On-treatment analysis of torsemide versus furosemide for patients hospitalized for heart failure: A post-hoc analysis of TRANSFORM-HF

AIM

The TRANSFORM-HF trial demonstrated no significant outcome differences between torsemide and furosemide following hospitalization for heart failure (HF), but may have been impacted by non-adherence to the randomized diuretic. The current study sought to determine the treatment effect of torsemide versus furosemide using an on-treatment analysis inclusive of all randomized patients except those confirmed non-adherent to study diuretic.

METHODS AND RESULTS

TRANSFORM-HF was an open-label, pragmatic randomized trial of 2859 patients hospitalized for HF from June 2018 through March 2022. Patients were randomized to a loop diuretic strategy of torsemide versus furosemide with investigator-selected dosage. This post-hoc on-treatment analysis included all patients alive with either known or unknown diuretic status, and excluded patients confirmed to be non-adherent to study diuretic. This modified on-treatment definition was applied separately at time of hospital discharge and 30-day follow-up. All-cause mortality and hospitalization outcomes were assessed over 12 months. Overall, 2570 (89.9%) and 2374 (83.0%) patients were included in on-treatment analyses at discharge and 30-day follow-up, respectively. There was no significant difference in all-cause mortality between torsemide and furosemide in patients on-treatment at discharge (17.5% vs. 17.8%; hazard ratio [HR] 1.01 [95% confidence interval [CI] 0.83-1.22], p = 0.96) and at 30-day follow-up (14.5% vs. 15.0%; HR 1.02 [95% CI 0.81-1.27], p = 0.90). All-cause mortality or all-cause hospitalization was similar between torsemide and furosemide in patients who were on-treatment at discharge (58.3% vs. 61.3%; HR 0.92 [95% CI 0.82-1.03]) and 30-day follow-up (60.9% vs. 64.4%; HR 0.93 [95% CI 0.82-1.05]). In patients who were on-treatment at 30-day follow-up, there were 677 total hospitalizations in the torsemide group and 686 total hospitalizations in the furosemide group (rate ratio 0.99 [95% CI 0.86-1.14], p = 0.87).

CONCLUSIONS

In TRANSFORM-HF, a post-hoc on-treatment analysis did not meaningfully differ from the original trial results. Among those deemed compliant with the assigned diuretic, there remained no significant difference in mortality or hospitalization after HF hospitalization with a strategy of torsemide versus furosemide.

CLINICAL TRAIL REGISTRATION

ClinicalTrials.gov Identifier: NCT03296813.

Prognostic implications of volume status assessed by blood volume analysis in ambulatory heart failure

The prognostic implications of intravascular volume status assessed by blood volume analysis (BVA) in ambulatory heart failure (HF) remain uncertain. The incremental benefits of assessing volume status, beyond the well-established filling pressures, in predicting HF outcomes are unknown.

Genitourinary Tract Infections in Patients Taking SGLT2 Inhibitors: JACC Review Topic of the Week

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) have been shown to reduce adverse cardiovascular events in patients with type 2 diabetes mellitus, all-cause mortality, and heart failure hospitalization in patients with heart failure, as well as adverse renal outcomes. However, concerns regarding the heightened risk of genitourinary (GU) infections, particularly urinary tract infections, remain a significant barrier to their wider adoption. Addressing these misconceptions using existing evidence is needed to ensure proper risk-benefit assessment and optimal utilization of this efficacious therapy. This review aims to provide a balanced perspective on the evidence-based cardiovascular and renal benefits of SGLT2is and the associated risk of GU infections. We also summarize and propose clinical practice considerations for SGLT2i-associated GU infections focusing on patients with cardiovascular disease.

