Impact of Cardiorespiratory Fitness on the Obesity Paradox in Heart Failure with Reduced Ejection Fraction

Fundamento:

Índice de massa corporal (IMC) elevado tem sido associado a desfechos melhores em pacientes com insuficiência cardíaca com fração de ejeção reduzida. Este achado tem levado ao conceito do paradoxo da obesidade.

Objetivo:

Investigar o impacto de tolerância ao exercício e capacidade cardiorrespiratória no paradoxo da obesidade.

Método:

Pacientes ambulatoriais com insuficiência cardíaca sintomática e fração de ejeção ventricular esquerda (FEVE) ≤ 40%, acompanhados no nosso centro, foram prospectivamente submetidos à avaliação abrangente de linha de base incluindo parâmetros clínicos, laboratoriais, eletrocardiográficos, ecocardiográficos e de exercício cardiopulmonar. A população do estudo foi dividida de acordo com o IMC (< 25, 25 – 29,9 e ≥ 30 kg/m²). Todos os pacientes foram acompanhados durante 60 meses. O desfecho composto foi definido como morte cardíaca, transplante cardíaco urgente ou necessidade de suporte circulatório mecânico. Valores de p < 0,05 foram considerados significativos.

Resultados:

Dos 282 pacientes incluídos (75% masculino, 54 ± 12 anos, IMC 27 ± 4 kg/m², FEVE 27% ± 7%), o desfecho composto ocorreu em 24,4% durante o acompanhamento. Os pacientes com IMC elevado eram mais velhos e apresentavam FEVE e níveis séricos de sódio mais elevados, bem como menor inclinação de eficiência ventilatória (VE/VCO₂). VE/VCO₂ e consumo de oxigênio de pico (VO₂p) eram fortes preditores prognósticos (p < 0,001). Na análise univariada de regressão de Cox, o IMC elevado foi associado a desfechos melhores (razão de risco 0,940, intervalo de confiança 0,886 – 0,998, p 0,042). Porém, após ajustar para ou inclinação VE/VCO₂ ou VO₂p, o papel protetor do IMC sumiu. O benefício de sobrevida do IMC não foi evidente quando os pacientes foram agrupados de acordo com a classe de aptidão cardiorrespiratória (VE/VCO₂, valor de corte de 35, e VO₂p, valor de corte de 14 mL/kg/min).

Conclusão:

Estes resultados sugerem que a aptidão cardiorrespiratória supera a relação entre o IMC e a sobrevida em pacientes com insuficiência cardíaca.

Melhora no Consumo Máximo de Oxigênio e na Ventilação após Tratamento com Sacubitril-Valsartana

Fundamento

O tratamento com sacubitril-valsartana teve seu benefício prognóstico confirmado no ensaio PARADIGM-HF. No entanto, dados sobre alterações no teste de esforço cardiopulmonar (TECP) com o uso de sacubitril-valsartana são escassos.

Objetivo

O objetivo deste estudo foi comparar os parâmetros do TECP antes e depois do tratamento com sacubitril-valsartana.

Métodos

Avaliação prospectiva de pacientes com insuficiência cardíaca (IC) crônica e fração de ejeção do ventrículo esquerdo ≤40%, mesmo sob terapia padrão otimizada, que iniciaram tratamento com sacubitril-valsartana, sem expectativa de tratamentos adicionais para a IC. Os dados do TECP foram coletados na semana anterior e 6 meses depois do tratamento com sacubitril-valsartana. Diferenças estatísticas com valor p <0,05 foram consideradas significativas.

Resultados

De 42 pacientes, 35 (83,3%) completaram o seguimento de 6 meses, uma vez que 2 (4,8%) morreram e 5 (11,9%) interromperam o tratamento devido a eventos adversos. A média de idade foi de 58,6±11,1 anos. A classe NYHA (classificação da New York Heart Association) melhorou em 26 (74,3%) pacientes. O consumo máximo de oxigênio (VO₂max) (14,4 vs. 18,3 ml/kg/min, p<0,001), a inclinação VE/VCO₂ (36,7 vs. 31,1, p<0,001) e a duração do exercício (487,8 vs. 640,3 s, p<0,001) também melhoraram com o uso de sacubitril-valsartana. O benefício foi mantido mesmo com a dose de 24/26 mg (13,5 vs. 19,2 ml/kg/min, p=0,018) de sacubitril-valsartana, desde que esta tenha sido a maior dose tolerada.

