Main results of the first Brazilian Registry of Heart Failure (BREATHE)

Background

Heart failure represents a common cause of hospitalization associated with poor short-term clinical outcomes. Little is known about the long-term prognosis of these patients in Latin America.

Methods

The rationale and design of the study were previously published (1). Briefly, BREATHE was the first nation-wide prospective observational study that included patients hospitalized due to acute heart failure in Brazil. In-hospital management as well as 12-month clinical outcomes were assessed. Patients were included during two time periods: from February 2011 to December 2012 (BREATHE I) and from June 2016 to July 2018 (BREATHE Extension). Adherence to evidence-based therapies was also evaluated.

Results

A total of 3,013 patients were included in 71 centers in Brazil. The median follow-up was 346 days. The BREATHE population included 39.3% of women, had a mean age of 65.2 (± 15.6) with a mean ejection fraction of 39.7% (± 17.5). Among the comorbidities, systemic arterial hypertension was the most common, present in almost 75% of the sample. At hospital admission, 83.8% of patients had clear signs of pulmonary congestion and the main cause of decompensation was poor adherence to heart failure medications, representing 27.8% of cases. Among patients with reduced ejection fraction, the concomitant use of renin-angiotensin-aldosterone inhibitors, beta-blocker and spironolactone at hospital discharge was 44.5% and decreased to 35.2% after 3 months (p<0.01). Mortality rate at 12 months was 28.9 for every 100 patient years with 26.2% readmission at 90 days and 46.4% at 365 days. The most common etiology of heart failure was ischemic disease (Figure 1) but the worst prognosis was associated with Chagas disease (Figure 2) including an analysis of a composite outcome encompassing death, myocardial infarction, stroke or cardiac arrest after discharge.

Conclusions

In this large national prospective registry of patients hospitalized with acute heart failure, mortality and readmission were higher than what have been reported globally. Poor adherence to evidence-based therapies was a common both at hospital discharge and 1-year of follow-up.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Brazilian Society of Cardiology

TIger II vs JUdkins Catheters for Transradial Coronary Angiography (TIJUCA Study): A Randomized Controlled Trial of Radiation Exposure

BACKGROUND

In high-expertise transradial (TR) centers, the radiation exposure to patients during coronary angiography (CAG) is equivalent to transfemoral use. However, there is no definitive information during TR-CAG regarding the use of a single, dedicated catheter to impart less radiation exposure to patients.

OBJECTIVE

We compare the radiation exposure to patients during right TR-CAG with Tiger II catheter (Terumo Interventional Systems) vs Judkins right (JR) 4.0/Judkins left (JL) 3.5 catheters (Cordis Corporation).

METHODS

This multicenter, randomized, and prospective trial included 180 patients submitted to right TR-CAG, with the primary objective of observing radiation exposure to patients through the measurement of fluoroscopy time, air kerma (AK), and dose-area product (DAP) using Tiger II (group 1) vs JR 4.0 and JL 3.5 Judkins catheters (group 2). Secondary outcomes included contrast volume usage and the need to use additional catheters to complete the procedure (the crossover technique).

RESULTS

Group 1 demonstrated reduced fluoroscopy time (2.47 ± 1.05 minutes in group 1 vs 2.68 ± 1.26 minutes in group 2; P=.01) and non-significant reduction of AK (540.9 ± 225.3 mGy in group 1 vs 577.9 ± 240.1 mGy in group 2; P=.34) and DAP (3786.7 ± 1731.7 μGy•m² in group 1 vs 4058.0 ± 1735.4 μGy•m² in group 2; P=.12). Contrast volume usage (53.46 ± 10.09 mL in group 1 vs 55.98 ± 10.43 mL in group 2; P=.13) and the need for additional catheters (5.56% in group 1 vs 4.44% in group 2; P>.99) were similar between groups.

CONCLUSION

The Tiger II catheter was able to reduce radiation exposure to patients submitted to TR-CAG through a significant reduction in fluoroscopy time.