Racial Differences in Hospice Care Outcomes in Patients With Advanced Heart Failure: Systematic Review and Meta-analysis

There remains a paucity of investigational data about disparities in hospice services in people with non-cancer diagnoses, specifically in heart failure (HF). Black patients with advanced HF have been disproportionally affected by health care services inequities but their outcomes after hospice enrollment are not well studied. We aimed to describe race-specific outcomes in patients with advanced HF who were enrolled in hospice services. We obtained the data from PubMed, Scopus, and Embase for all investigations published until January 11, 2023. All studies that reported race-specific outcomes after hospice enrollment in patients with advanced HF were included. Of the 1,151 articles identified, 5 studies (n = 24,899) were considered for analysis involving a sample size ranging from 179 to 11,754 patients. Black patients had an increased risk of readmission (odds ratio 1.55, 95% confidence interval [CI] 1.34 to 1.79, I2 0%) and discharge (odds ratio 1.75, 95% CI 1.53 to 1.99, I2 0%) compared with White patients. Moreover, Black patients have a nonsignificant lower risk of mortality compared with White patients (relative risk 0.67, 95% CI 0.43 to 1.05, I2 90%). In conclusion, this study showed that Black patients with advanced HF receiving hospice care have a higher risk of readmission and discharge compared with White patients.

Splanchnic Nerve Modulation Effects on Surrogate Measures of Venous Capacitance

Background Splanchnic nerve modulation (SNM) is an emerging procedure to reduce cardiac filling pressures in heart failure. Although the main contributor to reduction in cardiac preload is thought to be increased venous capacitance in the splanchnic circulation, supporting evidence is limited. We examined changes in venous capacitance surrogates pre- and post-SNM. Methods and Results This is a prespecified analysis of a prospective, open-label, single-arm interventional study evaluating the effects of percutaneous SNM with ropivacaine in chronic heart failure with elevated filling pressures at rest and with exercise. Patients underwent cardiopulmonary exercise testing with invasive hemodynamic assessment pre- and post-SNM. Blood pressure changes with modified Valsalva maneuver and hemoconcentration, pre- and post-SNM were compared using a repeated measures model. Inferior vena cava diameter and collapsibility (>50% decrease in size with inspiration), and presence of bendopnea pre- and post-SNM were also compared. Fifteen patients undergoing SNM (age 58 years, 47% women, 93% with left ventricular ejection fraction ≤35%) were included. After SNM, changes in systolic blood pressure during Valsalva (peak-to-trough) were greater (41 versus 48 mm Hg, P=0.025). Exercise-induced hemoconcentration was unchanged (0.63 versus 0.43 g/dL, P=0.115). Inferior vena cava diameter was reduced (1.59 versus 1.30 cm, P=0.034) with higher collapsibility (33% versus 73%, P=0.014). Bendopnea was less (47% versus 13%, P=0.025). Conclusions SNM resulted in increased venous capacitance, associated decreased cardiac preload, and decreased bendopnea. Minimally invasive measures of venous capacitance could serve as markers of successful SNM. Long-term effects of SNM on venous capacitance warrant further investigation for heart failure management. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03453151.

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

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

Pressure-Volume Profiles in Heart Failure Across Sexes and Phenotypes

Studies have shown poor correlation between intra-cardiac pressures and blood volume (BV) measurements including HF. The impact of sex and left ventricular ejection fraction (LVEF) on this relationship has not been studied. We obtained pressure (pulmonary artery diastolic pressure (PADP)) and volume (total blood volume (TBV) and estimated stress blood volume (eSBV)) measurements from HF patients at the time of CardioMEMS implantation. A total of 20 patients were included. There was no significant difference between PADP, TBV, and eSBV between sexes. There was only a moderate correlation between PADP and eSBV in men but not in women or with TBV in both sexes. HFrEF had higher PADP and eSBV than HFpEF. There was a consistent lack of correlation between PADP and both TBV and eSBV. Further studies evaluating mid- to long-term implications of pressure-volume profiles as well as changes following decongestion therapy are warranted to better understand the pressure-volume interplay and determine appropriate decongestion strategy for each pressure-volume phenotype.

Heart Failure-Related Ascites With Low Serum-Ascites Albumin Gradient: Diagnostic Clues From Triphasic Abdominal Computed Tomography

Serum-ascites albumin gradient (SAAG) is an initial and useful measure to differentiate causes of ascites. High gradient ascites (SAAG >1.1 g/dL) is one of the important features of heart failure. Low gradient ascites in heart failure is relatively rare and needs additional workups to rule out other serious causes, such as malignancy and infection. We herein report a case of a 42-year-old female with low-SAAG ascites from worsening congestive heart failure, which was confirmed to be portal hypertension-originated by triphasic abdominal computed tomography.