Conclusões

O tratamento com sacubitril-valsartana está associado a uma melhora acentuada do VO₂max, da inclinação VE/VCO₂ e da duração do exercício no TECP. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

C-reactive protein reduction with sacubitril-valsartan treatment in heart failure patients

OBJECTIVE

C-Reactive Protein (CRP) has emerged as an accessible measured product of inflammation. Whether systemic inflammation, a common feature of Heart Failure (HF), can be reduced by HF treatments in not well established. Sacubitril/Valsartan had prognosis benefit demonstrated in the PARADIGM-HF trial and was able to reduce proinflammatory cytokines in preclinical animal studies. However, no human studies evaluated if the benefits of this therapy are mediated by anti-inflammatory effects too. The aim of this study was to prospectively compare CRP values before and six months after Sacubitril-Valsartan therapy.

METHODS

Prospective evaluation of chronic HF patients with left ventricular ejection fraction ≤ 40% despite optimized standard of care therapy, in which Sacubitril/Valsartan therapy was started and no additional HF treatment was expected to change. Clinical, laboratorial (including CRP values), electrocardiographic, transthoracic echocardiography and cardiopulmonary exercise test (CPET) data were gathered in the week before starting Sacubitril/Valsartan therapy and six months thereafter.

RESULTS

There were 42 patients with a mean age of 59 ± 11 years, of which 35 completed the six months of follow-up, since 2 patients died and 5 discontinued treatment for adverse events. Patients with baseline CRP values above the median (> 2.5 mg/L) had a significantly higher percentage of New York Heart Association class ≥ III (65% vs. 33%, P=0.028) and a reduced exercise time in CPET (361 ± 297 vs. 575 ± 265 seconds, P=0.034). After 6 months of Sacubitril-Valsartan therapy, 24 (69%) patients had an improvement in CRP values with a significantly reduction as compared to baseline (median 2.5 mg/L (Interquartile range (IQR) 1.3-5.0) vs. 2.2 mg/L (IQR 0.9-4.0), P=0.014 in the Wilcoxon test). In the group of 17 (49%) patients with at least 25% improvement in CRP values with Sacubitril/Valsartan therapy, the benefit of several clinical, CPET and echocardiographic parameters were not significantly different from the benefit of patients with no improvement or an improvement inferior to 25% in CRP values.

CONCLUSION

Sacubitril/Valsartan therapy was able to reduce CRP values in a chronic HF population. Whether this reduction was only a consequence of clinical improvement with Sacubitril/Valsartan or an anti-inflammatory effect is also present should be further evaluated.

Heart failure units: State of the art in disease management

The prevalence of heart failure has increased over the past decades and is a major social and economic burden on healthcare services. Patient quality of life is severely impaired and heart failure is one of the main causes of death in Portugal. The functional organization of multidisciplinary teams engaged in the treatment of these patients is essential to improve health care provision and outcomes, specifically reducing mortality, hospital admissions, and improving quality of life. We describe current approaches to heart failure management and discuss the organization of heart failure units and cooperation among these units and also with other healthcare professionals.

Survivorship Following Hip Arthroscopy: Lessons Learned from a Comprehensive Database

PURPOSE OF REVIEW

Hip arthroscopy and its indications continue to expand. Understanding the durability of hip arthroscopic procedures remains important not only for counseling patients, but also for determining the success of certain procedures or in certain populations. Survivorship is defined as the proportion of hip arthroscopy patients who have not yet gone on to periacetabular osteotomy (PAO), total hip arthroplasty (THA), and/or revision surgery. The purpose of this review is to summarize the recent literature pertaining to survivorship after certain hip arthroscopic procedures and certain special populations.

RECENT FINDINGS

There is yet to be level 1 evidence published with relation to survivorship following hip arthroscopy. The best evidence in the recent literature is contained in just rew long-term prospective studies demonstrating good to excellent survivorship following hip arthroscopy for femoroacetabular impingement (FAI). Unfortunately, the follow-up for other conditions treated by hip arthroscopy is more limited. In summary, hip arthroscopy indications continue to expand. The most common indication for surgery is FAI, and its recently published long-term survivorship demonstrates excellent durability. Other hip arthroscopic procedures, including labral reconstruction, adjunctive procedures such as capsular closure, and special populations such as athletes, also demonstrate excellent survivorship in shorter term follow-up. Further prospective research is needed to further define survivorship of various hip conditions, associated procedures, and special populations commonly treated with hip arthroscopy.

Prognostic Prediction of Cardiopulmonary Exercise Test Parameters in Heart Failure Patients with Atrial Fibrillation

BACKGROUND

Atrial fibrillation (AF) is associated with increased mortality in heart failure (HF) patients.

