Sodium nitroprusside for advanced heart failure. A metanalysis of literature data

Advanced heart failure (HF) is associated with a very poor prognosis and places a big burden on health-care services. The gold standard treatment, i.e. long-term mechanical circulatory support or heart transplantation, is precluded in many patients but observational studies suggest that the use of SNP might be associated with favourable long-term clinical outcomes. We performed a metanalysis of published studies that compared sodium nitroprusside (SNP) with optimal medical therapy to examine the safety and efficacy of SNP as part of the treatment regimen of patients hospitalized for advanced heart failure (HF). We searched PUBMED, EMBASE and WEB OF SCIENCE for studies that compared SNP with optimal medical therapy in advanced HF on July 2022. After screening 700 full-text articles, data from two original articles were included in a combined analysis. The analysis demonstrated a 66% reduction in the odds of death in advanced HF patients treated with SNP. The results show the potential importance of the inclusion of SNP in the treatment regimen of patients hospitalized because of advanced HF and underlines that controlled, randomized studies are still required in this condition.

The crucial role of tricuspid regurgitation in patients with pulmonary arterial hypertension

Introduction

Pulmonary arterial hypertension (PAH) is a rare and progressive disease with high morbidity and mortality rate and its prognosis is critically affected by right ventricle (RV) dysfunction. Several studies have demonstrated that the presence of moderate-severe tricuspid regurgitation (TR) is associated with poor prognosis in PAH. However, the echocardiographic correlates and the impact on functional capacity of significant TR in PAH patients have not been thoroughly investigated.

Purpose

The aims of this study were to confirm the prognostic role of moderate-to-severe TR in PAH patients and to assess the effects of significant TR on remodelling of right cardiac chambers evaluated by echocardiography and on exercise capacity determined by six minute-walking-test (6MWT) and cardiopulmonary exercise testing (CPET).

Methods

This study is a retrospective longitudinal analysis of 103 patients with newly diagnosed PAH enrolled from 2010 to march 2021. Patients with portopulmonary PAH and with congenital heart disease PAH were excluded. Median follow up (FU) was 27 months and the primary endpoint was all-cause mortality.

Results

Our cohort was characterised by high BNP mean values (382 pg/mL), poor exercise capacity (260 mt at 6MWT, peak VO2 11 mL/kg/min at CPET), right ventricular dysfunction and severe PH at right heart catheterization (cardiac index 2.3 L/min/mq, mean pulmonary artery pressure 48 mmHg, pulmonary vascular resistance 12 WU). Sixty-nine percent (70/103) of the cohort had significant TR. Thirty percent of patients (30/103) died during follow-up.

At Cox univariate regression, moderate to severe TR was significantly associated with higher risk of death (HR 4.48, p=0.004) (Figure 1). At bivariate analysis combining TR grade and TAPSE/sPAP, significant TR showed to be associated with higher risk of death (HR 3.59, p=0.05). In particular, the combination of normal TAPSE and mild TR identified a subgroup of patients who had no events during the follow-up period (Figure 2).

At echocardiography patients with moderate-to-severe TR had more peripheral venous congestion, worse right ventricular function (TAPSE and TAPSE/sPAP), lower stroke volume index. The presence of moderate-to-severe TR promoted negative remodelling of the right atrium and of the right ventricle, which was more spherical, hypertrophic and stiff. Exercise capacity of patient with significant TR was significantly reduced both at CPET and at 6MWT.

Conclusions

Moderate-to-severe tricuspid regurgitation is associated with poor exercise capacity (both at CPET and at 6MWT) and poor survival in patients with PAH. Echocardiography can easily detect morphological and functional abnormalities associated with a worse prognosis in patients with PAH and represents an important non-invasive tool for risk stratification.

Funding Acknowledgement

Type of funding sources: None.

Hadrontherapy for intra- or para-cardiac tumors: evaluation of cardiac radiation dose distribution and acute cardiac effects

Background

There is growing interest in the possibility of using X-rays and hadrons (protons and carbon ions) for antiarrhythmic purposes both at the ventricular and the atrial level, but knowledge about the effects on cardiac tissue outside the target is still limited. Hadron therapy has the dosimetric advantage over photons of a greater ability to concentrate high doses on the target while minimizing the off-target dose. Oncological studies have shown a linear relationship between the mean total heart dose (Dm-heart) of X-rays and the long-term risk of heart damage, particularly when the Dm-heart is>5 Gray (Gy).

Objectives

We designed a prospective study aimed at investigating the effect of heavy particles on cardiac structure and function and on cardiac rhythm in patients undergoing hadrontherapy for intra or para-cardiac tumors.

Methods

Patients candidates to hadrontherapy with a mean predicted cardiac dose grather than zero underwent close cardiological monitoring including blood pressure detection, 12-lead ECG, 12-lead Holter ECG (including time-domain indices of heart rate variability in all cases and Brugada leads in selected cases), cardiac US and cardiac (troponin and natriuretic peptides) and inflammatory biomarkers. These assessments were obtained at baseline, during (ECG and biomarkers only) and at the end of the hadrontherapy cycle, and then every 3–6 months as appropriate. Physicists and radiotherapists collaborated to implement a robust optimization of the treatment plan aimed at minimizing cardiac dose. We present the results of the monitoring up to the end of the hadrontherapy.

Results

17 consecutive patients (56±18 years, range 20–77 years, 59% male) have been enrolled to date, including 3 cases (18%) of intra-cardiac tumors (2 primary and 1 metastatic), who have undergone to 16±6 sessions of radiotherapy each, in 71% of cases with respiratory gating during delivery. Most patients (76%) were treated with carbon ions, the remaining with protons (mean total dose on the neoplastic target 51.8±10.7 Gy, from 2 to 4.2 Gy per fraction). Sixty-one percent of patients had ≥1 cardiovascular risk factor, 6% had a known heart disease (valvular cardiomyopathy despite aortic valve replacement with biological prosthesis and post-surgical pericarditis). The mean dose on the whole heart was 3.58±2.05 Gy, the maximum dose was 33.78±23.99 Gy, with a very variable dose distribution on cardiac substructures depending on the tumor site (table). At the end of the scheduled radiotherapy sessions (24±9 days), no significant changes were observed in cardiac function, cardiac rhythm, ventricular repolarization, biomarkers and autonomic indices.