Direct oral anticoagulants vs. vitamin K antagonists for left ventricular thrombus: a systematic review and meta-analysis

BACKGROUND

Current guidelines recommend vitamin K antagonists (VKAs) to reduce the risk of systemic thromboembolic (STE) events in patients with left ventricular (LV) thrombus. Direct oral anticoagulants (DOACs) are an emerging alternative to VKAs; however, data supporting DOAC use in LV thrombus are still lacking. We conducted this systematic review and meta-analysis to compare the efficacy and safety between DOACs and VKAs in this population.

METHODS

We searched MEDLINE, Embase, and the Cochrane Library databases from inception to October 2020 to identify studies that compared clinical outcomes of interest, including stroke or any STE, LV thrombus resolution, and bleeding, between patients who used DOACs and VKAs for LV thrombus. Data from each study were combined using the random-effects model.

RESULTS

Eight cohort studies with a total of 1771 patients (426 in DOAC group, 1345 in VKA group) were included. There were no statistically significant differences between VKA group and DOAC group on rates of STE events (pooled RR = 1.12, 95% confidence interval [CI]: 0.91-1.39, p = .286), LV thrombus resolution (pooled RR = 1.09, 95% CI: 0.94-1.27, p = .242), or bleeding events (pooled RR = 0.94, 95% CI: 0.59-1.51, p = .808).

CONCLUSIONS

Our meta-analysis found no significant differences in rates of STE events, LV thrombus resolution, or bleeding events between the use of DOACs and VKAs in LV thrombus. Further randomised controlled trials are needed to confirm our findingsHighlightsThere is limited evidence comparing the use of direct oral anticoagulants (DOACs) to vitamin K antagonists (VKAs) in left ventricular (LV) thrombus.Our systematic review and meta-analysis showed that DOACs are not inferior to VKAs in the incidence of systemic thromboembolism (STE), the rate of LV thrombus resolution, and the risk of bleeding.Current evidence is based on observational studies only. Further randomised controlled trials are needed to confirm the findings.

Left ventricular assist device deactivation following cardiac recovery and pump thrombosis

Left ventricular assist devices (LVADs) have become an increasingly important component of the management of severe heart failure not only as bridge therapy to eventual orthotopic heart transplantation, but also as destination therapy. Timely diagnosis and management of device complications are of vital importance. Rarely, LVAD placement can result in cardiac recovery that may necessitate device removal. While there are reports of minimally invasive LVAD deactivation, there are currently no guidelines for device extraction or deactivation in the setting of cardiac recovery. This is a case of both cardiac recovery and pump thrombosis following LVAD implantation, managed with device inactivation and driveline excision.

Pre-operative atrial fibrillation and early right ventricular failure after left ventricular assist device implantation: a systematic review and meta-analysis

BACKGROUND

Right ventricular failure (RVF) remains a major cause of morbidity and mortality after left ventricular assist device (LVAD). Atrial fibrillation (AF) is known for its deleterious effects on cardiac function and hemodynamics. The association of pre-operative AF with the risk of early post-LVAD RVF has not been well described.

METHOD

A comprehensive literature search was performed through April, 9 2021. Cohort studies comparing the risk of post-operative RVF and/or need for right ventricular assist device (RVAD) after LVAD in patients with or without AF were included. Pooled odds ratio (OR) with 95% confidence intervals (CI) and I² statistic were calculated using the random-effects model.

RESULTS

Six studies were included in the analysis. Post-operative RVF was reported in 5 studies (1,841 patients) and RVAD use was reported in 4 studies (1,355 patients). There is a non-significant trend toward a higher risk of post-operative RVF in the AF group (pooled OR=1.25, 95%CI=0.99-1.58). No significant association between AF and RVAD use is noted (pooled OR=1.17, 95%CI=0.82-1.66).