OBJECTIVE

To evaluate whether the risk of AF patients can be precisely stratified by relation with cardiopulmonary exercise test (CPET) cut-offs for heart transplantation (HT) selection.

METHODS

Prospective evaluation of 274 consecutive HF patients with left ventricular ejection fraction ≤ 40%. The primary endpoint was a composite of cardiac death or urgent HT in 1-year follow-up. The primary endpoint was analysed by several CPET parameters for the highest area under the curve and for positive (PPV) and negative predictive value (NPV) in AF and sinus rhythm (SR) patients to detect if the current cut-offs for HT selection can precisely stratify the AF group. Statistical differences with a p-value <0.05 were considered significant.

RESULTS

There were 51 patients in the AF group and 223 in the SR group. The primary outcome was higher in the AF group (17.6% vs 8.1%, p = 0.038). The cut-off value of pVO2 for HT selection showed a PPV of 100% and an NPV of 95.5% for the primary outcome in the AF group, with a PPV of 38.5% and an NPV of 94.3% in the SR group. The cut-off value of VE/VCO2 slope showed lower values of PPV (33.3%) and similar NPV (92.3%) to pVO2 results in the AF group.

CONCLUSION

Despite the fact that AF carries a worse prognosis for HF patients, the current cut-off of pVO2 for HT selection can precisely stratify this high-risk group.

P1433 Antiarrhythmic effects of sacubitril-valsartan therapy assessed by mechanical dispersion index

Introduction

Sacubitril/Valsartan (LCZ696) significantly reduced sudden cardiac death in the PARADIGM-HF trial. However, there is little published data regarding the possible explanations for the antiarrhythmic effects found with LCZ696 therapy.

Previous trials have shown that mechanical dispersion by strain echocardiography can predict arrhythmic events in Heart Failure (HF) patients.

The aim of this study was to compare electrocardiographic (ECG) parameters and mechanical dispersion index with left ventricular (LV) global longitudinal strain (GLS) analysis before and after LCZ696 therapy.

Methods

Prospective evaluation of chronic HF patients with LV ejection fraction ≤ 40% despite optimized standard of care therapy, in which LCZ696 therapy was started and no additional HF treatment was expected to change.

ECG and transthoracic echocardiographic data were gathered in the week before starting LCZ696 therapy and 6 months after therapy. A semiautomated analysis of LV GLS was made and mechanical dispersion index was defined as the standard deviation from the 16 time intervals corresponding to each LV segment.

Results

Of the 42 patients, 35 (83.3%) completed the 6 months of follow-up, since 2 (4.8%) patients died and 5 (11.9%) discontinued treatment for adverse events. Mean age was 58.6 ± 11.1 years.

QTc interval (451.9 vs 426.0msec, p &lt; 0.001) and QRS interval (125.1 vs 120.8msec, p = 0.033) were reduced after 6 months of LCZ696 therapy. Mechanical dispersion index (88.4 vs 78.1msec, p = 0.036) was also significantly reduced after therapy.

Conclusion

LCZ696 therapy is associated with antiarrhythmic effects with a reduction in QTc and QRS intervals in ECG and a reduction in mechanical dispersion index as assessed by LV GLS.

Abstract P1433 Figure.

1037 Differences in reverse remodelling between ischemic and non-ischemic left ventricular segments as assessed by myocardial work after sacubitril-valsartan therapy

Introduction

Myocardial work (MW) is a new transthoracic echocardiographic (TTE) parameter that enhances the information provided through left ventricular (LV) global longitudinal strain (GLS), allowing to investigate LV performance even in cases of changes in afterload.

None is known about the effects of Sacubitril-Valsartan (LCZ696) therapy in MW parameters.

Purpose

Compare the changes in MW parameters between ischemic and non-ischemic segments after LCZ696 therapy.

Methods

The study was a prospective evaluation of chronic Heart Failure (HF) patients with optimized standard of care therapy and LV ejection fraction ≤40%, in which LCZ696 therapy was started and no other HF treatment was expected to change.

A TTE study was performed before and 6 months after LCZ696 therapy, using the GE Vivid E95 ultrasound system. A semiautomated analysis of GLS was performed after two-dimensional images were acquired in the standard apical 4-, 3- and 2 chamber views. MW and related indices were estimated using custom software.

Two groups were created according to the 17 segment model TTE study before LCZ696 therapy:

G1 (ischemic group): dyskinesia/akinesia/hypokinesia segments in patients with ischemic HF etiology;

G2 (non-ischemic group): normokinesia segments in patients with ischemic and all segments in patients with non-ischemic HF etiology;

Results

Of the 42 patients, 35 (83.3%) completed the six-months follow-up with LCZ696, since 2 patients (4.8%) died and 5 patients (11.9%) discontinued treatment for adverse events. Mean age was 58.6 ± 11.1 years, with ischemic etiology in 15 (42.9%), resulting in a total of 26.5% segments for G1.