P247 Added value of 3D echo in diagnosing and monitoring transcatheter valve in mac procedure in a patient with severe mitral stenosis

INTRODUCTION

Mitral annular calcification (MAC) is a chronic degenerative process involving calcification of the fibrous base of the mitral valve accounting for 12% to 26% of all mitral stenosis (MS) and eventually for significant mitral regurgitation. Calcification often extends to other parts of the mitral valve apparatus but, unlike rheumatic stenosis, does not produce commissural fusion. Surgical treatment carries a high mortality rate due to technical difficulties involving the heavily calcified annulus, advanced age and comorbidities of affected patients. In recent years, transcatheter mitral valve replacement using ballon expandable transcatheter aortic valves in severe MAC (valve-in-MAC) has been used with acceptable success rates.

PURPOSE

To describe the added value of 3D echo in the diagnostic work-up, decision making and monitoring during the interventional procedure of valve-in-MAC.

CASE PRESENTATION

Two years ago a 90-year-old female in sinus rhythm with hypertension and known coronary artery disease (CAD) was admitted with symptoms of pulmonary congestion (PC). At that time, a transthoracic 3D echocardiogram showed important MAC with a mitral valve area (MVA) estimated through 3D planimetry of 1.1 cm2, pulmonary artery pressure (PAP) of 53 mmHg, preserved biventricular function and left atrial enlargement. One year later, she was readmitted with unstable CAD and treated with percutaneous transluminal angioplasty. At that time a 3D transesophageal echocardiogram (3DTOE) showed worsening of the MVA now estimated in 0.6 cm2, a mean gradient of 19 mmHg and PAP of 88 mmHg. Albeit optimized medical therapy, her functional status worsened and less than a month later she was again readmitted in NYHA functional class III. Therefore decision making for valve-in-MAC was undertaken. Valve sizing was performed with computed tomography (CT) using the D-shape method with similar findings when compared with 3D TOE measurements. Both methods showed a favourable anatomy of the left ventricular outflow tract. Valve-in-MAC procedure was performed through transvenous transseptal access and an Edwards Sapien3-nr 29 balloon-expandable valve was deployed uneventfully, except for a residual interatrial septal defect measuring 2.2x0.8cm closed two weeks after, as she persisted with PC and pulmonary hypertension. During the procedure, 3DTOE showed a partial thrombosis involving one of the prosthesis leaflets with preserved transvalvular gradients despite anticoagulation. After that, PC resolved and PAP dropped dramatically. The patient was discharged under lifelong anticoagulation and remains asymptomatic until now.

CONCLUSION

Diagnosing and treating patients with severe MS due to MAC remains a challenge as traditional parameters and interventional procedures don’t apply for this population. Valve-in-MAC is a feasible alternative and 3DTOE may have a pivotal role in the diagnostic work-up and interventional monitoring of these cases.

Abstract P247 Figure. 3D echo timeline valve in MAC

Impact of psychotropic drugs on QT interval dispersion in adult patients

Background

Drug-induced increase in QT dispersion has been associated with potentially fatal ventricular arrhythmias. Little is known about the use of psychotropic substances, alone or in combination with other drugs on QT dispersion.

Objectives

To evaluate the impact of psychotropic drugs on QT interval dispersion in adults.

Methods

An observational cohort study was designed involving 161 patients hospitalized from an emergency department at a tertiary hospital, divided into psychotropic users or non-users. Demographic, clinical, laboratory data and drugs used on a regular basis were collected on admission, in addition to 12-lead electrocardiogram with QT dispersion measurement.

Results

QT dispersion was significantly higher in the psychotropic user group compared to non-users (69.25 ± 25.5 ms vs. 57.08 ± 23.4 ms; p = 0.002). The QT interval corrected by Bazzett formula was also higher in the psychotropic drugs user group, with statistical significance. (439.79 ± 31.14 ms vs. 427.71 ± 28.42 ms; p = 0.011). A regression analysis model showed a positive association between the number of psychotropic drugs used and QT interval dispersion, with r = 0.341 and p < 0.001.

Conclusions

The use of psychotropic drugs was associated with increased QT dispersion and this increase was accentuated, as the number of psychotropic drugs used was higher.