CONCLUSIONS

Pre-operative AF is not significantly associated with higher risks of post-operative RVF and RVAD use after LVAD implantation, although the trend toward higher post-operative RVF is observed in patients with pre-operative AF. Additional research using a larger study population is warranted to better understand the association of pre-operative AF and the development of post-LVAD RVF.

Early diuretic strategies and the association with In-hospital and Post-discharge outcomes in acute heart failure

BACKGROUND

Decongestion is a primary goal during hospitalizations for decompensated heart failure (HF). However, data surrounding the preferred route and strategy of diuretic administration are limited with varying results in prior studies.

METHODS

This is a retrospective analysis using patients from ASCEND-HF with a stable diuretic strategy in the first 24 hours following randomization. Patients were divided into three groups: intravenous (IV) continuous, IV bolus and oral strategy. Baseline characteristics, in-hospital outcomes, 30-day composite cardiovascular mortality or HF rehospitalization and 180-day all-cause mortality were compared across groups. Inverse propensity weighted modeling was used for adjustment.

RESULTS

Among 5,738 patients with a stable diuretic regimen in the first 24 hours (80% of overall ASCEND trial), 3,944 (68.7%) patients received IV intermittent bolus administration of diuretics, 799 (13.9%) patients received IV continuous therapy and 995 (17.3%) patients with oral administration. Patients in the IV continuous group had a higher baseline creatinine (IV continuous 1.4 [1.1-1.7]; intermittent bolus 1.2 [1.0-1.6]; oral 1.2 [1.0-1.4] mg/dL; P <0.001) and high NTproBNP (IV continuous 5,216 [2,599-11,603]; intermittent bolus 4,944 [2,339-9,970]; oral 3,344 [1,570-7,077] pg/mL; P <0.001). There was no difference between IV continuous and intermittent bolus group in weight change, total urine output and change in renal function till 10 days/discharge (adjusted P >0.05 for all). There was no difference in 30 day mortality and HF readmission (adjusted OR 1.08 [95%CI: 0.74, 1.57]; P = 0.701) and 180 days mortality (adjusted OR 1.04 [95%CI: 0.75, 1.43]; P = 0.832).

CONCLUSION

In a large cohort of patients with decompensated HF, there were no significant differences in diuretic-related in-hospital, or post-discharge outcomes between IV continuous and intermittent bolus administration. Tailoring appropriate diuretic strategy to different states of acute HF and congestion phenotypes needs to be further investigated.

Clinical phenotypes and prognosis of thyrotoxic heart failure and cardiomyopathy in patients hospitalized for acute heart failure

Background

We sought to examine clinical characteristics and outcomes in patients hospitalized for acute heart failure (HF) and thyrotoxicosis.

Methods

Patients with thyrotoxic HF were compared with age and gender‐matched patients hospitalized for acute HF (controls). Thyr‐HF was defined by the Framingham criteria for HF and clinical hyperthyroidism. Thyrotoxic cardiomyopathy was defined as left ventricular ejection fraction (LVEF) < 55%.

Results

Of 11 109 consecutive patients hospitalized for acute HF between 1 January 2002 and 1 January 2017, 92 patients (0.8%) had thyrotoxic HF. Clinical and echocardiographic data were available in 87 patients (age 51 ± 16 years; 74% female), representing the study population. Compared with controls, patients with Thyr‐HF had a smaller body surface area (BSA), a higher LVEF, a lower LV end‐diastolic diameter, a higher tricuspid annular plane systolic excursion (TAPSE), higher blood pressure, higher heart rate, and were more likely to have right‐sided HF at presentation (P < 0.01 for all). The survival rate among patients with thyrotoxic HF was higher than the control group (HR: 4.3; 95% CI: 2.1–9.5). Fifty‐eight percent of patients with thyrotoxic HF had thyrotoxic cardiomyopathy. In multivariate analysis, TAPSE (OR = 46; 95% CI: 1.04–2008.20; P = 0.047) and leukocytosis (OR = 16; 95% CI 1.01–259.39; P = 0.049) correlated with thyrotoxic cardiomyopathy. LV recovery was observed in 69% of these patients.