Conclusions

Hadrontherapy with protons and carbon ions aimed at the treatment of para-cardiac or intra-cardiac tumors allowed to maintain a low heart Dm and showed no signs of acute cardiac toxicity. The collection of potential cardiac effects in the medium and long term is ongoing.

Funding Acknowledgement

Type of funding sources: None.

Long-term outcome of patients with cardiolaminopathy undergoing defibrillator implantation: single-center experience

Background

Mutations in the LMNA gene are associated with a high arrhythmic risk. The history of the disease in patients undergoing ICD implantation is poorly characterized.

Purpose

To evaluate the phenotype of patients with cardiolaminopathy at the time of first ICD implantation, the incidence, characteristics and timing of ventricular arrhythmias (VAs) during follow up and the predictive value of the European score (that assigns a point each to non-sustained VT (NSVT), left ventricular ejection fraction (LVEF)<45% at first contact, male sex and non-missense mutations) and of the Wahbi score (that also includes conduction disturbances) for both VAs and heart failure (HF) related outcomes.

Methods

Patients were identified retrospectively. Clinical and device data were collected at baseline and during follow-up.

Results

We identified 26 patients (54% male, 42±8 years, 31% with familial history of sudden cardiac death, 31% with non-missense mutation) undergoing ICD implantation, 96% in primary prevention, 47% with single chamber ICD, 38% with dual chamber ICD. At the time of implantation, 30% had skeletal muscle involvement, 15% history of syncope, 4% of cardiac arrest, 62% previous NSVT. Also, 38% had a history of supraventricular arrhythmias and 61% had AV conduction disturbances. LVEF was 41±11%, 35% were in NYHA class ≥2, the mean European and Wahbi scores were 2.1±0.8 and 18.2±8.9, respectively. During 8.3±5 years, 15% were transplanted, 8% died due to HF, 4% underwent LVAD implantation, despite 31% having received an upgrade to CRT-D. Appropriate device interventions occurred in 46% of patients with a median time to first event of 29 months (IQR 13–93), for a total of 137 ATP, 51% of which effective (median 3ATP/patient, IQR 1–8) and of 26 shocks, 96% of which effective (median 2 shocks/patient, IQR 1–3); 12% had an arrhythmic storm. The first treated arrhythmia was a polymorphic VT/VF in 17%, a monomorphic VT in the others (medium cycle length 293±37 msec). Survival free from appropriate ICD interventions at 1 and at 5 years was 75% and 19% respectively in case of a European score ≥3 vs 94% and 82% in case of a score <3 (Logrank test p<0.01), 72% and 46% in case of Wahbi score ≥30 vs 100% and 86% with score <30 (p<0.01), with no differences in terms of death/transplant (figure). At last follow-up, 92% of patients a were taking beta-blocker, 42% amiodarone, 8% sotalol, 4% flecainide, 8% mexiletine. Also, 4% had undergone invasive VT ablation, 8% bilateral cardiac sympathetic denervation.

Conclusions

Patients with cardiolaminopathy are at a high risk of both arrhythmic and heart failure progression over the first decade after implantation of the first ICD. A European score ≥3 identifies patients with 5-year shock/ATP free survival of less than 20% but does not predict death/transplantation. The first arrhythmic event in these patients is more frequently a rapid monomorphic VT with modest ATP efficacy.

Funding Acknowledgement

Type of funding sources: None.

Myocardial injury in patients hospitalized for SARS-CoV19: a maker or a marker of prognosis?

Background

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, literature data are progressively accumulating, attesting to the possible prognostic role of cardiac troponins in patients who need hospitalization because of COVID-19 infection.

Purpose

To assess whether myocardial injury (measured by high sensitivity troponins) is an independent cause of disease severity and prognosis.

Methods

We performed a patient-level metanalysis (PROSPERO ID: CRD42020213209) in unselected patients hospitalized because of COVID-19 infection in whom the severity of respiratory failure was also evaluated at admission. To allow for comparison, troponin values were normalized to their threshold levels to obtain a normalized troponin (nTn) value which was used as a continuous variable in all analysis.

Results

A total of 722 patients were included in the analysis. Of note, patients who had elevated troponins at hospital admission had a significantly lower oxygenation status than those with normal nTn (PaO2/FiO2 232±215 vs. 276±124 mmHg/%; p<0.001). On the contrary, those with cardiovascular comorbidities had similar PaO2/FiO2 but higher nTn than those without (5.6817 vs. 2.1110 ng/mL; p=0.002).

After a median follow-up of 14 days, 180 deaths were observed. At multivariable regression analysis, age, male sex, moderate-severe renal dysfunction (eGFR <30 mL/min/m2) and lower PaO2/FiO2, were independent predictor of death (igure 1). The restricted cubic spline curves in Figure 2A and 2B show the hazard ratios (HRs) and 95% confidence interval for death according to nTn and PaO2/FiO2 levels as continuous variables. A linear increase in the HR is observed with lower PaO2/FiO2 values below the normal value of 300. On the contrary, the nTn spline curve is near-flat with large confidence interval for values above the normality thresholds.

Conclusion

In patients hospitalized for COVID-19, mortality is mainly driven by gender, age and respiratory failure while myocardial damage is not an independent predictor of worse survival when respiratory function is accounted for.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Long-term follow-up of heart transplant patients treated with permanent pacemaker: a monocentric study

Funding Acknowledgements

Type of funding sources: None.

Background and purpose

Permanent pacemaker implantation (PPMi) is needed in about 5% of patients following heart transplant (HTx) primarily due to sinus node dysfunction (SND), which commonly occurs in an early phase, or to atrio-ventricular block (ABV), which is common later on. Currently, data on rate of ventricular pacing (VP) is lacking and little is known on long-term outcomes after PPMi.

Methods

This was a retrospective, monocentric study. Among 1123 patients treated with HTx, all with biatrial technique, from november 1985 to march 2019 at our institution, 61 (5.4%) patients needed PPMi. PM parameters, clinical and echocardiographic data were collected at 1 month and at 1-3-5-10 years follow-up. The primary aim was to analyse the percentage of right ventricular pacing in the overall population and in subgroups stratified by the timing of PPMi and by pacing indication. Secondary endpoints were to analyze long-term outcomes according to the percentage of ventricular pacing and to the type of implanted PM (single vs. dual chamber). 