Baseline global MW index (GWI) had no statistical difference between G1 and G2 (566.1 VS 584.8mmHg%, p = 0.257), but baseline MW efficiency (GWE) were significantly lower in G1 (71.9 VS 78.8%, p &lt; 0.001).

The table represents the mean values for MW parameters in G1 and G2 before and 6 months after LCZ696 therapy, with a significantly increase in GWI and GWE values in both groups. Despite no difference in the increase in GWE (p = 0.872), the increase in GWI were higher in G2 than G1 (p &lt; 0.001).

Conclusion

MW seems to be a new tool providing signs of reverse remodelling and better cardiac performance in ischemic and non-ischemic segments after LCZ696 therapy.

Table 1 Time 0 6 months p GWI in ischemic segments (mmHg%) 566.1 ± 364.0 696.5 ± 445.2 &lt;0.001 GWE in ischemic segments (%) 71.9 ± 25.0 78.9 ± 19.1 0.009 GWI in non-ischemic segments (mmHg%) 584.8 ± 434.3 812.3 ± 442.0 &lt;0.001 GWE in non-ischemic segments (%) 78.8 ± 21.2 85.7 ± 15.8 0.004 MW data before and after six months of LCZ696 therapy

P1429 B-Type natriuretic peptide prediction of right catheterization parameters in the first year after heart transplant

Introduction

Despite being the gold-standard for hemodynamic assessment, right heart catheterization (RHC) was overcome by plasma B-Type Natriuretic Peptide (BNP) levels in daily clinical routine. However, in the first year after heart transplantation (HT), the relationship between BNP and adverse hemodynamics have yielded conflicting results.

Purpose

The aim of this study was to evaluate whether BNP values can be used to estimate adverse hemodynamics in the first year after HT.

Methods

Prospective study of consecutive RHC performed in the first year after HT (according to the endomyocardial biopsies program). Plasma BNP levels were measured at the same day.

The area under the curve (AUC) was analysed to find the BNP values with higher sensitivity and specificity to detect adverse hemodynamics.

Results

From 2017 to 2018, 50 RHC were performed. Mean age was 48.7 ± 8.3 years, with mean BNP value of 964.4 ± 1114.7pg/ml.

Prediction of adverse hemodynamics by AUC results are represented in the table. BNP values were significantly increased in patients with pulmonary capillary wedge pressure (PCWP) &gt;12mmHg (p &lt; 0.001), cardiac index &lt;2.5L/min/m2 (p = 0.001), mean pulmonary artery pressure (mPAP) ≥25mmHg (p &lt; 0.001), pulmonary vascular resistance &gt; 1,5WU (p = 0.044) and right atrial pressure &gt;5mmHg (p = 0.003).

BNP &gt;500pg/ml had a sensitivity of 78.3% and 87.5% and a specificity of 76.0% and 67.7% to detect PCWP &gt;12mmHg and mPAP ≥25mmHg, respectively.

Conclusion Significant associations were found between BNP values and adverse hemodynamics in RHC, supporting the clinical utility of BNP in the first year after HT.

BNP prediction AUC values SR HEMODYNAMIC PARAMETERS AUC p 95% CI Best BNP value Sensitivity Specificity Pulmonary capillary wedge pressure (PCWP) &gt; 12mmHg 0.798 &lt;0.001 0.671-0.925 &gt; 500pg/ml 78.3% 76.0% Mean pulmonary artery pressure (mPAP) ≥ 25mmHg 0.830 &lt;0.001 0.714-0.946 &gt; 500pg/ml 87.5% 67.7% Cardiac output &lt; 4L/min 0.833 0.002 0.667-1.000 &gt; 1500pg/ml 77.8% 87.5% Cardiac index (CI) &lt; 2.5L/min/m2 0.810 0.001 0.663-0.957 &gt; 1150pg/ml 76.9% 86.1% Pulmonary vascular resistance (PVR) &gt; 1,5WU 0.678 0.044 0.509-0.848 &gt; 200pg/ml 83.3% 47.1% Right atrial pressure (RAP) &gt; 5mmHg 0.744 0.003 0.607-0.880 &gt; 500pg/ml 70.8% 65.4% BNP prediction

P354 Right heart catheterization parameters, echocardiography parameters and B-Type natriuretic peptide prediction of acute cellular rejection in the first year after heart transplant

Introduction

Since the mid-1970s, the diagnosis of acute cellular rejection (ACR) has been made by endomyocardial biopsy (EMB). Whether B-Type Natriuretic Peptide (BNP), transthoracic echocardiography (TTE) parameters and right heart catheterization (RHC) parameters can detect rejection in heart transplant (HT) patients have yielded conflicting results and did not overcome the use of EMB in the first year after HT.