Conclusions

Thyrotoxic HF was uncommon among patients hospitalized for acute HF. However, after definitive therapy, these patients had a more favourable prognosis than those hospitalized for acute HF without thyrotoxic HF. Clinical phenotypes of thyrotoxic HF include small BSA, middle‐aged female, HF‐pEF, and right‐sided HF. Thyrotoxic cardiomyopathy affected over half of the patients with thyrotoxic HF with a two‐third recovery rate.

COVID-19 in solid organ transplant recipients: A systematic review and meta-analysis of current literature

Severe acute respiratory virus syndrome 2 (SARS-CoV-2) has led to a worldwide pandemic. Early studies in solid organ transplant (SOT) recipients suggested a wide variety of presentations, however, there remains a paucity of robust data in this population. We conducted a systematic review and meta-analysis of SOT recipients with SARS-CoV-2 infection from January 1st t October 9th, 2020. Pooled incidence of symptoms, treatments and outcomes were assessed. Two hundred and fifteen studies were included for systematic review and 60 for meta-analysis. We identified 2,772 unique SOT recipients including 1,500 kidney, 505 liver, 141 heart and 97 lung. Most common presenting symptoms were fever and cough in 70.2% and 63.8% respectively. Majority (81%) required hospital admission. Immunosuppressive medications, especially antimetabolites, were decreased in 76.2%. Hydroxychloroquine and interleukin six antagonists were administered in59.5% and 14.9% respectively, while only few patients received remdesivir and convalescent plasma. Intensive care unit admission was 29% from amongst hospitalized patients. Only few studies reported secondary infections. Overall mortality was 18.6%. Our analysis shows a high incidence of hospital admission in SOT recipients with SARS-CoV-2 infection. As management of SARS-CoV-2 continues to evolve, long-term outcomes among SOT recipients should be assessed in future studies.

Phosphodiesterase-5 Inhibitors and Outcomes During Left Ventricular Assist Device Support: A Systematic Review and Meta-Analysis

BACKGROUND

Phosphodiesterase-5 inhibitors (PDE5i) have been used to treat pulmonary hypertension and right ventricular failure in patients with left ventricular assist devices (LVAD). The effects of PDE5i on post-LVAD outcomes including hemocompatibility-related adverse events are not well-established. This systematic review and meta-analysis aims to evaluate the effects of PDE5i on post-LVAD outcomes.

METHODS AND RESULTS

A comprehensive literature search was conducted using Pubmed and Embase databases from inception through November 25, 2020, to compare post-LVAD outcomes in patients with or without PDE5i use. Pooled odds ratio (OR) with 95% confidence intervals (CI) and I² statistic were calculated. Thirteen observational studies were included in this analysis. The use of PDE5i was not significantly associated with lower postoperative right ventricular failure (OR 0.38, 95% CI 0.02-5.96, P = .41). There was no significant association between PDE5i and gastrointestinal bleeding (OR 1.23, 95% CI 0.76-1.98, P = .2), overall stroke (OR 0.60, 95% CI 0.21-1.68, P = .17), ischemic stroke (OR 0.61, 95% CI 0.09-4.07, P = .38), or pump thrombosis (OR 0.71, 95% CI 0.14-3.54, P = .46).

CONCLUSIONS

Our meta-analysis showed no significant association between PDE5i and post-LVAD right ventricular failure. Despite the antiplatelet effects of PDE5i, there was no significant association between PDE5i and gastrointestinal bleeding, overall stroke, ischemic stroke, or pump thrombosis. Randomized controlled studies are warranted to evaluate the net benefits or harms of PDE5i in the LVAD population.

In-hospital outcomes after bariatric surgery in patients with heart failure

Based on the largest publicly available all-payer inpatient database in the United States, this study sought to evaluate real-world outcomes after bariatric surgery among patients with heart failure.

Do psychosocial factors affect readmission in heart failure patients? A single centre study in a veteran population in south Florida, USA

Background

We aim to determine the influence of psychosocial factors on readmission rates in a south Florida hospital serving a largely minority Veteran population with unique psychosocial co-morbidities that impact their health care.

Purpose

We aim determine which psychosocial factors are predictors of readmission in patients with heart failure (HF).