Results

Among patients treated with PPMi (68.9% single-chamber), 62.2% were implanted for SND and 36% for AVB. Early PPMi (< 3 months after HTx), occurred in 34.4% of patients, mainly due to SND, while late PPMi (> 3 months after HTx) occurred in 65,6% with an equal distribution between SND and AVB. Median follow-up time from HTx was 140 months and 82 months from PPMi. Overall mean rate of VP was 21%. Rate of VP was higher in patients implanted early rather than late after HTx, both at 1 month (91% vs 2%, P = 0,002) and at 1 year after the procedure (43 vs 1, P = 0,037). Patients with AVB had a greater rate of VP compared to those implanted for SND, irrespective of timing of implantation and these findings were still present at 3 and 5 years follow-up (62 vs 1%, P = 0,011 at 3 years and 80 vs 6%, P = 0,002 at 5 years). VP declined progressively after PPM implantation. No differences were observed in terms of 10-years mortality between early vs late PPMi, dual vs single-chamber and mean VP > 21% vs ≤ 21%.

Conclusions

Patients treated with PPMi after HTx show on average low percentage of VP over long-term follow-up. AV block indication and early implantation are associated with a higher percentage of VP. The rate of VP, the timing of PPMi and the use of single vs dual chamber PM do not affect overall prognosis or left ventricular systolic function. Our data may justify implantation of a single-chamber PPM, which bears less complications and procedural time, in the majority of HTx patients needing PPMi.

Extract from the Marine Seaweed Padina pavonica Protects Mitochondrial Biomembranes from Damage by Amyloidogenic Peptides

The identification of compounds which protect the double-membrane of mitochondrial organelles from disruption by toxic confomers of amyloid proteins may offer a therapeutic strategy to combat human neurodegenerative diseases. Here, we exploited an extract from the marine brown seaweed Padina pavonica (PPE) as a vital source of natural bioactive compounds to protect mitochondrial membranes against insult by oligomeric aggregates of the amyloidogenic proteins amyloid-β (Aβ), α-synuclein (α-syn) and tau, which are currently considered to be major targets for drug discovery in Alzheimer's disease (AD) and Parkinson's disease (PD). We show that PPE manifested a significant inhibitory effect against swelling of isolated mitochondria exposed to the amyloid oligomers, and attenuated the release of cytochrome c from the mitochondria. Using cardiolipin-enriched synthetic lipid membranes, we also show that dye leakage from fluorophore-loaded vesicles and formation of channel-like pores in planar bilayer membranes are largely prevented by incubating the oligomeric aggregates with PPE. Lastly, we demonstrate that PPE curtails the ability of Aβ42 and α-syn monomers to self-assemble into larger β-aggregate structures, as well as potently disrupts their respective amyloid fibrils. In conclusion, the mito-protective and anti-aggregator biological activities of Padina pavonica extract may be of therapeutic value in neurodegenerative proteinopathies, such as AD and PD.

Determinants of pulmonary vascular resistance reduction with upfront oral therapy in idiopathic pulmonary arterial hypertension: relevance in risk assessment

Background

In pulmonary arterial hypertension (PAH) upfront oral therapy represents the standard of care for naive patients at low and intermediate risk. However little is known about associated changes in risk assessment and prediction of low risk status achievement.

Purpose

To evaluate determinants of PVR reduction in patients treated with upfront oral therapy and to create a score to predict PVR reduction after upfront oral treatment and compared its additive value on top of the European and REVEAL scoring system in predicting treatment response.

Methods

One-hundred-eighty-one consecutive naive PAH patients treated with upfront therapy at 11 italian centers were retrospectively evaluated. Evaluation included clinical, hemodynamic and simple echocardiographic parameters, together with European and REVEAL 2.0 risk scores.

Results

At the time of diagnosis, the majority of the patients was idiopathic PAH (80.6%), female (66.3%), at intermediate risk, 71.8% and 55.2%, respectively, according to the European (average method) and the REVEAL 2.0 risk scores. Ambrisentan-Tadalafil was the most frequent combination used (62%). The median PVR reduction obtained after 180 days (IQR 79–394) was −40.4% (IQR −25.8; −45.3).

Age ≥60 years, male-sex, baseline mPAP 48 mmHg associated with low CI (<2.5 l/min/m2), and RV/LV ratio >1 associated with low TAPSE (<18 mm) emerged as independent predictors of poor PVR reduction, defined as the lower tertile of PVR changes (−25.8%). A treatment response score was created deriving weighted integers from the beta coefficient.

At second evaluation 78 (43.1%) patients achieved or remained at European-derived low risk status, while 63 (34.8%) considering the REVEAL 2.0 score.

Multivariate analysis for the prediction of treatment failure, defined as the absence of low-risk status at follow-up, demonstrated the incremental prognostic power of the models incorporating the treatment response score (≥3) on top of the European and REVEAL 2.0 scores, improving risk discrimination by 63.2% (IDI index 0.056) and 36.8% (IDI index 0.080), respectively.

Conclusions

A significant proportion of PAH patients treated with upfront oral combination are not able to achieve a low-risk status. The treatment response score helps clinicians in predicting treatment failure at the time of diagnosis.

Funding Acknowledgement

Type of funding source: None

Toxic oligomers of the amyloidogenic HypF-N protein form pores in mitochondrial membranes

Studies on the amyloidogenic N-terminal domain of the E. coli HypF protein (HypF-N) have contributed significantly to a detailed understanding of the pathogenic mechanisms in neurodegenerative diseases characterised by the formation of misfolded oligomers, by proteins such as amyloid-β, α-synuclein and tau. Given that both cell membranes and mitochondria are increasingly recognised as key targets of oligomer toxicity, we investigated the damaging effects of aggregates of HypF-N on mitochondrial membranes. Essentially, we found that HypF-N oligomers characterised by high surface hydrophobicity (type A) were able to trigger a robust permeabilisation of mito-mimetic liposomes possessing cardiolipin-rich membranes and dysfunction of isolated mitochondria, as demonstrated by a combination of mitochondrial shrinking, lowering of mitochondrial membrane potential and cytochrome c release. Furthermore, using single-channel electrophysiology recordings we obtained evidence that the type A aggregates induced currents reflecting formation of ion-conducting pores in mito-mimetic planar phospholipid bilayers, with multi-level conductances ranging in the hundreds of pS at negative membrane voltages. Conversely, HypF-N oligomers with low surface hydrophobicity (type B) could not permeabilise or porate mitochondrial membranes. These results suggest an inherent toxicity of membrane-active aggregates of amyloid-forming proteins to mitochondria, and that targeting of oligomer-mitochondrial membrane interactions might therefore afford protection against such damage.

