year history of refractory familial amyloid polyneuropathy who underwent liver transplantation. The operation was complicated by severe hypotension because the neuropathy involved the autonomic system. Perioperatively, the patient had a myocardial infarction, and during the next 10 days, a complete interventricular septal rupture developed, resulting in a systemic-to-pulmonary shunt. Coronary angiographic findings were normal. However, the shunt caused unstable hemodynamics, resulting in cardiogenic shock. An attempt to close the rupture percutaneously failed. The patient underwent successful heart transplantation 50 days later. Macroscopic examination of the explanted heart showed thickening of both ventricles, septal rupture, and a gray scar in the interventricular septum around the cavity. Histopathologic examination revealed intramural amyloid angiopathy. Our case shows that heart rupture can occur in patients with familial amyloid polyneuropathy who have no history of obstructive coronary artery disease, perhaps as a result of tissue fragility caused by amyloid angiopathy. Therefore, autonomic disturbances should be regarded with concern and promptly treated in the perioperative period.

Identification of novel circulating microRNAs in advanced heart failure by next-generation sequencing

Aims

Risk stratification in patients with advanced chronic heart failure (HF) is an unmet need. Circulating microRNA (miRNA) levels have been proposed as diagnostic and prognostic biomarkers in several diseases including HF. The aims of the present study were to characterize HF‐specific miRNA expression profiles and to identify miRNAs with prognostic value in HF patients.

Methods and results

We performed a global miRNome analysis using next‐generation sequencing in the plasma of 30 advanced chronic HF patients and of matched healthy controls. A small subset of miRNAs was validated by real‐time PCR (P < 0.0008). Pearson's correlation analysis was computed between miRNA expression levels and common HF markers. Multivariate prediction models were exploited to evaluate miRNA profiles' prognostic role. Thirty‐two miRNAs were found to be dysregulated between the two groups. Six miRNAs (miR‐210‐3p, miR‐22‐5p, miR‐22‐3p, miR‐21‐3p, miR‐339‐3p, and miR‐125a‐5p) significantly correlated with HF biomarkers, among which N‐terminal prohormone of brain natriuretic peptide. Inside the cohort of advanced HF population, we identified three miRNAs (miR‐125a‐5p, miR‐10b‐5p, and miR‐9‐5p) altered in HF patients experiencing the primary endpoint of cardiac death, heart transplantation, or mechanical circulatory support implantation when compared with those without clinical events. The three miRNAs added substantial prognostic power to Barcelona Bio‐HF score, a multiparametric and validated risk stratification tool for HF (from area under the curve = 0.72 to area under the curve = 0.82).

Conclusions

This discovery study has characterized, for the first time, the advanced chronic HF‐specific miRNA expression pattern. We identified a few miRNAs able to improve the prognostic stratification of HF patients based on common clinical and laboratory values. Further studies are needed to validate our results in larger populations.

Prognostic value and usefulness of Pulmonary Artery Pulsatility index (PAPi) in evaluation of heart transplant candidates

Background

Heart transplantation (HTx) is considered the best available treatment for patients with end stage heart failure. Candidate evaluation with right heart catheterization (RHC) is fundamental in order to exclude pulmonary hypertension with irreversible high pulmonary vascular resistance (PVR), which is associated with elevated post-HTx mortality. PVR, rather than directly measured, is derived by cardiac output and pulmonary artery pressures, which are strictly dependent on right ventricular (RV) function. The pulmonary artery pulsatility index (PAPi) is a hemodynamic parameter integrating the information of RV function and of pulmonary circulation, which could be useful in pre-HTx evaluation.

Purpose

We designed this study to evaluate the potential predictive influence of pre-HTx PAPi on post-HTx survival and to assess whether this index could add useful information in the pre-HTx evaluation of patients with advanced heart failure.

Methods

Consecutive adult HTx recipient at two medium-large tranplant centers between 2000 and 2017 with available data on pre-HTx RHC were retrospectively included. PAPi was calculated as the ratio of pulmonary artery pulse pressure to right atrial pressure. PAPi values in the lowest quartile were defined as reduced (PAPi&lt;1.67). The primary endpoint was all-cause mortality at 1-year post-HTx. The association of reduced PAPi with the primary endpoint was evaluated. Cox regression was used to adjust for clinical and hemodynamic variables. Analyses stratified by PVR status (≥3 WU vs. &lt;3 WU) were also performed.