Methods

This is a retrospective study conducted at the Miami Veteran Affairs Medical Center (VAMC) in South Florida, USA. Patients who were admitted for heart failure exacerbations from September 2018 to August 2019 were identified and included in this study. Data on baseline charateristics and co-morbidities was obtained from review of patients' electronic health records. Psychosocial assessment was done via telephone interview using a previously validated questionnaire on gender, self-reported ethnicity, level of education, marital status, employment status, homelessness, monthly financial strain, overall stress level, neighbourhood safety and social interaction. Perceived health competence was assessed with the two items Perceived Health Competence Scale (PHCS-2).

Results

We identified 185 patients during the study period (mean age 70.8±11.9 years, 98% male). Thirty-eight of these patients had one or more readmissions within one year. Our cohort was 22% White, 15% Hispanic and 60% African American based on self-reported race. We interviewed 78 patients; 14 with readmission, 64 without readmission. 21% had died at the time of our follow-up and we were unable to contact 27% of patients. On univariate analysis, homelessness and ejection fraction (LVEF) ≤40% were significantly associated with HF readmission (OR 8.3 p=0.002 and OR 6.8 p=0.008, respectively). No significant differences in other psychosocial characteristics were noted between groups. After adjustment for age in multivariate analysis, homelessness and LVEF &lt;40% remained significant predictors for HF readmission (OR 13.4 p=0.005 and OR 8.8 p=0.02, respectively).

Conclusions

Our study population was largely a minority population (15% Hispanic and 60% African American). After comparing multiple psychosocial factors, homelessness was found to be a significant and independent risk factor for heart failure readmission. This suggests that the recent focus on heart failure readmissions may need to include social interventions targeting homelessness. Future research should aim to determine whether multidisciplinary interventions aimed at addressing homelessness in patients with heart failure would help reduce hospital readmissions for congestive heart failure.

Funding Acknowledgement

Type of funding source: None

Angiotensin II antagonists and gastrointestinal bleeding in left ventricular assist devices: A systematic review and meta-analysis

Gastrointestinal bleeding (GIB) especially from arteriovenous malformations (AVM) remains one of the devastating complications following continuous-flow left ventricular device (CF-LVAD) implantation. Blockade of angiotensin II pathway using angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) was reported to mitigate the risk of GIB and AVM-related GIB by suppressing angiogenesis. We performed a systematic review and meta-analysis to evaluate the association between ACEI/ARB treatment and GIB in CF-LVAD population. Comprehensive literature search was performed through December 2019. We included studies reporting risk of GIB and/or AVM-related GIB events in LVAD patients who received ACEI/ARB with those who did not. Data from each study were combined using the random-effects to calculate odd ratios and 95% confidence intervals. Three retrospective cohort studies were included in this meta-analysis involving 619 LVADs patients (467 patients receiving ACEI/ARB). The use of ACEI/ARB was statistically associated with decreased incidence of overall GIB (pooled OR 0.35, 95% CI 0.22-0.56, I² = 0.0%, p < 0.001). There was a non-significant trend toward lower risk for AVM-related GIB in patients who received ACEI/ARB (pooled OR 0.46, 95% CI 0.19-1.07, I² = 51%, p = 0.07). Larger studies with specific definitions of ACEI/ARB use and GIB are warranted to accurately determine the potential non-hemodynamic benefits of ACEI/ARB in CF-LVAD patients.

Fragmented QRS predicts reperfusion failure and in-hospital mortality in ST-Elevation myocardial infarction: a systematic review and meta-analysis

