Predictors of short-term outcome in Chinese patients with ambulatory heart failure for heart transplantation with ejection fraction <25%

Cardiological Challenges Related to Long-Term Mechanical Circulatory Support for Advanced Heart Failure in Patients with Chronic Non-Ischemic Cardiomyopathy

Long-term mechanical circulatory support by a left ventricular assist device (LVAD), with or without an additional temporary or long-term right ventricular (RV) support, is a life-saving therapy for advanced heart failure (HF) refractory to pharmacological treatment, as well as for both device and surgical optimization therapies. In patients with chronic non-ischemic cardiomyopathy (NICM), timely prediction of HF's transition into its end stage, necessitating life-saving heart transplantation or long-term VAD support (as a bridge-to-transplantation or destination therapy), remains particularly challenging, given the wide range of possible etiologies, pathophysiological features, and clinical presentations of NICM. Decision-making between the necessity of an LVAD or a biventricular assist device (BVAD) is crucial because both unnecessary use of a BVAD and irreversible right ventricular (RV) failure after LVAD implantation can seriously impair patient outcomes. The pre-operative or, at the latest, intraoperative prediction of RV function after LVAD implantation is reliably possible, but necessitates integrative evaluations of many different echocardiographic, hemodynamic, clinical, and laboratory parameters. VADs create favorable conditions for the reversal of structural and functional cardiac alterations not only in acute forms of HF, but also in chronic HF. Although full cardiac recovery is rather unusual in VAD recipients with pre-implant chronic HF, the search for myocardial reverse remodelling and functional improvement is worthwhile because, for sufficiently recovered patients, weaning from VADs has proved to be feasible and capable of providing survival benefits and better quality of life even if recovery remains incomplete. This review article aimed to provide an updated theoretical and practical background for those engaged in this highly demanding and still current topic due to the continuous technical progress in the optimization of long-term VADs, as well as due to the new challenges which have emerged in conjunction with the proof of a possible myocardial recovery during long-term ventricular support up to levels which allow successful device explantation.

Prognostic value of selected echocardiographic, impedance cardiographic, and hemodynamic parameters determined during right heart catheterization in patients qualified for heart transplantation

The aim of the study was to verify prognostic value of selected echocardiographic (UKG), impedance cardiography (ICG), and right heart catheterization (RHC) parameters in systolic heart failure (HF). UKG, ICG, and RHC were performed in 46 patients with chronic HF with ejection fraction <35%. During a 1-year follow-up, composite endpoint (death or hospitalization due to HF exacerbation) was achieved by 23 (50.0%) patients. Analysis of receiver operating characteristic (ROC) curves identified UKG parameters: inferior vena cava diameter on inspiration (IVCinsp) >13 mm [area under curve (AUC), 0.791], right atrial (RA) >5.2 cm (AUC 0.710) and ventricular dimension (RVD) >3.5 cm (AUC 0.717), tricuspid annular plane systolic excursion (TAPSE) <17 mm (AUC 0.682), and its velocity (S'RV) <6.07 cm/s (AUC 0.716) as unfavorable prognostic factors. RHC parameters: low values of cardiac index (CI < 2.1 L/min; AUC 0.846) and high pulmonary capillary wedge pressure (PCWP > 24 mmHg; AUC 0.773) turned out to be the most accurate single predictors of worse outcome. Prognostic value of non-invasive parameters was improved due to the use of their composite measures: IVC% × TAPSE (<430%/mm; AUC 0.826), RVSP/TAPSE (>2.4 mmHg/mm; AUC 0.800), IVC% × SBP (>2097% mmHg; AUC 0.826), and RA × IVCinsp/S'RV (>11.8 cm s; AUC 0.839). In conclusion, composite measures based on non-invasive parameters, such as IVC%/TAPSE, RVSP/TAPSE and RA × IVCinsp/S'RV, may provide equally accurate prognosis as the invasive examination. PCWP and CI determined during RHC were the best individual predictors of the composite endpoint. In addition, echocardiographic parameters: RVD, RA, IVC, TAPSE, and S'RV are accurate predictors of the unfavorable outcome.