Results

Among 655 HTx recipients (female 20,8%, age 53±11 years), median pre-HTx PAPi was 3.0 (interquartile range 1.67–5.32). Patients in the lowest versus the remaining PAPi quartiles had significantly reduced 1-year survival (78.0% vs 87.2%, p=0.006), also after adjusting for age, estimated glomerular filtration rate, total bilirubin, high PVR and urgent transplantation (adj-hazard ratio: 0.64; 95% confidence interval 0.51–0.82). When stratifying patients by estimated PVR status, reduced PAPi was associated with worse 1-year survival among patients with normal PVR (78.3% vs. 88.3% p=0.011), but not in those with increased PVR (78.0% vs. 82.6%, p=0.36) (Figure 1).

Conclusions

Pre-HTx PAPi, integrating information of RV function and pulmonary circulation, provides incremental prognostic value over traditional clinical and hemodynamic parameters among HTx recipient. The prognostic value appears important among patients with normal estimated PVR, possibly due to an underestimation of PVR in patients with impaired RV function. The integration of PAPi in the pre-HTx evaluation may lead to better patient selection and post-HTx survival.

Figure 1. 1 year survival stratified by PVR status

Funding Acknowledgement

Type of funding source: None

A case series of novel coronavirus infection in heart transplantation from 2 centers in the pandemic area in the North of Italy

Background

Little is known about the coronavirus SARS-CoV-2 disease (COVID-19) in solid organ transplanted patients. We here report a series of heart transplanted patients with COVID-19 from two centers of Italy.

Methods

All heart transplanted patients of Transplant Centers of Bergamo and Torino with a microbiologically confirmed SARS-CoV-2 infection were enrolled. Data collection included clinical presentation, laboratory and radiological findings, treatment and outcome. Follow-up was performed by visit or phone.

Results

From February to March 2020 twenty-six heart transplanted patients (age 62±12 years; 77% males; time from transplant 10±10 years; 69% with comorbidities) had a microbiologically confirmed COVID-19. The most frequent symptom was fever, followed by cough. Seventeen patients had a pneumonia, 8 of them severe pneumonia. Seven patients died (27%) and 17 (65%) were hospitalized. Discontinuation of immunosuppression was associated with death (71 vs 21%, p=0.02). Conversely, all patients receiving steroids survived (p<0.001). Patients who received heart transplantation during COVID-19 outbreak survived and no acute graft rejection occurred. Patients who died were older than survivors, had a longer time from transplant and a worse clinical presentation at diagnosis.

The current regimen enabled the prolonged survival and function of orthotopic cardiac xenografts in altogether 6 of 8 baboons, of which 4 were now added. These results exceed the threshold set by the Advisory Board of the International Society for Heart and Lung Transplantation.

Conclusions

COVID-19 has a significant impact on long term heart transplanted patients. Conversely, SARS-CoV-2 infection seems to have a limited influence on more recent transplants. Our experience may suggest that heart transplantation programs can be maintained even during the pandemic phase if specific and tailored paths to prevent and to limit virus transmission are provided.

P2685Improving myocardial perfusion in refractory angina: extracorporeal shockwave myocardial revascularization in a monocentric cohort

Background

The incidence of patients with refractory angina (RA) is increasing. Medical therapy for RA is limited and prognosis is poor. Experimental data and small clinical studies suggest that the use of Extracorporeal shockwave myocardial revascularization (ESMR) may contribute to angiogenesis and improve symptoms in patients with RA.

Purpose

The aim of this study was to assess the efficacy of ESMR in the improvement of myocardial perfusion and symptoms in patients with RA.

Methods

Patients with RA despite optimal medical therapy and not suitable for further myocardial revascularization were enrolled and underwent ESMR. Characteristics such as angina class scores (CCS class score), nitroglycerin consumption and hospitalization rate among cases (patients with RA who received ESMR) and controls (patients with RA who did not receive ESMR) were compared at baseline and 6 months after ESMR therapy. In patients receiving ESMR the effect of on cardiac perfusion was assessed at six months.