Purpose

The aim of this study was to evaluate whether BNP, TTE and RHC parameters can be used to detect ACR in the first year after HT.

Methods

Prospective study of consecutive EMB performed in the first year after HT. Plasma BNP levels, TTE and RHC were performed at the same day.

Clinical significant ACR was defined as ≥ 2R, according to the ISHLT 2004 grading. The area under the curve (AUC) was analysed for statistically significant associations to detect ACR.

Results

From 2017 to 2018, 50 EMB were performed with the following results: 2R - 5 (10.0%); 1R- 29 (58.0%); 0 – 16 (32%). Mean age was 48.7 ± 8.3 years, with mean BNP value of 964.4 ± 1114.7pg/ml.

AUC results of BNP and several TTE and RHC parameters for the prediction of ACR are represented in the table. Right atrial pressure (RAP) value (p = 0.027) was the only significantly predictor of ACR, while isovolumic relaxation time measured by TTE revealed a borderline significant trend (p = 0.076).

RAP &gt; 10mmHg had a sensitivity of 60.0% and a specificity of 84.4% for detecting ACR.

Conclusion

Detecting ACR without EMB remains a clinical challenge, but RAP measured by RHC was a significant predictor of ACR in the first year after HT, while BNP values did not correlate with ACR.

AUC values PARAMETERS AUC p 95% CI BNP 0.658 0.251 0.405-0.911 Troponin I 0.591 0.507 0.260-0.923 Left ventricular ejection fraction 0.416 0.541 0.218-0.614 E/A 0.480 0.895 0.282-0.678 Deceleration time 0.463 0.463 0.161-0.765 Isovolumic relaxion time 0.745 0.076 0.427-1.000 Cardiac index 0.595 0.488 0.346-0.845 Pulmonary capillary wedge pressure 0.628 0.401 0.329-0.926 Mean pulmonary artery pressure 0.684 0.181 0.511-0.857 Right atrial pressure 0.804 0.027 0.631-0.978 AUC values

P175 Cardiac device infection: to extract or not to extract, that is the question

Introduction

The incidence of infectious complications related to intracardiac devices has been increasing in recent year and is associated with a poor prognosis, which is determined not only by the infectious process but also by the severity of the underlying cardiac pathology and the spectrum of comorbidities presented. Appropriate antibiotic therapy and extraction of the devices are fundamental in the management of these patients.

Case report

We describe the case of a 66-year-old patient on a waiting list for transplantation due to non-ischemic dilated cardiomyopathy with poor left ventricular systolic function (LVEF of 10%), with severe functional mitral regurgitation and severe pulmonary hypertension, who received a CRT-D for secondary prevention (non-responder). He was admitted for decompensated heart failure (NYHA functional class IV and "dry-cold" profile) requiring inotropic support becoming dependent on dobutamine. During hospitalization, there was a progressive increase in inflammatory markers accompanied by recurrent febrile peak and inflammatory signs of the central venous catheter, with catheter-tip and serial hemocultures positive for Morganella morganii. Piperacillin / tazobactam was started. Due to the lack of response to pathogen directed antibiotic therapy, he underwent a transesophageal echocardiogram (TEE) that revealed several filiform images associated with the electrodes, with no image of valvular vegetations, which led to the association of gentamicin and device extraction (DE), according to the Pisa technique, that occurred without complications. On the 7th day after DE, there was a progressive clinical deterioration in spite of increasing doses of inotropes and vasopressors. It was considered that patient would not be candidate for cardiac transplantation or mechanical ventricular assist, and died on the 118th day of hospitalization in refractory cardiogenic shock.

Conclusion

Device endocarditis is a class I indication for intracardiac DE and TEE is fundamental in its diagnosis. Despite being a considered a non-responder to cardiac resynchronization therapy based on clinical and echocardiographic criteria, this case illustrates how the loss of cardiac resynchronization may have contributed to the patient’s hemodynamic deterioration and have played a fundamental role in the clinical outcome.