Predictors of mortality in medically treated patients with congestive heart failure of nonrheumatic etiology and reduced systolic function

OBJECTIVE

We investigated the prognostic value of various parameters on the mortality of patients with nonrheumatic chronic heart failure and left ventricular (LV) systolic dysfunction.

METHODS

This study included 132 consecutive patients with congestive heart failure and reduced LV systolic function without rheumatic valve disease. The primary outcome was mortality. Mean follow-up was 38+/-6 months.

RESULTS

During the follow-up period there were 47 deaths (35.6%). The age (64.1+/-13.5 vs. 58.7+/-11.8 years, P=0.019), left bundle branch block (44.7% vs. 18.8%, P=0.002), urea concentration (11.4+/-5.3 vs. 8.9+/-4.6 mmol/L, P=0.006), LV end-diastolic and end-systolic dimensions (6.7+/-0.8 vs. 6.4+/-0.8 cm, P=0.025 and 5.5+/-0.8 vs. 4.9+/-0.8 cm, P<0.001, respectively), grade 3-4 mitral regurgitation (40.4 vs. 22.4%, P<0.001), fractional shortening (16.7+/-5.3% vs. 19.8+/-5.7%, P=0.002) and LV ejection fraction (32.9+/-8.5% vs. 38.7+/-11.3%, P=0.003) were different between non-survivors and survivors. Multivariate analysis identified severity of mitral regurgitation (OR=1.99, 95% CI 1.18-3.34; P=0.009), age (OR=1.07, 95% CI 1.02-1.12; P=0.01) and LV end-systolic dimension (OR=1.09, 95% CI 1.02-1.16; P=0.014) as independent correlates of mortality.

CONCLUSIONS

In medically treated patients with nonrheumatic chronic heart failure and left ventricular systolic dysfunction, severity of mitral regurgitation, age and enlarged LV end-systolic dimension were independently associated with increased risk of death.

Prediction of short-term outcomes in patients with idiopathic dilated cardiomyopathy referred for transplantation using standard echocardiography and strain imaging

OBJECTIVE

We sought to evaluate the short-term prognostic value of echocardiography including two-dimensional (2D) strain imaging in patients with end-stage idiopathic dilated cardiomyopathy (IDCM).

METHODS

To evaluate the short-term (6-month) prognostic value of different parameters used for the assessment of IDCM patients referred for heart transplantation, we performed at the baseline transthoracic echocardiography including 2D strain imaging, N-terminal pro-BNP measurements, and exercise testing for all patients included in the study. After 6 months, all parameters, including endsystolic strain (ESS), peak systolic strain rate (SSR(max)), early and late diastolic strain rates, their ratio (diastolic strain rate E [DSR(E)], dialostolic strain rate A [DSR(A)], diastolic strain rate E and A wave ratio [DSR(E/A)]), and systolic intraventricular dyssynchrony indexes (IVDSI) were tested for their prognostic value to predict a patient's outcome.

RESULTS

At the baseline stable patients had significantly lower transmitral E and A wave ratio (E/A), DSR(E/A), higher DSR(A) values, longer transmitral E wave deceleration time (DcT), higher longitudinal ESS and SSR(max) values, lower systolic circumferential and longitudinal IVDSI.

CONCLUSION

The highest sensitivity for rapid heart failure progression was shown by DcT <100 ms, E/A > 1.5, DSR(A) < 0.3/s, circumferential IVDSI > 0.16, and longitudinal IVDSI > 0.22 (91%, 78%, 94%, 83%, and 75%, respectively).

