A multicentric observational study of patients affected by advanced heart failure with implantable cardioverter defibrillator and left ventricular assist devices

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular assist device (LVAD) implantation is increasingly used in patients with end-stage heart failure. Most patients already have an implantable defibrillator (ICD) at the time of L-VAD implantation. Studies on this patient population are limited by the small sample size and the short duration of follow-up.

Purpose

The aim of this study was to retrospectively describe the real-world management of patients implanted with both ICD and LVAD. The main objective was to evaluate the incidence and predictors of appropriate and inappropriate therapies of the ICD and the incidence and predictors of ICD related complications.

Methods

212 patients were enrolled in four Centers in the period between July 2006 and November 2020. The inclusion criteria were age> 18 years, advanced heart failure, patients with ICD and concomitant or subsequent continuous flow LVAD implantation. ICD therapy was defined as antitachycardia pacing therapy or shock.

The data available at the last visit with a median follow up of 21 months were analyzed.

Outcome predictors were assessed by univariate logistic regression and the variables of interest included in a multivariate model.

Results

The rate of appropriate ICD therapies was 29.7%, while the incidence of inappropriate therapies was 10.4%; in the multivariate analysis the presence of a zone therapy with low detection rate (VT zone with median detection rate of 164.5 bpm) was found to be an independent predictor of the composite of appropriate and inappropriate therapies (OR = 19.05; CI = 2.19-165.21; p = 0.007). Interference between ICD and LVAD occurred in 7.5% of cases; the incidence of infectious complications related to the ICD was 7.1% and bleeding complications of 5.2%; in the multivariate analysis, ICD generator replacement was an independent predictor of total complications related to the ICD (interference, infectious and bleeding; OR = 4.45; IC = 1.60-12.36; p = 0.004). 103 patients had CRT defibrillator (48,6%). At follow up there was no statistically significant difference in the incidence of appropriate therapies between those who had CRT-on (n=74) and those who had CRT-off (n=29; p = 0.61).

Conclusions

Patients with LVAD implanted with an ICD experience a high rate of appropriate and inappropriate ICD therapies. An active VT zone at low heart rate was found to be an independent predictor of ICD therapies. Of more, ICD generator replacement was found to be an independent predictor of total complications related to the ICD. Our findings suggest the importance of tailoring device programming in order to minimize the incidence of ICD therapies, thus sparing the need for generator replacement in this population.

C78 PREVALENCE AND MECHANISMS OF SEVERE MITRAL AND TRICUSPID REGURGITATION IN A HEART FAILURE OUTPATIENTS POPULATION

Introduction

Mitral regurgitation (MR) and tricuspid regurgitation (TR) are a known cause of morbidity and mortality in heart failure (HF) patients. Maximal up–titration of guideline–directed medical therapy (GDMT) for HF may not be enough to reduce the severity of the valve’s incompetence and patients’ symptoms. The development and successful results of transcatheter therapies for mitral/tricuspid disease have opened new therapeutic opportunities when surgery is not feasible. Accurate valve regurgitation’s mechanisms evaluation is essential to choose the best treatment option. This study aims at evaluating the prevalence and underlying mechanisms of at least moderate–to–severe (≥3+/4+) MR and/or TR in a cohort of HF outpatients.

Methods

We retrospectively analyzed the medical records of 1260 outpatients evaluated by our HF unit between January 2020 and June 2021. All patients with echocardiographic evidence of ≥ 3+/4+ MR and/or TR were included (treated ones were excluded), and a thorough echocardiographic images review was conducted. A full collection of patients’ clinical, laboratory and therapy regimens details was performed as well.

Results

Of the 1260 analyzed patients, 173 (13.7%) exhibited ≥3+/4+ MR and/or TR and were included in the registry. Table 1 shows the main clinical/echocardiographic characteristics. Mean age was 80±7 years, median ejection fraction was 45% (IQR=33–55). All patients were treated with maximal tolerated doses of GDMT and, if appropriate, with cardiac devices/myocardial revascularization. ≥3+/4+ MR and/or TR was observed in 92 (7.3%) and 117 (9.3%) patients, respectively. Patients with isolated significant MR were 56 (4.4%), with isolated significant TR were 81 (6.4%); the remaining 36 (2.8%) had both MR/TR. Among patients with significant MR, 50 (54%) had functional/secondary valvular defect (details in Figure 2): the majority (41,82%) presented a ventricular etiology (asymmetric tethering in 18/41) while 9 (18%) an atrial one (atriogenic tethering in 3/9).