Results

Among screened patients, 159 met the inclusion/exclusion criteria. 151 patients were enrolled in the present study and 121 treated with ESMR. There were 121 patients in the treatment group and 29 patients in the control group. The mean age of the patients was 70±8.8 years in the case group and 71±5.3 years in the control group. Other characteristics were similar in both groups. After ESMR myocardial perfusion by SPECT significantly improved: mean SSS was reduced from 21.2±9.42 to 14.2±10, with a 33% relative reduction (p=0.0001). Clinical follow up of both group demonstrated a significant improvement CCS class score at six months (1.5±0.6 in treatment and 1.92±0.69 in controls; p 0.0013) a significant improvement NYHA class score (1.4±0.6 in cases and 1.73±0.59 in controls; p 0.008); also, nitroglycerin consumption (29% in case cases, and 44.8% in controls; P 0.15) and hospitalization rate were reduced in the treatment group compared to control (16% vs. 37.9%; P 0.02).

Clinical outcome of two groups at 6 months follow up Treatment group (n=121) Control group (n=29) p CCS class 1.5±0.6 1.92±0.7 <0.001 NYHA class 1.4±0.6 1.7±0.6 <0.008 Nitrates uptake 35 (29%) 13 (45%) <0.15 Admission to emergency department 20 (16%) 11 (38%) <0.02

SPECT results after 6 months follow up

Conclusion

ESMR therapy is a non-invasive safe and potentially effective new option for patients with refractory angina. This study confirms the beneficial effect of ESMR therapy on cardiac symptoms, myocardial perfusion and hospitalizations in patients with refractory angina.

Diuretic treatment in high-risk acute decompensation of advanced chronic heart failure-bolus intermittent vs. continuous infusion of furosemide: a randomized controlled trial

BACKGROUND

Diuretic resistance is a common issue in patients with acute decompensation of advanced chronic heart failure (ACHF). The aim of this trial was to compare boluses and continuous infusion of furosemide in a selected population of patients with ACHF and high risk for diuretic resistance.

METHODS

In this single-centre, double-blind, double-dummy, randomized trial, we enrolled 80 patients admitted for acute decompensation of ACHF (NYHA IV, EF ≤ 30%) with criteria of high risk for diuretic resistance (SBP ≤ 110 mmHg, wet score ≥ 12/18, and sodium ≤ 135 mMol/L). Patients were assigned in a 1:1 ratio to receive furosemide by bolus every 12 h or by continuous infusion. Diuretic treatment and dummy treatment were prepared by a nurse unassigned to patients' care. The study treatment was continued for up to 72 h. Coprimary endpoints were total urinary output and freedom from congestion at 72 h.

RESULTS

80 patients were enrolled with 40 patients in each treatment arm. Mean daily furosemide was 216 mg in continuous-infusion arm and 195 mg in the bolus intermittent arm. Freedom from congestion (defined as jugular venous pressure of < 8 cm, with no orthopnea and with trace peripheral edema or no edema) occurred more in the continuous infusion than in the bolus arm (48% vs. 25%, p = 0.04), while total urinary output after 72 h was 8612 ± 2984 ml in the bolus arm and 10,020 ± 3032 ml in the continuous arm (p = 0.04). Treatment failure occurred less in the continuous-infusion group (15% vs. 38%, p = 0.02), while there was no significant difference between groups in the incidence of worsening of renal function.

CONCLUSION

Among patients with acute decompensation of ACHF and high risk of diuretic resistance, continuous infusion of intravenous furosemide was associated with better decongestion.

DRAIN TRIAL

ClinicalTrials.gov number NCT03592836.

G-CSF for Extensive STEMI

RATIONALE

In the exploratory Phase II STEM-AMI (Stem Cells Mobilization in Acute Myocardial Infarction) trial, we reported that early administration of G-CSF (granulocyte colony-stimulating factor), in patients with anterior ST-segment-elevation myocardial infarction and left ventricular (LV) dysfunction after successful percutaneous coronary intervention, had the potential to significantly attenuate LV adverse remodeling in the long-term.

OBJECTIVE

The STEM-AMI OUTCOME CMR (Stem Cells Mobilization in Acute Myocardial Infarction Outcome Cardiac Magnetic Resonance) Substudy was adequately powered to evaluate, in a population showing LV ejection fraction ≤45% after percutaneous coronary intervention for extensive ST-segment-elevation myocardial infarction, the effects of early administration of G-CSF in terms of LV remodeling and function, infarct size assessed by late gadolinium enhancement, and myocardial strain.