A Bridge to Wellness: Gains from a health fair among fishermen in the Port of New Bedford, USA

Background

Globally, it has been noted that fishermen have a higher mortality from cardiovascular disease, cancer, and injury from work-related accidents when compared to the general population. A potential increase in unemployment in fishermen in New Bedford could result in a lower income level which relates to an increase in risk behaviors, less health screenings, and negative health behaviors. While there is a lack of health-related data among fishermen across the globe, there is little information regarding the health among fishermen, who are predominantly immigrants, in the US.

Objectives

The objectives include designing a health promotion fair to prepare nursing students with the skills to educate fishermen associated with nutrition, diabetes mellitus, cancer and hypertension as identified by key informants in the community.

Results

Students expressed gains in achieving nursing competencies related to collaboration, communication, and teaching/learning by designing a fair with stations related to the four health topics with posters and activities. Educational materials were available in both Portuguese and English to support this aggregate who expressed learning new knowledge. Networking among local fishing agencies, nursing students and the fishermen supported this project from start to finish.

Conclusions

Despite limited access to this vulnerable group, learning nursing competencies and increased fishermen’s knowledge were realized. Connecting students with vulnerable populations is an effective way to promote learning for both groups.

Key messages

Multiple gains are noted when nursing students are paired with vulnerable community aggregates. Learning to work in the community with local agencies and groups is an effective teaching/learning pedagogy.

Bridging Generations: Sharing stories from the past with the future

Background

As the immigration population continues to grow; little is known about this phenomenon from the immigrants’ perspective. In recent years, nurses have embraced narrative inquiry to better understand the human experience. When relaying their stories, vulnerable groups legitimize their behavior, share their emotional experiences, and amplify their voices that may have otherwise remained silent.

Objective

Eight elderly Portuguese women who immigrated to the United States (US) were interviewed about their experience of immigration by nursing students from Portugal and U.S., as part of a student exchange. The objective of this project was to better understand the impact of immigration through narrative inquiry.

Results

On average, the women lived in the US for approximately fifty years; immigrating in their early twenties. Most women arrived alone or accompanied by spouse and/or children. Their first memories were related to snow, and solitude of being in a new country. The participants attended classes to obtain documents or learn English. All worked in the textile industry; their greatest accomplishment was buying their own house. Challenges faced were related to language and difficult jobs. Overall, they had no regrets except in leaving family members behind. Their message to the students was that love and family are most important in the world. Students were able to realize emigration and immigration from their respective countries.

Conclusions

Rich descriptions provided an in-depth understanding of the details of the women’s experience. Student nurses gained valuable skills and knowledge to understand the impact of immigration among Portuguese women using narrative inquiry.

Key messages

The use of narrative inquiry proved to be a valuable method to interview Portuguese immigrant women. Every immigrant has a unique narrative to share that allowed for nursing student’s appreciation of the experience across generations.

262Circulating muscle-derived mir-206 links skeletal muscle dysfunction to cardiac autonomic denervation

Purpose

Recent studies and our preliminary data demonstrate that muscle-specific ablation of the autophagy-related protein Atg7, leads to block of autophagy, sarcopenia and destabilization of the neuro-muscular junction (NMJ). In addition, Atg7 knock-out (Atg7 KO) muscle fibers release exosomes containing the muscle specific, miR-206, which is consistently elevated in the plasma. Interestingly, we found that miR-206 content was elevated in the heart, suggesting cardiac uptake of the miR-carrying circulating exosomes. We thus aimed at defining the effects of miR-206 on heart homeostasis.

Methods

Here, we analyzed the cardiac phenotype of adult (12mo.) and aged (24mo.) Atg7 KO mice, as well as of adult C57BL/6J mice injected, via tail vein, with scramble- or miR-206-loaded exosomes. Exosomes were isolated from EDL muscle of control and Atg7 KO mice, as well as from HEK293 cells. Heart function was assessed by echocardiography and ECG-telemetry. Confocal IF, whole-mount IF on heart blocks and multiphoton imaging were used to assess heart structure and sympathetic innervation. Bioinformatics, molecular and biochemical analyses were performed to identify novel targets of miR-206. IF, BRET assay and imaging of TrKA translocation were performed in cultured sympathetic neurons (SNs).