P1711 Exploring the full spectrum of right ventricular exercise contractile reserve among health and disease: a prospective clinical and echocardiography observational multicenter study

Funding Acknowledgements

None

OnBehalf

RIGHT-NET

Background

Exercise Doppler echocardiography (EDE) has been implemented for applications beyond coronary artery disease detection, but its role in assessing subclinical pulmonary vascular disease and right ventricle (RV) impairment is less clear. The RIGHT heart international NETwork (RIGHT-NET) is a prospective clinical and echocardiography observational multicenter study designed to explore the full spectrum of RV function and non-invasive pulmonary circulation hemodynamics during exercise in a large cohort of subjects, from healthy individuals and elite athletes to patients with overt or at risk of developing pulmonary hypertension (PH). Right ventricular (RV) exercise contractile reserve (RVECR) can be assessed through the ratio between tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP) and has proved to provide prognostic value in patients with left heart disease (LHD) and pulmonary arterial hypertension (PAH).

Methods

We enrolled 1424 patients (age 55.4 ± 15 years old, 44.4% males): 353 healthy controls, 40 athletes, 369 patients with cardiovascular risk factors (CVRF: arterial hypertension and/or diabetes mellitus), 46 with PAH (confirmed by right heart catheterization), 487 with systemic sclerosis (SSc) without overt PH, and 129 with LHD (including coronary artery disease and heart failure with reduced or preserved ejection fraction).

All enrolled subjects underwent resting and EDE examinations on a semirecumbent cycle ergometer with an incremental workload of 25 Watts every 2 minutes up to the symptom-limited maximal tolerated workload, according to standardised protocols. Key echocardiographic measurements have been acquired at baseline, at 50 Watts, at peak exercise, and after 5-minutes recovery, including but not limited to RV function (TAPSE) and sPAP.

Results

In all six groups the ratio TAPSE/sPAP was significantly different at peak exercise compared to rest values (all p < 0.01). At rest, TAPSE/sPAP values were not significantly different among controls, athletes and CVRF patients, whereas during exercise TAPSE/sPAP values were significantly different, with CVRF showing the lowest values (p < 0.0001 vs controls and athletes). Patients with PAH and LHD had the worst RVECR both at rest and at peak exercise (all p < 0.0001 vs the other groups), while SSc groups reported intermediate values, which were lower than controls (p < 0.0001) and athletes (p < 0.0001), but higher than CVRF subjects (p = 0.003). (Figure)

Conclusions

EDE can non-invasively characterise different dynamic behaviours of the RVECR among healthy subjects, athletes and patients with various pathologic conditions. Whether a thorough EDE assessment of non-invasive hemodynamics, RVECR and coupling may predict later development of manifest PH, clinical deterioration or decreased survival will be further investigated during the ongoing follow-up.

Abstract P1711 Figure

P5554Follow the light - The prognostic value of late gadolinium enhancement in hypertrophic cardiomyopathy

Background and aim

Hypertrophic cardiomyopathy (HCM) is a genetic based cardiomyopathy with heterogeneous phenotypic expression. Since it is one of the most common cause of sudden cardiac death (SCD) in the young different risk score have been proposed to properly identify the patients that would benefit from a primary prevention with an implantable cardioverter-defibrillator (ICD). ESC guidelines on HCM suggest to estimate the risk of SCD considering clinical and echocardiographic parameters and mention the use of cardiac magnetic resonance (CMR) only in the case of poor echo windows. The aim of the present study-level meta-analysis was to explore the prognostic value of late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) for adverse fatal events.

Methods

We searched PubMed and EMBASE for studies that investigated the prognostic value of LGE in patients with HCM. The outcomes of interest were SCD or aborted SCD, all-cause mortality and cardiovascular (CV) mortality. Random-effects Odds Ratios (ORs) were estimated using a DerSimonian-Laird method with a person-year approach. Moreover, an univariate meta-regression was performed to assess the moderator effect of mean age, LGE % of left ventricle (LV) and gender (expressed as male percentage).

Results

A total of 7 studies (n=3351) were included in the analysis. Mean follow-up was 3±0.63 years. Mean age was 47.7±14.6 years and 56.9% were male. LGE was detected in 1845 (55%) patients with a mean LGE percentage of LV of 7%. The presence of LGE was associated with an increased incidence of SCD or aborted SCD (OR 3.44; 95% CI 2.02–5.86; p<0.001- Figure), all-cause mortality (OR 1.92; 95% CI 1.31–2.81; p<0.001) and CV mortality (OR 3.16; 95% CI 1.77–5.64; p<0.001) compared with the absence of LGE at CMR. The LGE percentage of LV, mean age and gender did not have any moderator effect on the outcomes of interest. However, LGE % of LV was reported only in 4 studies and the absence of any moderator effect of this parameter could be due to a type II error.

Prognostic value of LGE for SCD

Conclusions

The presence of LGE at CMR in patients with HCM exhibited a substantial prognostic value in fatal events and, in particular, in the prediction of SCD. LGE assessment is an effective tool to stratify the arrhythmic risk in HCM. Therefore, it should be considered, especially in borderline cases, to improve the identification of HCM patients who could benefit from ICD implantation.

P5416A single-center, thirty-year experience of heart transplantation: analysis of the evolution of patients profile and long term outcomes

Background

Heart Transplantation is still the gold standard therapy for patients suffering from end-stage cardiomyopathy and has been successfully performed in our center since 1985. Over this 30 years period there has been a significant evolution in patients characteristics and in candidate selection (either as a donor and as recipient) as shown by the recent benchmark from International Society of Heart and Lung Transplantation (ISHLT). Here we analyze the evolution of patients profile in our population and we correlated such evolution to the clinical outcomes and to the overall data from ISHLT.