METHODS AND RESULTS

Within the Italian, multicenter, prospective, randomized, Phase III STEM-AMI OUTCOME trial, 161 ST-segment-elevation myocardial infarction patients were enrolled in the CMR Substudy and assigned to standard of care (SOC) plus G-CSF or SOC alone. In 119 patients (61 G-CSF and 58 SOC, respectively), CMR was available at baseline and 6-month follow-up. Paired imaging data were independently analyzed by 2 blinded experts in a core CMR lab. The 2 groups were similar for clinical characteristics, cardiovascular risk factors, and pharmacological treatment, except for a trend towards a larger infarct size and longer symptom-to-balloon time in G-CSF patients. ANCOVA showed that the improvement of LV ejection fraction from baseline to 6 months was 5.1% higher in G-CSF patients versus SOC (P=0.01); concurrently, there was a significant between-group difference of 6.7 mL/m² in the change of indexed LV end-systolic volume in favor of G-CSF group (P=0.02). Indexed late gadolinium enhancement significantly decreased in G-CSF group only (P=0.04). Moreover, over time improvement of global longitudinal strain was 2.4% higher in G-CSF patients versus SOC (P=0.04). Global circumferential strain significantly improved in G-CSF group only (P=0.006).

CONCLUSIONS

Early administration of G-CSF exerted a beneficial effect on top of SOC in patients with LV dysfunction after extensive ST-segment-elevation myocardial infarction in terms of global systolic function, adverse remodeling, scar size, and myocardial strain.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01969890.

Extracorporeal membrane oxygenation after lung transplantation: risk factors and outcomes analysis

Background

Lung transplantation is the treatment of choice for end-stage pulmonary disease in selected patients. However, severe primary graft dysfunction is a significant complication of transplant and requires the implantation of an extracorporeal support. The aim of the study is to evaluate the impact of extracorporeal membrane oxygenation (ECMO) after transplant in our center.

Methods

From January 2008 till June 2018, 195 consecutive unselected patients receiving a lung transplant were considered. Mean age was 49±15 years. Main indications for transplant were idiopathic pulmonary fibrosis in 72 patients, chronic obstructive pulmonary disease in 60 patients, and cystic fibrosis in 40 patients. Prior to transplant, 18 patients were on mechanical ventilation and 14 were on ECMO.

Results

Twenty-five patients required venous-venous ECMO after transplant. Vascular disease as cause of transplant [relative risk (RR) 7.8, 95% CI: 1.5-41, P=0.02], donor age (RR 1.6, 95% CI: 1.03-2.3, P=0.03) and need for cardiopulmonary by-pass during transplant (RR 3.1, 95% CI: 1.02-9, P=0.04) were associated with ECMO implantation. Patients requiring post-transplant ECMO received more transfusions (P<0.01), had a longer mechanical ventilation (P<0.01) and ICU stay (P<0.01) and had a higher hospital mortality (P<0.01). Post-transplant ECMO significantly influenced one- and five-year survival [hazard ratio (HR) 5.5, 95% CI: 3-10, P<0.001 and HR 3.5, 95% CI: 2-6, P<0.001, respectively]. However, conditional survival after t months is similar for patients with or without post-transplant ECMO.

Conclusions

In our experience, although ECMO is a reliable and effective strategy to support pulmonary function, severe graft dysfunction after lung transplantation still has a significant impact on early and late results.

Noninvasive Assessment of Hemodynamic Status in HeartWare Left Ventricular Assist Device Patients: Validation of an Echocardiographic Approach

OBJECTIVES

The aim of this prospective study was to validate an echocardiographic protocol derived from 5 HeartWare left ventricular assist device (HVAD) patients for the noninvasive evaluation of right atrial pressure (RAP) and left atrial pressure (LAP) in HVAD patients.

BACKGROUND

Echocardiography is an invaluable tool to optimize medical treatment and pump settings and also for troubleshooting residual heart failure. Little is known about the echocardiographic evaluation of hemodynamic status in HVAD patients.

METHODS

Right heart catheterization and Doppler echocardiography were performed in 35 HVAD patients. Echocardiography-estimated RAP (eRAP) was assessed using inferior vena cava diameter, hepatic venous flow analysis, and tricuspid E/e' ratio. Echocardiography-estimated LAP was assessed using E/A ratio, mitral E/e' ratio, and deceleration time.