Results

We demonstrate that circulating exosomes, containing miR-206, are taken up by the heart leading to sympathetic dysinnervation, accompanied to reduction in the neurogenic control of cardiac rhythm and increased arrhythmogenesis. In vitro assays demonstrated that exosome-carried miR-206 targets cardiac SNs (cSNs), compromising cell structure and function. Indeed, increased miR-206 expression is accompanied by cSN atrophy, irregular axonal distribution of the active neurotransmitter release sites, and reduction in axonal sprouting. These effects are likely attributed to the miR-206-mediated down-regulation of the NGF receptor p75, as demonstrated by bioinformatics, luciferase assay, molecular and biochemical analyses in vitro and ex vivo. BRET assay, performed in cultured SNs treated with exosomes carrying miR-206, showed reduced formation of p75/TrkA complexes, which generate high-affinity binding sites for NGF and enhance neurotrophin responsiveness. Consistent with impaired NGF retrograde transport, miR-206 over-expressing SNs displayed reduced NGF protein content and decreased phosphorylation of Akt, which is an NGF downstream target, regulating neuronal survival. Interestingly, these latter results were confirmed in the stellate ganglia from Atg KO and miR-206 treated mice.

miR-206 causes heart dysinnervation

Conclusions

We identify miR-206 as a key molecular player in the “muscle-to-heart” communication. miR-206 may participate to the pathogenesis of secondary cardiac dysfunction in skeletal muscle diseases associated to increased circulating levels of miR-206, ranging from ageing to neurodegenerative disorders (i.e. ALS, DMD).

4940Early reverse remodelling assessed by myocardial work after sacubitril-valsartan therapy

Introduction

Sacubitril/Valsartan (LCZ696) had prognosis benefit demonstrated in PARADIGM-HF trial, however less is known about his effects in cardiac dimensions and function.

Myocardial work (MW) is a new transthoracic echocardiographic (TTE) parameter. None is known about the effects of LCZ696 therapy in MW parameters.

Purpose

The aim of this study was to prospectively compare several TTE parameters, including MW, before and after LCZ696 therapy.

Methods

Prospective evaluation of chronic HF patients with optimized standard of care therapy and LVEF≤40%, in which LCZ696 therapy was started.

TTE study was performed before and 6 months after LCZ696 therapy. A semiautomated analysis of GLS was performed and MW were estimated using custom software of GE Vivid E95 ultrasound system.

Results

Of the 42 patients, 35 (83.3%) completed the 6 months follow-up, since 2 patients (4.8%) died and 5 patients (11.9%) discontinued treatment for adverse events. Mean age was 58.6±11.1 years with 82.9% of male patients.

LV dimensions and atrial volumes were significantly lower at 6 months of treatment. LVEF had a mean absolute raise of 8.9% and GLS a relative decrease of 27.8%. MW had a significant increase in constructive work (720.2mmHg VS 900.6mmHg, p=0.016) and work efficiency (78.6% VS 86.6%, p=0.027), with a non-significant decrease in the wasted work (150.2mmHg VS 136.8mmHg, p=0.441).

TTE data before and after 6 months of LCZ696 treatment Time 0 6 months p LV end-diastolic diameter (mm) 71.3±8.4 66.9±7.6 0.001 LV end-systolic diameter (mm) 57.8±9.4 53.1±9.3 0.002 Interventricular septum (mm) 9.6±1.7 9.9±1.9 0.280 LVEF (%) 29.3±6.4 38.2±8.9 <0.001 GLS (%) −7.0±2.9 −8.9±2.8 0.001 MW – Constructive (mmHg) 720.2±230.5 900.6±343.2 0.016 MW – Wasted (mmHg) 150.2±83.3 136.8±54.2 0.441 MW – Efficiency (%) 78.6±10.8 86.6±12.0 0.027 E/e' 13.7±4.5 12.8±4.9 0.449 Pulmonary artery systolic pressure (mmHg) 38.3±12.2 30.9±10.6 <0.001 Left atrium volume (ml/m2) 51.5±22.6 43.7±15.8 0.004 Right atrium volume (ml/m2) 33.1±4.4 28.5±13.5 0.036 TAPSE (mm) 19.2±4.4 20.0±4.9 0.404

Conclusion

LCZ696 therapy is associated with signs of reverse remodelling in TTE, including an increase in constructive work and work efficiency.

Antiarrhythmic Effect of Sacubitril-Valsartan: Cause or Consequence of Clinical Improvement?