Materials and methods

Overall 1122 patients underwent heart transplantation at our center from November 19th1985 to date. To analyze the evolution patients profile and donor criteria, patient population was divided in 4 groups according era of transplantation following ISHLT model (Group A from 1985 to 1991; Group B from 1992 to 2003; Group C from 2004 to 2008 and Group D from 2009 to date). Patients characteristics at time of transplantation, donor criteria ad clinical outcomes were analyzed and compared within 4 groups. An overall comparison of our results to the data from ISHLT was also performed.

Results

Overall Kaplan-Meier survival curve correlates favourably with ISHLT data showing a 20 years survival approaching 40%. Patients age at transplantation changed significantly among 4 groups from a median of 49 years (95% CI 47 to 51) in Group A to 54 years (95% CI 50 to 57) in Group D (p<0.001). Likewise donor age also changed significantly from a median of 24 years (95% CI 22 to 28) in Group A to 43 years (95% CI 39 to 47) in group D (p<0.001). Time on waiting list also changed significantly from a median of 115 days (95% CI 94 to 137) in Group A to 293 (95% CI 200 to 401) in Group D (p<0.001). As a marker of evolution of accepted donor criteria also ischemic time changed from 125±52 minutes of Group A to 153±61 minutes of Group D (p<0.001). As showed in Fig 1, Kaplan-Meier survival curves demonstrated a worse 1-year survival in Group D compared to others 3 Group.

Figure 1

Conclusions

The significant changing characteristics of both recipients and donors, over 30 years of activity, had a significant impact in early (1 year) postoperative survival following heart transplantation. Although medium/long term outcomes are still satisfactory in patients surviving at least 1 year, these data clearly suggest a more accurate patients selection and the need of alternative treatment before patients conditions deteriorate while on waiting list for heart transplantation

P6478Resting and exercise pulmonary artery systolic pressure to rule out later development of pulmonary arterial hypertension in systemic sclerosis

Background

Patients with systemic sclerosis (SSc) are at risk of developing pulmonary arterial hypertension (PAH), which is often diagnosed late when the benefits of vasoactive therapies are limited. The concept of exercise pulmonary hypertension as a possible transitional phase anticipating resting PAH has been assessed in several pathologies, but has not been endorsed by the latest European Guidelines, because not supported by sufficient data.

Purpose

To evaluate whether PASP values at rest and at peak exercise, estimated at echocardiography, could be predictors of further development of PAH.

Methods

Four hundred and twenty-nine SSc patients without a previous diagnosis of PAH, enrolled at 4 referral Centres, underwent standard exercise Doppler echocardiography with PASP estimation at rest and at peak stress. Patients were then followed-up to assess the development of PAH, as diagnosed by a complete diagnostic work-up including right heart catheterization. PAH was defined by pre-capillary pulmonary hypertension (mean pulmonary artery pressure ≥25 mmHg with pulmonary arterial wedge pressure ≤15 mmHg), without significant interstitial lung disease and/or left heart disease.

Results

During the median follow-up of 75 months (IQR 29–114), 16 patients developed PAH. A combined cut-off of ≥24 mmHg as resting PASP and ≥40 as peak PASP was identified as the best predictor of further development of PAH (see Figure). Both resting PASP and peak PASP were predictors of PAH at univariate analysis (resting PASP OR 1.13, 95% C.I. 1.07–1.19, p<0.0001; peak PASP OR 1.13, 95% C.I. 1.07–1.18, p<0.0001). At multivariate analysis, only peak PASP was independently associated to PAH development (OR 1.13, 95% C.I. 1.04–1.18, p<0.001). Only one patient among those with resting PASP <24 mmHg and peak PASP <40 mmHg (34.7% of the total population) developed PAH during the follow-up (after 10 years from normal exercise Doppler echocardiography).

Kaplan-Meier curves

Conclusions

Exercise increase in PASP is an independent predictor of later development of PAH in SSc. An increase in exercise PASP is frequent and is not necessarily associated with a later development of PAH, whereas the very high negative predictive value of a normal PASP both at rest and at peak exercise can be used in the clinical practice to confidently rule out about one third of patients.

Acknowledgement/Funding

Italian Ministry of Health (Ricerca Finalizzata 2011-2012)

P1856Percutaneous mitral edge-to-edge valvuloplasty in end-stage heart failure as a bridge to heart transplant: a case series from a single tertiary referral center

Background

Improved outcomes after percutaneous edge-to-edge mitral valvuloplasthy with MitraClip implantation were recently observed in patients with heart failure (HF) and functional severe mitral regurgitation (MR). Nonetheless, its efficacy in end-stage heart failure (HF) are lacking.

Purpose

Our aim was to investigate feasibility, preliminary efficacy on hemodynamics and follow-up of MitraClip implantation in a cohort of patients with very advanced HF.

Methods

Patients were retrospectively included in the present analysis if already in HT list, unsuitable for HT despite optimal medical and device therapy, or if implantation was a “bridge-to-candidacy”.

Results

Baseline and procedural characteristics are listed in Table 1; MR etiology was predominantly functional (n=7). No major complications were observed in the peri-operative period. At 6-month follow-up, invasive hemodynamics was available for 8 patients. A significant increase in cardiac index was observed (Least Square Mean Difference, LSMD = +0.47 L/min/m2; p=0.03; Figure 1), in conjunction with a numerical reduction in pulmonary vascular resistance (LSMD = −1.02 WU; p=0.3), a trend towards lower mean pulmonary arterial pressure (LSMD = −6.5 mmHg; p=0.053) and lower ejection fraction (LSMD = −6.5%; p=0.053). At a median follow-up of 772 days (IQR 156–1,578), all three patients unsuitable for HT at baseline could be eligible to HT list and one of them received LVAD. Moreover, two patients were transplanted, four experienced unplanned rehospitalization for HF, and one died of non-cardiac cause.