Conclusion

Despite optimized GDMT, the prevalence of patients with hemodynamically significant valvular defects was considerably high in our HF population. This is the first registry to comprehensively detail atrioventricular valve regurgitations’ mechanisms in a wide real–life cohort of HF outpatients. Further studies are needed to identify reasons for potential undertreatment and patients who would benefit the most from percutaneous correction of their valvular defects.

Clinical effects of early sacubitril/valsartan administration in patients with ST-segment elevation myocardial infarction: a systematic review and meta-analysis

Introduction

The combination of sacubitril, a neprilysin inhibitor and valsartan, an angiotensin receptor blocker, has been proven to be a game-changer in reducing morbidity and mortality in patients with chronic heart failure with reduced ejection fraction. Recent evidence regarding the early use of sacubutril/valsartan in patients after ST-segment Elevation Myocardial Infarction (STEMI) are emerging.

Purpose

To provide a comprehensive synthesis of effect estimates, we performed a systematic review and meta-analysis of randomized controlled trials (RCTs) directly comparing sacubitril/valsartan and an ACE-inhibitor early after successful primary percutaneous coronary intervention (pPCI) in patients presenting with STEMI

Methods

We searched the PubMed, EMBASE and Cochrane databases from inception to March 28, 2021 to identify RCTs that report clinical outcomes and compare sacubitril/valsartan versus an ACE-inhibitor in patients presenting with STEMI after pPCI. The primary efficacy endpoint was the risk of hospitalization for heart failure. Secondary efficacy endpoints were major adverse cardiac events (MACE) and left ventricle ejection fraction (LVEF). Safety endpoints were hypotension, hyperkalemia, worsening renal function and angioedema. Pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CIs) were used as summary statistics for endpoints of interest and were calculated using a random-effects model according to DerSimonian and Laird.

Results

A total of three studies with 493 patients randomly allocated to sacubitril/valsartan (n=247) or ACE-inhibitor (n=246) were included for analysis. Main study and patient characteristics are reported in figure1. Heterogeneity between studies was low. Individual trial definitions of MACE and adverse events were used in the analysis (figure 1). Sacubitril/valsartan was associated with a significant reduction in the risk of heart failure hospitalizations (RR, 0.55; 95% CI 0.39–0.79, P<0.01, event rate 15.4% vs 28.5%, number needed to treat 8), MACE (RR, 0.64; 95% CI, 0.48–0.84, P<0.01, event rate 20.2% vs 33.3%, number needed to treat 8), and with a significant improvement of LVEF (MD, 3.09; 95% CI, 1.70–4.49, P<0.01), (figure 2). No significant difference was found between sacubitril/valsartan and ACE-inhibitors regarding the incidence of hypotension (RR, 1.42; 95% CI, 0.74–2.72, P=0.29), hyperkalemia (RR, 0.44; 95% CI 0.06–3.08, P=0.41) and worsening renal function (RR, 0.70; 95% CI 0.22–2.24, P=0.55), (figure2). No angioedema was observed in included studies.

Conclusion

This is the first systematic review and meta-analysis comparing sacubitril/valsartan and ACE inhibitors in STEMI patients. Based on the presented findings and larger data on the horizon, we may soon find sacubitril/valsartan to be an important addition to our arsenal in improving care to STEMI patients.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Italian Ministry of Education Figure 1Figure 2

Transcatheter aortic valve replacement in severe aortic stenosis and cardiac amyloidosis: a systematic review and meta-analysis

Background

Aortic stenosis (AS) and cardiac amyloidosis (CA) are typical degenerative diseases of the elderly. According to recent studies, up to 16% of patients referred to transcatheter aortic valve replacement (TAVR) have a concomitant diagnosis of CA. Until recently, TAVR in patients with CA and AS has been considered futile, following the results of small observational studies. However, few studies recently suggested a beneficial impact of TAVR in patients with AS and CA as compared with medical therapy alone.

Purpose

To clarify the efficacy and safety profile of TAVR in CA-AS patients.

Methods

We performed a systematic review and meta-analysis of studies evaluating the risk of mortality after TAVR in CA-AS patients as compared with medical therapy. Moreover, we performed a systematic review and descriptive meta-analysis of studies reporting outcomes and complication rates of TAVR in CA-AS patients as compared with patients with AS alone.