Sacubitril/Valsartan (LCZ696) reduced sudden cardiac death in the PARADIGM-HF trial. However, the mechanism by which LCZ696 reduces ventricular arrhythmias remains unclear. The aim of this study was to compare electrocardiographic (ECG) parameters and mechanical dispersion index, assessed by left ventricular (LV) global longitudinal strain (GLS), before and after LCZ696 therapy. We prospectively evaluated chronic Heart Failure (HF) patients with LV ejection fraction ≤40%, despite optimal medical and device therapy, in which LCZ696 therapy was started, while no additional HF treatment was expected to change. ECG and transthoracic echocardiographic data were gathered in the week before starting LCZ696 and at six months of therapy. A semiautomated analysis of LV GLS was performed and mechanical dispersion index was defined as the standard deviation from 16 time intervals corresponding to each LV segment. Of the 42 patients, 35 completed the six month follow-up, since two patients died and five discontinued treatment for adverse events. QTc interval (451.9 vs. 426.0 ms, p < 0.001), QRS duration (125.1 vs. 120.8 ms, p = 0.033) and mechanical dispersion index (88.4 vs. 78.1 ms, p = 0.036) were significantly reduced at six months. LCZ696 therapy is associated with a reduction in QTc interval, QRS duration and mechanical dispersion index as assessed by LV GLS.

Neurohormonal modulation: The new paradigm of pharmacological treatment of heart failure

The current paradigm of medical therapy for heart failure with reduced ejection fraction (HFrEF) is triple neurohormonal blockade with an angiotensin-converting enzyme inhibitor (ACEI), a beta-blocker (BB) and a mineralocorticoid receptor antagonist (MRA). However, three-year mortality remains over 30%. Stimulation of counter-regulatory systems in addition to neurohormonal blockade constitutes a new paradigm, termed neurohormonal modulation. Sacubitril/valsartan is the first element of this new strategy. PARADIGM-HF was the largest randomized clinical trial conducted in HFrEF. It included 8442 patients and compared the efficacy and safety of sacubitril/valsartan versus enalapril. The primary endpoint was the composite of cardiovascular mortality and hospitalization due to HF, which occurred in 914 (21.8%) patients receiving sacubitril/valsartan and in 1117 (26.5%) patients receiving enalapril (HR 0.8, 95% CI 0.73-0.87, p=0.0000002; NNT 21). Sacubitril/valsartan reduced both primary endpoint components, as well as sudden cardiac death, death due to worsening HF, and death from all causes. Patients on sacubitril/valsartan reported less frequent deterioration of HF and of quality of life, and discontinued study medication less frequently because of an adverse event. PARADIGM-HF demonstrated the superiority of sacubitril/valsartan over enalapril, with a 20% greater impact on cardiovascular mortality compared to ACEIs. Accordingly, in 2016, the European (ESC) and American (ACC/AHA/HFSA) cardiology societies simultaneously issued a class I recommendation for the replacement of ACEIs by sacubitril/valsartan in patients resembling PARADIGM-HF trial participants.

Bartholin's gland abscess caused by Streptococcus pneumoniae in a sexually active young woman

Gynaecological infections are frequent in women, particularly in young women during their reproductive time. Anatomophysiologically, Bartholin's gland is greatly susceptible to infections and is characterised by an inherent polymicrobial population. In fact, gynaecological microbiota has a set of agents coming from the perianal region that colonise the vagina and, in particular, Bartholin's gland. Taking this into account, infections caused by agents that do not belong to the genital microbiota are less frequent. Here, we describe a case of a 23-year-old young woman with an abscess in Bartholin's gland caused by Streptococcus pneumoniae.

Adipocyte proteome and secretome influence inflammatory and hormone pathways in glioma

Gliomas represent the most common primary malignant brain tumors in adults, with an extremely poor prognosis. Among several risk factors, lifestyle was also recently identified as a major risk factor for the development of primary glioma. In the present study, we explore the relationship between obesity and glioma in a cellular model. Thus, we have study the influence of adipocytes secretome on glioma cell line GL261. Using the 3T3-L1 adipocyte cell line, and its conditioned medium (adipokines-enriched medium), we showed that adipocyte-released factors relate with glioma angiogenic, growth, hormones and metabolic behavior by MALDI-TOF-MS and proteomic array analysis. In a first view, STI1, hnRNPs and PGK1 are under expressed on CGl. Similarly, both carbonic anhydrase and aldose reductase are even suppressed in glioma cells that grown under adipokines-enriched environment. Contrariwise, RFC1, KIF5C, ANXA2, N-RAP and RACK1 are overexpressed in GL261 cell the in the presence of the adipokines-enriched medium. We further identified the factors that are released by adipocyte cells, and revealed that several pro-inflammatory and angiogenic factors, such as IL-6, IL-11, LIF, PAI-1, TNF-α, endocan, HGF, VEGF IGF-I, were secreted to the medium into a high extent, whereas TIMP-1 and SerpinE1 were under expressed on CGl. This study discloses an interesting in vitro model for the study of glioma biology under a "obesity" environment, that can be explored for the understanding of cancer cells biology, for the search of biomarkers, prognostic markers and therapeutic approaches.