Table 1. Baseline clinical evaluation (n=10) Age (y) 53.67±8.43 HF Etiology – post ischemic 4 (40) Male sex 6 (60) HF Etiology – no CAD 4 (40) Body Surface Area (m2) 1.76±0.22 HF Etiology – other 2 (20) Chronic Resynchronization Therapy 5 (50) Euroscore II 6.00±2.74 Baseline MR grade (+) 4 (40) STS mortality 1.71±2.65 Residual MR grade (+) 1.71±0.49 Clips implanted (number) 1.78±0.67 Data are expressed as mean ± SD or count (valid %). MR scored on a scale from 0+ to 4+. STS, Society of Thoracic Surgeons.

Figure 1

Conclusions

Percutaneous edge-to-edge mitral valvuloplasty with MitraClip appears safe and effective in end-stage patients, impacts on clinical decision-making and therefore might be considered as a “bridge” towards a more definite strategy.

Acknowledgement/Funding

None

Tau-induced mitochondrial membrane perturbation is dependent upon cardiolipin

Misfolding and aggregate formation by the tau protein has been closely related with neurotoxicity in a large group of human neurodegenerative disorders, which includes Alzheimer's disease. Here, we investigate the membrane-active properties of tau oligomers on mitochondrial membranes, using minimalist in vitro model systems. Thus, exposure of isolated mitochondria to oligomeric tau evoked a disruption of mitochondrial membrane integrity, as evidenced by a combination of organelle swelling, efflux of cytochrome c and loss of the mitochondrial membrane potential. Tau-induced mitochondrial dysfunction occurred independently of the mitochondrial permeability transition (mPT) pore complex. Notably, mitochondria were rescued by pre-incubation with 10-N-nonyl acridine orange (NAO), a molecule that specifically binds cardiolipin (CL), the signature phospholipid of mitochondrial membranes. Additionally, NAO prevented direct binding of tau oligomers to isolated mitochondria. At the same time, tau proteins exhibited high affinity to CL-enriched membranes, whilst permeabilisation of lipid vesicles also strongly correlated with CL content. Intriguingly, using single-channel electrophysiology, we could demonstrate the formation of non-selective ion-conducting tau nanopores exhibiting multilevel conductances in mito-mimetic bilayers. Taken together, the data presented here advances a scenario in which toxic cytosolic entities of tau protein would target mitochondrial organelles by associating with their CL-rich membrane domains, leading to membrane poration and compromised mitochondrial structural integrity.

Cardiolipin Promotes Pore-Forming Activity of Alpha-Synuclein Oligomers in Mitochondrial Membranes

Aggregation of the amyloid-forming α-synuclein (αS) protein is closely associated with the etiology of Parkinson's disease (PD), the most common motor neurodegenerative disorder. Many studies have shown that soluble aggregation intermediates of αS, termed oligomers, permeabilize a variety of phospholipid membranes; thus, membrane disruption may represent a key pathogenic mechanism of αS toxicity. Given the centrality of mitochondrial dysfunction in PD, we therefore probed the formation of ion-permeable pores by αS oligomers in planar lipid bilayers reflecting the complex phospholipid composition of mitochondrial membranes. Using single-channel electrophysiology, we recorded distinct multilevel conductances (100-400 pS) with stepwise current transitions, typical of protein-bound nanopores, in mitochondrial-like membranes. Crucially, we observed that the presence of cardiolipin (CL), the signature phospholipid of mitochondrial membranes, enhanced αS-lipid interaction and the membrane pore-forming activity of αS oligomers. Further, preincubation of isolated mitochondria with a CL-specific dye protected against αS oligomer-induced mitochondrial swelling and release of cytochrome c. Hence, we favor a scenario in which αS oligomers directly porate a local lipid environment rich in CL, for instance outer mitochondrial contact sites or the inner mitochondrial membrane, to induce mitochondrial dysfunction. Pharmacological modulation of αS pore complex formation might thus preserve mitochondrial membrane integrity and alleviate mitochondrial dysfunction in PD.

Secretome profile of Cellulomonas sp. B6 growing on lignocellulosic substrates

AIMS

Lignocellulosic biomass deconstruction is a bottleneck for obtaining biofuels and value-added products. Our main goal was to characterize the secretome of a novel isolate, Cellulomonas sp. B6, when grown on residual biomass for the formulation of cost-efficient enzymatic cocktails.

METHODS AND RESULTS

We identified 205 potential CAZymes in the genome of Cellulomonas sp. B6, 91 of which were glycoside hydrolases (GH). By secretome analysis of supernatants from cultures in either extruded wheat straw (EWS), grinded sugar cane straw (SCR) or carboxymethylcellulose (CMC), we identified which proteins played a role in lignocellulose deconstruction. Growth on CMC resulted in the secretion of two exoglucanases (GH6 and GH48) and two GH10 xylanases, while growth on SCR or EWS resulted in the identification of a diversity of CAZymes. From the 32 GHs predicted to be secreted, 22 were identified in supernatants from EWS and/or SCR cultures, including endo- and exoglucanases, xylanases, a xyloglucanase, an arabinofuranosidase/β-xylosidase, a β-glucosidase and an AA10. Surprisingly, among the xylanases, seven were GH10.

CONCLUSIONS

Growth of Cellulomonas sp. B6 on lignocellulosic biomass induced the secretion of a diverse repertoire of CAZymes.

SIGNIFICANCE AND IMPACT OF THE STUDY

Cellulomonas sp. B6 could serve as a source of lignocellulose-degrading enzymes applicable to bioprocessing and biotechnological industries.