Results

We identified 4 observational studies reporting data on mortality in CA-AS patients treated with either TAVR or medical therapy. Mortality was significantly lower in patients undergoing TAVR (OR 0.23, 95% CI 0.07–0.73, I2=0%, NNT=2.6) as compared with medical therapy. A sensitivity analysis with hazard ratio as effect estimate showed consistent results. Then, we identified 4 observational studies reporting data on mortality, re-hospitalizations and periprocedural complications of TAVR in CA-AS patients as compared with patients with AS alone. We found higher rates of mortality, cardiovascular hospitalization and need for permanent pacemaker implantation in CA-AS patients as compared to lone AS patients undergoing TAVR. Conversely, no differences were found in terms of stroke, acute kidney injury and vascular complications.

Conclusions

Our analysis rejects the idea of futility of TAVR in CA-AS patients showing a clear survival benefit of CA-AS patients undergoing TAVR as compared with medical therapy. Moreover, these patients may undergo TAVR with an acceptable procedural risk, that is substantially comparable to lone AS patients, except for a higher incidence of permanent pacemaker implantation.

Funding Acknowledgement

Type of funding sources: None.

Predictors of haemodynamic performance in patients with aortic stenosis and small annulus undergoing TAVI with self-expandable valves

Background

Small aortic annular size is one of the most important predictor of poor hemodynamic and clinical outcomes in patients treated for aortic stenosis. Post-hoc analyses of pivotal trials showed that transcatheter aortic valve intervention (TAVI) offer better outcomes then surgery in patients with small aortic annulus, especially with self-expandable valves (SEV). However, data about SEVs comparison in this population are limited.

Purpose

Our aim is to assess how valve design and oversizing, with anatomical and echographic features, impact on the hemodynamic performance of SEVs in TAVI patients with small aortic annulus.

Methods

The TAVI SMALL registry enrolled 859 patients with small aortic annulus (CT-scan annular perimeter≤72 mm or area ≤400 mm2) treated for aortic stenosis with currently available SEVs (Evolut R=397; Evolut PRO =84; Acurate Neo=140; Acurate TA= 61; Portico=177) at 9 European centers between 2011 and 2018. We performed multivariable backward logistic regression analyses to identify predictors of high postprocedural mean gradient, moderate-to-severe PPM, and moderate-to-severe para-valvular leak (PVL).

Results

After adjustment for LVEF, we identified annular perimeter and percentage of oversizing as independent predictors of lower post-procedural mean gradient.

Implantation of intra-annular rather than supra-annular bioprosthesis was the only independent predictor of moderate-to-severe PPM.

Predictors of moderate-to-severe PVL are reported in the Table.

Conclusions

Among patients with aortic stenosis and small aortic annulus treated with transcatheter SEVs, use of supra-annular bioproshtesis and oversizing were associated with improved valve performance.

Funding Acknowledgement

Type of funding source: None

The cytokinome in osteoarthritis, a new paradigm in diagnosis and prognosis of cartilage disease

At present, diagnosis and progression monitoring of osteoarthritis (OA) is made through radiological and clinical assessment. Several studies investigated the role of synovial fluid analysis, to find out whether joint disease could be characterized by the pattern of cytokines, which acts during the pathogenic process or in specific stages of it. Online PubMed-Medline search was performed in order to retrieve evidence concerning synovial fluid analysis of cytokines involved in OA degenerative process. Concerning pro-inflammatory cytokines, it has been shown that interleukin (IL)-6, TNF-α and IL-17 are mainly over-expressed in the synovial fluid of OA joints, as well as anti-inflammatory cytokine IL-10. Variations of cytokines levels occur with radiological and clinical progression. It was also reported that metalloproteinases are involved. Synovial fluid analysis may be helpful in defining stage and type of OA, but more research is needed, especially focusing on the variation of sets of cytokines during OA stages and correlating these patterns with clinical features.

Total intravenous anesthesia using remifentanil in extracorporeal shock wave lithotripsy (ESWL). Comparison of two dosages: a randomized clinical trial

BACKGROUND

Extracorporeal Shock Wave Lithotripsy is usually performed in day surgery setting, consequently people who undergo to this procedure need a safe and fast recovery. Conscious sedation with remifentanil can relieve from pain and keep patients in touch with anaesthesiologists. Few publications tell about infusion rates administered to perform this procedure7. The aim of this study is to assess which is the most appropriate infusion rate.