Objective: Recent studies have shown that fragmented QRS (fQRS) is associated with unfavourable outcomes in STEMI patients. However, there is controversy amongst studies. We performed a systematic review and meta-analysis to explore the effect of fQRS on reperfusion failure and in-hospital mortality among this population.Methods: We searched the databases of MEDLINE and EMBASE from inception to October 2018. Included studies were published cohort studies of STEMI patients that underwent primary percutaneous coronary intervention (pPCI) and thrombolysis. Data from each study were combined using the random-effects model.Results: Ten studies from January 2011 to October 2018 (2753 patients, 1075 patients with fQRS), were included. The fQRS was associated with higher risk of reperfusion failure in pPCI when defined by ST-segment resolution (OR = 3.08, 95% CI = 1.27-7.46, p-value = .013) but not when defined by TIMI flow grade (pooled OR = 1.45, 95% CI = 0.83-2.54, p-value = .192). In thrombolysis, fQRS was associated with higher risk of reperfusion failure when defined by both ST-segment resolution (pooled OR = 4.35, 95% CI = 1.80-10.49, p-value = .001) and TIMI flow grade (OR = 3.70, 95% CI = 2.10-6.53, p-value < .001). The fQRS was also associated with an increased risk of in-hospital mortality in both pPCI (pooled OR = 4.41, 95% CI = 1.60-12.16, p-value = .004) and thrombolysis (pooled OR = 2.38, 95% CI = 1.06-5.35, p-value = .036).Conclusions: Our meta-analysis demonstrated that fQRS in STEMI patients was associated with reperfusion failure as well as in-hospital mortality.

Impact of Atrial Fibrillation on In-Hospital Mortality and Thromboembolic Complications after Left Ventricular Assist Device Implantation

The association between atrial fibrillation (AF) and thromboembolic (TE) complications in left ventricular assist device (LVAD) recipients is controversial, and there is paucity of large-scale data evaluating the impact of AF on early outcomes after device implantation. Using the National Inpatient Sample, we identified hospitalizations where patients underwent LVAD implantation from 2010 to 2015. Multivariate logistic regression was used to evaluate the association of AF on in-hospital outcomes. A total of 18,378 patients (41.7% with AF) underwent LVAD implantation. Patients with AF were older (59.9 vs. 54.0 years, p < 0.001), more commonly male (79.9 vs. 74.1%, p < 0.001), and had a greater burden of comorbidities as measured by the Elixhauser comorbidity index (7.2 vs. 6.3, p < 0.001). Patients with AF had less incidence of ischemic stroke (3.1 vs. 4.7%, p = 0.04, OR 0.68), hemorrhagic stroke (1.0 vs. 2.4%, p = 0.006, OR 0.43), and other systemic embolism (1.8 vs. 3.7%, p = 0.01, OR 0.55). There was no significant difference in the incidence of bleeding requiring transfusion between AF and no AF cohorts (29.3 vs. 24.2%, p = 0.09, OR 1.15). LOS was shorter in patients with AF (32.9 vs. 36.7 mean days, p < 0.001). Patients with AF had lower in-hospital mortality (8.9 vs. 14.9%, p < 0.001, OR 0.48). In a large real-world US cohort of patients undergoing LVAD implantation, a diagnosis of AF was common among device recipients. After adjustment for demographics and comorbidities, AF was associated with reduced TE events and in-hospital mortality.

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

Introduction

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

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

Method

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

Result

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

Conclusion

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

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

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

Baseline significant tricuspid regurgitation is associated with higher mortality in transcatheter aortic valve replacement: systemic review and meta-analysis

INTRODUCTION

Significant tricuspid regurgitation is a well recognized indicator of right ventricular dysfunction. Recent studies have shown that significant tricuspid regurgitation is potentially associated with increased mortality in patients with severe aortic stenosis who underwent transcatheter aortic valve replacement (TAVR). However, data remained sparse and inconclusive. Thus, we performed a systematic review and meta-analysis of the literature to assess the association between significant tricuspid regurgitation and mortality in post TAVR patients.

HYPOTHESIS

Significant tricuspid regurgitation is predictive for higher mortality in patients undergoing TAVR.

METHODS

We comprehensively searched the databases of MEDLINE and EMBASE from inception to October 2018. Included studies were published observational studies that reported multivariate analysis of the effects of significant tricuspid regurgitation on all-cause mortality among patients undergoing TAVR. Data from each study were combined utilizing the random-effects, generic inverse variance method of DerSimonian and Laird to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Nine cohort studies from August 2011 to May 2018 consisting of 27 614 patients with severe aortic stenosis undergoing TAVR (6255 with and 21 359 without significant tricuspid regurgitation) were included in this meta-analysis. The presence of significant tricuspid regurgitation was associated with higher all-cause mortality (pooled OR = 2.26, 95% CI: 1.45-3.52, P < 0.001). We found that all-cause mortality remained statistically substantial in all subgroups (30-day all-cause mortality: OR = 2.05, 95% CI: 1.20-3.49, P = 0.009; midterm all-cause mortality: OR = 9.67, 95% CI: 2.44-38.31, P = 0.001; and long-term all-cause mortality: OR = 1.48, 95% CI: 1.19-1.85, P < 0.001). Funnel plots and Egger's regression asymmetry test were performed and showed no publication bias.