Extracts from two ubiquitous Mediterranean plants ameliorate cellular and animal models of neurodegenerative proteinopathies

A signature feature of age-related neurodegenerative proteinopathies is the misfolding and aggregation of proteins, typically amyloid-β (Aβ) in Alzheimer's disease (AD) and α-synuclein (α-syn) in Parkinson's disease (PD), into soluble oligomeric structures that are highly neurotoxic. Cellular and animal models that faithfully replicate the hallmark features of these disorders are being increasing exploited to identify disease-modifying compounds. Natural compounds have been identified as a useful source of bioactive molecules with promising neuroprotective capabilities. In the present report, we investigated whether extracts derived from two ubiquitous Mediterranean plants namely, the prickly pear Opuntia ficus-indica (EOFI) and the brown alga Padina pavonica (EPP) alleviate neurodegenerative phenotypes in yeast (Saccharomyces cerevisiae) and fly (Drosophila melanogaster) models of AD and PD. Pre-treatment with EPP or EOFI in the culture medium significantly improved the viability of yeast expressing the Arctic Aβ42 (E22G) mutant. Supplementing food with EOFI or EPP dramatically ameliorated lifespan and behavioural signs of flies with brain-specific expression of wild-type Aβ42 (model of late-onset AD) or the Arctic Aβ42 variant (model of early-onset AD). Additionally, we show that either extract prolonged the survival of a PD fly model based on transgenic expression of the human α-syn A53T mutant. Taken together, our findings suggest that the plant-derived extracts interfere with shared mechanisms of neurodegeneration in AD and PD. This notion is strengthened by evidence demonstrating that EOFI and to a greater extent EPP, while strongly inhibiting the fibrillogenesis of both Aβ42 and α-syn, accumulate remodelled oligomeric aggregates that are less effective at disrupting lipid membrane integrity. Our work therefore opens new avenues for developing therapeutic applications of these natural plant extracts in the treatment of amyloidogenic neurodegenerative disorders.

Interaction of α-synuclein with biomembranes in Parkinson's disease--role of cardiolipin

One of the key molecular events underlying the pathogenesis of Parkinson's disease (PD) is the aberrant misfolding and aggregation of the α-synuclein (αS) protein into higher-order oligomers that play a key role in neuronal dysfunction and degeneration. A wealth of experimental data supports the hypothesis that the neurotoxicity of αS oligomers is intrinsically linked with their ability to interact with, and disrupt, biological membranes; especially those membranes having negatively-charged surfaces and/or lipid packing defects. Consequences of αS-lipid interaction include increased membrane tension, permeation by pore formation, membrane lysis and/or leakage due to the extraction of lipids from the bilayer. Moreover, we assert that the interaction of αS with a liquid-disordering phospholipid uniquely enriched in mitochondrial membranes, namely cardiolipin (1,3-diphosphatidyl-sn-glycerol, CL), helps target the αS oligomeric complexes intracellularly to mitochondria. Binding mediated by CL may thus represent an important pathomechanism by which cytosolic αS could physically associate with mitochondrial membranes and disrupt their integrity. Impaired mitochondrial function culminates in a cellular bioenergetic crisis and apoptotic death. To conclude, we advocate the accelerated discovery of new drugs targeting this pathway in order to restore mitochondrial function in PD.

Tricuspid annular plane systolic excursion and pulmonary arterial systolic pressure relationship in heart failure: an index of right ventricular contractile function and prognosis

Echo-derived pulmonary arterial systolic pressure (PASP) and right ventricular (RV) tricuspid annular plane systolic excursion (TAPSE; from the end of diastole to end-systole) are of basic relevance in the clinical follow-up of heart failure (HF) patients, carrying two- to threefold increase in cardiac risk when increased and reduced, respectively. We hypothesized that the relationship between TAPSE (longitudinal RV fiber shortening) and PASP (force generated by the RV) provides an index of in vivo RV length-force relationship, with their ratio better disclosing prognosis. Two hundred ninety-three HF patients with reduced (HFrEF, n = 247) or with preserved left ventricular (LV) ejection fraction (HFpEF, n = 46) underwent echo-Doppler studies and N-terminal pro-brain-type natriuretic peptide assessment and were tracked for adverse events. The median follow-up duration was 20.8 mo. TAPSE vs. PASP relationship showed a downward regression line shift in nonsurvivors who were more frequently presenting with higher PASP and lower TAPSE. HFrEF and HFpEF patients exhibited a similar distribution along the regression line. Given the TAPSE, PASP, and TAPSE-to-PASP ratio (TAPSE/PASP) collinearity, separate Cox regression and Kaplan-Meier analyses were performed: one with TAPSE and PASP as individual measures, and the other combining them in ratio form. Hazard ratios for variables retained in the multivariate regression were as follows: TAPSE/PASP </≥ 0.36 mm/mmHg [hazard ratio (HR): 10.4, P < 0.001]; TAPSE </≥ 16 mm (HR: 5.1, P < 0.01); New York Heart Association functional class </≥ 3 (HR: 4.4, P < 0.001); E/e’ (HR: 4.1, P < 0.001). This study shows that the TAPSE vs. PASP relationship is shifted downward in nonsurvivors with a similar distribution in HFrEF and HFpEF, and their ratio improves prognostic resolution. The TAPSE vs. PASP relationship as a possible index of the length-force relationship may be a step forward for a more efficient RV function evaluation and is not affected by the quality of LV dysfunction.

Effects on survival of loop diuretic dosing in ambulatory patients with chronic heart failure using a propensity score analysis

OBJECTIVE

To ascertain whether increasing doses of orally administered furosemide are associated with impaired survival in outpatients with chronic heart failure (CHF) and left ventricular (LV) systolic dysfunction.

METHODS

Transthoracic echo-Doppler examination was carried out at baseline in 813 consecutive CHF outpatients with LV ejection fraction ≤ 45%. The total daily dose of furosemide was assessed for each patient. Chronic kidney disease (CKD) was defined by a glomerular filtration rate < 60 ml/min/1.73 m(2). The end-point was all-cause mortality. To control the prognostic effect of furosemide for the propensity of using high doses of the drug, the Cox model was stratified by the propensity score, itself computed from a multivariable logistic model. Mean follow up was 44 months.

RESULTS

After stratification for the propensity score, the risk of death increased linearly across quartiles of furosemide dose (HR 1.38, 95% CI 1.14-1.68, p < 0.001). A daily dose of 50 mg was identified as the best threshold value to predict a high risk of death within 3 years with an area under the ROC curve of 0.68 (95% CI 0.64-0.72). Increasing doses of furosemide were associated with an increased risk of death regardless of LV filling pattern, CKD and background therapy with ACE-inhibitors or beta-blockers.

CONCLUSIONS

In outpatients with CHF, after stratification for the propensity score, the risk of death increased linearly across quartiles of furosemide daily dose. A threshold furosemide dose of 50 mg was related with the worse outcome.