METHODS

Patients were randomly assigned to two groups. Two different infusion rates were compared: 0,05 mcg/kg/min, GROUP A (N.=114), vs. 0.1 µg/kg/min, GROUP B (N.=114). Patients' vital signs, additional analgesic requests, PONV (postoperative nausea and vomiting) and other side effects were registered. The deepness of sedation and patient's satisfaction were evaluated referring to Obsever's Assessment of Alertness and Sedation scale (O/ASS) and using a Likert's scale respectively. Pain intensity was assessed with a 11-points VAS (visual analogue scale). Differences between groups were analyzed using Student t test for independent variables. The χ2 test was used to analyze categorical variables.

RESULTS

The study enrolled 228 patients and assigned them to two groups (N.=114). No significant differences were found regarding Likert's scale values (P=0.20), additional analgesic request (P=0.30) and mean VAS values (P>0.05) between the two groups. The difference between the two groups about PONV, hypotension, oxygen desaturation and respiratory depression was statistically significant (P<0.05), as a matter of fact in group A these side effects occurred less frequently. The fifth degree of O/ASS was estimated in about 1.61±0.19 min and 2.987±0.20 min in group A and in group B respectively (P<0.05).

CONCLUSION

According with previous results remifentanil at the infusion rate of 0.05 µg/kg/min provides an effective analgesia, causing a lower incidence of side effect than 0.1 µg/kg/min, granting a fast and safe recovery.

Safety and efficacy of transdermal buprenorphine and transdermal fentanyl in the treatment of neuropathic pain in AIDS patients

BACKGROUND

Multifactor neuropathic pain is one of the most frequent symptoms in AIDS patients and analgesic treatment is primarily based on the use of drug combination of opioids, tricyclic antidepressants and antiepileptics. However, the chronic use of opioids in AIDS patients presents a risk due to the immunosuppressive action of these drugs. Until now, buprenorphine has been regarded as one of the safest opioid analgesics for the treatment of patients with compromised immune systems. To assess the suitability of transdermal fentanyl for the treatment of neuropathic pain in AIDS patients, the present study compares the efficacy, tolerability and the immunosuppressive effects of transdermal buprenorphine vs. fentanyl.

METHODS

Forty advanced AIDS patients (28 male and 12 female) with chronic peripheral neuropathic pain were enrolled onto this clinical trial. Neuropathic pain was assessed for its constituent types of pain (burning, stabbing and shooting), its overall intensity and allodynia; scores were awarded using the Neuropathic Pain Scale, expressed as 10 item VAS scores.

RESULTS

Both treatment groups showed statistically significant reductions in each of the individual types of neuropathic pain and allodynia (P<0.05; 95% CI: -14.7, -3.1) and significant improvements in Karnofsky Performance Status (P<0.05; mean value, 69; range: 40-90). Both buprenorphine and fentanyl were well tolerated. Neither buprenorphine nor fentanyl affected CD4+ or CD8+levels and both treatments, but particularly buprenorphine group, resulted in more stable CD4+ concentrations.

CONCLUSION

The high efficacy, tolerability and patient compliance of both buprenorphine and fentanyl make both these two opioids valid therapeutic options for the treatment of neuropathic pain in patients with AIDS.

Risk factors for acute renal failure in trauma patients

OBJECTIVE

To elucidate the risk factors for the development of acute renal failure (ARF) in severe trauma.

DESIGN

Prospective observational study.

SETTING

A general intensive care unit (ICU) of a university hospital.

PATIENTS

A cohort of 153 consecutive trauma patients admitted to the ICU over a period of 30 months.

RESULTS

Forty-eight (31%) patients developed ARF. They were older than the 105 patients without ARF (p = 0.002), had a higher Injury Severity Score (ISS) (p < 0.001), higher mortality (p < 0.001), a more compromised neurological condition (p = 0.007), and their arterial pressure at study entry was lower (p = 0.0015). In the univariate analysis, the risk of ARF increased by age, ISS > 17, the presence of hemoperitoneum, shock, hypotension, or bone fractures, rhabdomyolysis with creatine phosphokinase (CPK) > 10000 IU/l, presence of acute lung injury requiring mechanical ventilation, and Glasgow Coma Score < 10. Sepsis and use of nephrotoxic agents were not associated with an increased risk of ARF. In the logistic model, the need for mechanical ventilation with a positive end-expiratory pressure > 6 cm H2O, rhabdomyolysis with CPK > 10000 IU/l, and hemoperitoneum were the three conditions most strongly associated with ARF.

CONCLUSIONS

The identified risk factors for post-traumatic acute renal failure may help the provision of future strategies.