RESULTS

eRAP and estimated LAP significantly correlated with invasive RAP and LAP (respectively, r = 0.839, p < 0.001, and r = 0.889, p < 0.001) and accurately detected high RAP and high LAP (respectively, area under the curve 0.94, p < 0.001, and area under the curve 0.91, p < 0.001). High eRAP was associated with high LAP (area under the curve 0.92, p < 0.001) and correlated with death or hospitalization at 180 days (odds ratio: 8.2; 95% confidence interval: 1.1 to 21.0; p = 0.04). According to estimated LAP and eRAP, patients were categorized into 4 hemodynamic profiles. Fifteen patients (43%) showed the optimal unloading profile (normal eRAP and normal wedge pressure). This profile showed a trend toward a lower risk for adverse cardiac events at follow-up (odds ratio: 0.2; 95% confidence interval: 0.1 to 1.0; p = 0.05) compared with other hemodynamic profiles.

CONCLUSIONS

Doppler echocardiography accurately estimated hemodynamic status in HVAD patients. This algorithm reliably detected high RAP and LAP. Notably, high RAP was associated with high wedge pressure and adverse outcome. The benefit of noninvasive estimation of hemodynamic status in the clinical management of patients with left ventricular assist devices needs further evaluation.

Meta-analysis of the usefulness of Mitraclip in patients with functional mitral regurgitation

Midterm outcomes for patients presenting with heart failure and functional mitral regurgitation (MR) treated with Mitraclip remain unclear. Pubmed, Medline, and Google Scholar were systematically searched for studies enrolling patients with severe-moderate MR who underwent Mitraclip implantation. All events after at least 6 months were the primary safety end point (including death, rehospitalization for heart failure, and reinterventions), whereas change in the ejection fraction, left ventricular volumes, arterial pulmonary pressure, and left atrial diameters were considered as secondary end points. Meta-regression analysis was performed to evaluate the effect of baseline clinical and echocardiographic parameters on efficacy outcomes: 875 patients were included in 9 studies; 1.48 clips (1.3 to 1.7) for patients were implanted, and after a median follow-up of 9 months (6 to 12), 409 patients (78% [75% to 83%]) were in class New York Heart Association I/II and 57 (11% [8% to 14%]) still had moderate-to-severe MR. Overall adverse events occurred in 137 (26% [20% to 31%]) of the patients and 78 (15% [1% to 17%]) of them died; 6-minute walk test improved by 100 m (83 to 111), whereas a significant reduction in left ventricular volumes and systolic pulmonary pressure was reported. At meta-regression analysis, an increase in left ventricle systolic volumes positively affected reduction of volumes after Mitraclip, whereas atrial fibrillation reduced the positive effect of the valve implantation on ejection fraction on end-diastolic and -systolic volumes. In conclusion, Mitraclip represents an efficacious strategy for patients with heart failure and severe MR. It offers a significant improvement in functional class and in cardiac remodeling, in patients with severely dilated hearts as well, although its efficacy remains limited in the presence of atrial fibrillation.

Clinical and prognostic role of ammonia in advanced decompensated heart failure. The cardio-abdominal syndrome?

BACKGROUND

Advanced heart failure is associated with end-organ damage. Recent literature suggested an intriguing crosstalk between failing heart, abdomen and kidneys. Venous ammonia, as a by-product of the gut, could be a marker of abdominal injury in heart failure patients. The aim of the study was to investigate the clinical and prognostic role of ammonia in patients with advanced decompensated heart failure (ADHF).

METHODS & RESULTS

90 patients admitted with ADHF were prospectively studied. The prognostic role of ammonia at admission was evaluated. Primary end-points were: a composite of cardiac death, urgent heart transplantation and mechanical circulatory support at 3 months and need for renal replacement therapies (RRT). In the study cohort (age 59.0 ± 12.0 years, FE 21.6 ± 9.0%, INTERMACS profile 3.7 ± 0.9, creatinine 1.71 ± 0.95 mg/dl) 27 patients (30%) underwent the cardiac composite endpoint, while 9 patients (10%) needed RRT. At ROC curve analysis ammonia ≥ 130 μg/dl (abdominal damage) showed the best diagnostic accuracy. At multivariate analysis abdominal damage predicted the cardiac composite endpoint. Abdominal damage further increased risk among patient with cold profile at admission (HR 2.7, 95% CI 1.1-7.0, p = 0.046). At multivariate analysis abdominal damage also predicted need for RRT (OR 10.8, 95% CI 1.5-75.8, p = 0.017). The combined use of estimated right atrial pressure and ammonia showed the highest diagnostic accuracy and a very high specificity in prediction of need for RRT.

CONCLUSION

In a selected population admitted for ADHF ammonia, as a marker of abdominal derangement, predicted adverse cardiac events and need for RRT.