Mitochondrial membrane permeabilisation by amyloid aggregates and protection by polyphenols

Alzheimer's disease and Parkinson's disease are neurodegenerative disorders characterised by the misfolding of proteins into soluble prefibrillar aggregates. These aggregate complexes disrupt mitochondrial function, initiating a pathophysiological cascade leading to synaptic and neuronal degeneration. In order to explore the interaction of amyloid aggregates with mitochondrial membranes, we made use of two in vitro model systems, namely: (i) lipid vesicles with defined membrane compositions that mimic those of mitochondrial membranes, and (ii) respiring mitochondria isolated from neuronal SH-SY5Y cells. External application of soluble prefibrillar forms, but not monomers, of amyloid-beta (Aβ42 peptide), wild-type α-synuclein (α-syn), mutant α-syn (A30P and A53T) and tau-441 proteins induced a robust permeabilisation of mitochondrial-like vesicles, and triggered cytochrome c release (CCR) from isolated mitochondrial organelles. Importantly, the effect on mitochondria was shown to be dependent upon cardiolipin, an anionic phospholipid unique to mitochondria and a well-known key player in mitochondrial apoptosis. Pharmacological modulators of mitochondrial ion channels failed to inhibit CCR. Thus, we propose a generic mechanism of thrilling mitochondria in which soluble amyloid aggregates have the intrinsic capacity to permeabilise mitochondrial membranes, without the need of any other protein. Finally, six small-molecule compounds and black tea extract were tested for their ability to inhibit permeation of mitochondrial membranes by Aβ42, α-syn and tau aggregate complexes. We found that black tea extract and rosmarinic acid were the most potent mito-protectants, and may thus represent important drug leads to alleviate mitochondrial dysfunction in neurodegenerative diseases.

Paediatric nurses' perception of the child-family dyad's autonomy in managing a chronic disease situation: the experience of an Italian paediatric department

INTRODUCTION

Chronically ill patients have to take several medications and non-adherence to treatment can lead to severe and negative outcomes. Therefore, several interventions are suggested in literature to improve adherence rates in clinical practice. Adherence to treatment can be particularly troublesome in adolescents, who strive for autonomy and self-care independence. Literature suggests that improving adherence is useful to guarantee positive outcomes and reduce costs.

AIM

To explore how nurses perceived autonomy in parents, adolescents, and children related to the management of chronic disease.

MATERIALS AND METHODS

A qualitative study including 1 focus group and 7 semi-structured interviews conducted between September 2011 and October 2011. The qualitative date were analysed with the thematic analysis method. The sample included 12 paediatric nurses working in a Children's Cystic Fibrosis Unit and Neuromuscular Disease Unit.

RESULTS

The 5 main categories that emerged from this qualitative study after he process of categorization were: 'Changes in daily lifestyle', 'Nurses' attitude towards educating the dyad', 'Adolescence and transition', 'Parents' attitudes towards chronic disease', and 'Availability of information'.

DISCUSSION

Correct information and education is crucial for families who have a chronically ill child. Internet can be a misleading source of information and provide wrong information also in relation to prevention.

Cigarette smoking and hypertension influence nitric oxide release and plasma levels of adhesion molecules

Progression of atherosclerosis is currently believed to involve interactions between leukocytes and vascular endothelium. Epidemiological risk factors for atherosclerosis such as hypertension and smoking are known to cause endothelial dysfunction, which is an early event in the atherosclerotic process; they also may be considered in the light of their effects on adhesion molecule expression and release. Little is known about the additive effect between these two risk factors on endothelial adhesion molecule expression and nitric oxide release. Soluble adhesion molecules and the nitric oxide were quantified in smoking hypertensive patients in comparison to those from patients with hypertension alone. Cotinine, a stable metabolite of nicotine, has been used to identify smokers. One hundred and three hypertensive patients were selected: 51 smokers (plasma cotinine levels >25 ng/ml) and 52 non-smokers. Plasma concentrations of soluble intercellular cell adhesion molecule-1 (sICAM-1), soluble endothelial leukocyte adhesion molecule-1 (sELAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-I) were quantified with ELISA methods. Plasma concentration of nitric oxide metabolites was measured by HPLC, whilst plasma concentration of cotinine was measured by RIA. Significant increases of sICAM-1 and sVCAM-1 were demonstrated in smokers (p<0.001 and p<0.05, respectively). In the same patients, a positive significant correlation between sVCAM-1 and plasma cotinine levels was observed (p<0.002). Nitric oxide metabolites were reduced significantly (p<0.04) in smokers. In conclusion, our data show that the two risk factors, smoking and hypertension, are additive risk factors in generating endothelial dysfunction and vascular damage, which plays a key role in atherogenesis.

Doppler velocimetry in superior vena cava provides useful information on the right circulatory function in patients with congestive heart failure

BACKGROUND

Although flow velocities curves recorded with pulsed-wave Doppler in systemic vein are known to provide functional data on the right circulatory function, little information is available on the relationship between right heart filling dynamics and right ventricular function.

METHODS

Consecutive patients with chronic heart failure due to severe systolic left ventricular dysfunction and in sinus rhythm underwent echocardiography and right heart catheterization. In the initial part of the study, the hemodynamic correlates of different flow velocity patterns recorded into the superior vena cava were evaluated in 120 patients. The accuracy of the prediction of different right heart hemodynamic profiles by means of the different venous flow patterns was then prospectively tested in a subsequent series of 86 patients.

RESULTS

The venous flow pattern was closely related to right heart hemodynamics. A normal Doppler pattern identified patients with normal right heart hemodynamics (sensitivity 86%, specificity 78%); a "predominant systolic wave" pattern identified patients with a reduced thermodilution-derived right ventricular ejection fraction (< 30%) and normal or slightly elevated right atrial pressure (< or = 8 mmHg) (sensitivity 69%, specificity 81%); a "predominant diastolic wave" pattern identified patients with a reduced right ventricular ejection fraction (< 3 0%) and elevated right atrial pressure (> 8 mmHg) (sensitivity 52%, specificity 95%). The observed and the predicted hemodynamic profiles turned out to be concordant in 80% of patients.

CONCLUSIONS

The analysis of the flow velocity pattern into the superior vena cava is a useful tool to estimate the extent of the right circulatory impairment in patients with congestive heart failure.