Association of Impedance Cardiography Parameters With Changes in Functional and Quality-of-Life Measures in Patients With Chronic Heart Failure

Assessment and prognosis of chronic heart failure is often difficult due to a lack of objective and easily obtainable parameters that accurately reflect disease status. This study was conducted to determine whether impedance cardiography (ICG) parameters were associated with changes in functional and quality-of-life measures in chronic heart failure patients. Retrospective chart review identified 64 patients (73% male, aged 73+/-13 years) with paired ICG measurements followed for 180+113 days. Outcome measures were changes in New York Heart Association class, 6-minute walk distance, patient visual analog scale score, and Minnesota Living with Heart Failure Questionnaire score. Measures of ICG, heart rate and blood pressure, left ventricular ejection fraction, and B-type natriuretic peptide levels were assessed for their association with outcome measures. From baseline to final evaluation, there were significant changes (p<0.05) in New York Heart Association class (from 3.2+/-0.5 to 3.0+/-0.6), 6-minute walk distance (from 668+/-380 m to 874+/-390 m), patient visual analog scale score (from 49+/-10 to 64+/-20), Minnesota Living with Heart Failure Questionnaire score (from 54+/-22 to 39+/-22), and ICG parameters of stroke index (from 38+/-9 to 41+/-8), left ventricular ejection time (from 273+/-42 to 291+/-33), and systolic time ratio (from 0.56+/-0.2 to 0.52+/-0.2). Changes in multivariate ICG parameters were significantly correlated to changes in New York Heart Association class (R, 0.80), 6-minute walk distance (R, 0.94), patient visual analog scale score (R, 0.69), and Minnesota Living with Heart Failure Questionnaire score (R, 0.67). ICG provides objective data that reflects changes in chronic heart failure disease status and treatment effectiveness.

Noninvasive hemodynamic monitoring in heart failure: utilization of impedance cardiography

The annual health care cost incurred by heart failure patients is about $56 billion, two thirds of which is spent on management of acutely decompensated patients. Hemodynamic evaluation is helpful for optimization of treatment, monitoring clinical outcomes, and overall prognostication of heart failure patients, but historically could only be obtained via costly invasive procedures that carry substantial risks. Impedance cardiography (ICG) is a noninvasive and economical outpatient procedure that has been shown to provide reliable hemodynamic values comparable to those obtained from pulmonary artery catheterization. Recent clinical studies involving hundreds of patients have validated the accuracy and reproducibility of ICG compared with invasive techniques. The direct and derived measurements and the clinical applications of ICG in the diagnosis and treatment of heart failure are presented, as are three clinical case studies demonstrating the utility of ICG in the hemodynamic-guided management of heart failure. ICG is a viable, noninvasive technique in early- and late-stage heart failure that provides assistance in diagnostic evaluation, longitudinal prognostication, and therapeutic decisions.

Long-term survival of non-elderly patients with severe heart failure treated with angiotensin-converting enzyme inhibitors assessment of treatment with captopril and enalapril survival study (ACESS)

The present study examined the effect of treatment with angiotensin-converting enzyme inhibitors (ACEIs) on the long-term prognosis in 119 patients with dilated cardiomyopathy (DCM). Conventional therapy was used in 29 patients and 90 patients were treated with ACEIs: 50 were taking captopril and 40 were taking enalapril; 24 were taking > or = 75 mg captopril or > or = 20 mg enalapril daily (high-dose group) and 66 patients received smaller doses (low-dose group). No significant differences between groups were detected with respect to demographics and clinical signs of congestive heart failure (CHF). During follow-up, 65 patients survived and 54 patients died: 34 patients were in group 1 and 20 patients were in the placebo group. Patients treated with ACEIs had a significantly better survival during the first to third year, but the difference was not significant between the high- and low-dose groups. Comparison of the cumulative probability of death in the enalapril and captopril groups showed a trend of significant reduction of mortality by 13% in the enalapril group (p<0.10). These data indicate that ACEIs have a beneficial effect on prolonging the short- and long-term survival in DCM patients, so it is strongly recommended that all patients with DCM should be treated with ACEIs unless contraindicated. In this study, lower doses of ACEI seemed prognostically equivalent to higher doses, and enalapril appeared to be preferable to captopril in the treatment of severe CHF. Additional prospective large studies are necessary to verify the relationship observed here between the optimal dosage as well as the duration of action of different ACEIs and their outcomes.