CONCLUSION

Significant tricuspid regurgitation increased risk of mortality by up to two-fold among patients with severe aortic stenosis undergoing TAVR. Our study suggests that significant tricuspid regurgitation should be considered a component of risk stratification tools.

Baseline atrial fibrillation is a risk factor for erectile dysfunction: Systemic review and meta-analysis

Objective: To assess the association between atrial fibrillation (AF) and erectile dysfunction (ED) by a systematic review of the literature and meta-analysis, as ED is commonly found amongst male patients with concurrent cardiovascular conditions, especially atherosclerosis, coronary syndrome, and diabetes; and recent studies suggest that AF is associated with ED in the general male population.

Methods: Studies from inception to May 2018 in the Medical Literature Analysis and Retrieval System Online (MEDLINE) and Excerpta Medica dataBASE (EMBASE) were searched. Prospective or retrospective cohort studies that compared new-onset ED between male patients with and without AF were included. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios (RRs) and 95% confidence intervals (CIs).

Results: Five studies from 2007 to 2016 were included in the meta-analysis involving 29829 male patients (4096 with AF and 25733 without). The presence of AF was associated with ED (pooled RR 1.61, 95% CI 1.23–2.10; P < 0.001, I² = 42%).

Conclusions: Baseline AF increased the risk of ED up to 1.6-fold amongst the general male population. This suggests that AF in male patients is significantly associated with ED.

Abbreviations: AF: atrial fibrillation; CV: cardiovascular; ED: erectile dysfunction; EMBASE: Excerpta Medica database; HR: hazard ratio; ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification; (S)IR: (standardised) incidence ratio; IIEF: International Index of Erectile Function; LVDD: left ventricular diastolic dysfunction; MEDLINE: Medical Literature Analysis and Retrieval System Online; NO: nitric oxide; OR: odds ratio; RR: relative risk

Non-Transfemoral Transcatheter Aortic Valve Replacement Approach is Associated with a Higher Risk of New-Onset Atrial Fibrillation: A Systematic Review and Meta-Analysis

BACKGROUND

New-onset atrial fibrillation (NOAF) is a frequent arrhythmic complication following transcatheter aortic valve replacement (TAVR). Choice of access routes for TAVR could be a factor that determines the risk of NOAF although the data is still not well-characterised. We aimed to assess the association between different access routes for TAVR (transfemoral versus non-transfemoral) and the risk of NOAF.

METHODS

A comprehensive literature review was performed through September 2018 using EMBASE and Medline. Eligible studies must compare the incidence of NOAF in patients without pre-existing atrial fibrillation who underwent TAVR. Relative risk (RR) and 95% confidence intervals (CI) were extracted from each study and combined together using the random-effects model, generic inverse variance method of DerSimonian and Laird.

RESULTS

Seven (7) retrospective studies with 18,425 patients who underwent TAVR (12,744 with the transfemoral approach and 5,681 with the non-transfemoral approach) met the eligibility criteria. After the procedures, 2,205 (12.0%) patients developed NOAF (656 [5.1%] patients in the transfemoral group and 1,549 [27.3%] patients in the non-transfemoral group). There was a significant association between the non-transfemoral approach and an increased risk of NOAF with the pooled RR of 2.94 (95%CI, 2.53-3.41; p < 0.00001). Subgroup analysis showed the highest risk of NOAF in the transapical subgroup with the pooled RR of 3.20 (95% CI, 2.69-3.80; I² 33%).

CONCLUSIONS

A significantly increased risk of NOAF following TAVR among those who underwent a non-transfemoral approach compared with transfemoral approach was observed in this meta-analysis.