Abnormal immune activation and fibrosis of epicardial adipose tissue in people living with HIV: results from the PIECVIH study

Background

Increased Epicardial Adipose Tissue (EAT) volume has been associated with increased risk of CAD in people living with HIV (PLWH). However, the underlying mechanisms remain unknown.

Purpose

We conducted the PIECVIH study to compare EAT properties in relation with CAD between PLWH and HIV-negative patients, all undergoing coronary artery bypass graft (CABG).

Methods

The PIECVIH study is a cross sectional prospective study performed in a single center enrolling 11 ART-controlled PLWH and 11 matched (age ± 3 years and sex) HIV-negative patients requiring CABG. During surgery, EAT and thoracic subcutaneous fat samples were taken. Gene expression was analyzed in samples with sufficient mRNA quality (7 PLWH and 7 HIV− for subcutaneous fat, 9 PLWH and 8 HIV− samples for EAT). The expression of 30 genes, mainly related to inflammation, immune activation, fibrosis and adipokines, was evaluated and related to the expression of the reference gene 18S.

Results

The mean age of the cohort was 59.8 years (100% male). The cardiovascular risk profile was quite similar between both groups including 66% smokers, 64% hypercholesterolemia, 36% hypertriglyceridemia and 56% hypertension. However, HIV− subjects had a higher prevalence of diabetes (73% vs 18%, p=0.002) and a higher body mass index than HIV− (23,2 vs 27.5 kg/m2, p=0.017). The level of gene expression of all tested genes was not different between PLWH and HIV− subjects in subcutaneous fat. Conversely, in EAT, the relative expression of IL-6 and CCL2 was 3–5-fold higher in samples issued from PLWH than from HIV−: respectively 0.46 vs 0.13 (p=0.03) and 1.13 vs 0.24 (p=0.03). Moreover, only in EAT, and only in PLWH, the expression of the chemokines CCL2 and CCL5 and of the macrophage immune activation markers (CD68, CD163, CD206), was globally related to the expression of genes involved into fibrosis: collagen genes (COL1A1, COL3A1, COL3A1, COL6A2, COL6A3), TGFB, LOX (lysyl-oxidase) and ASAH1 (acid ceraminidase). Only in EAT and only in PLWH, the expression of IGF1 and CES (carboxylesterase 1), two genes associated with increased cardiovascular risk, was related to the expression of genes associated with immune activation, fibrosis and vascularization (VEGFA). Only in PLWH, the Gensini score, evaluating the severity of CAD, was associated with EAT expression of collagen 6 and of the CV risk factors IGF1 and CES.

Conclusion

In very high CV risk subjects undergoing CABG, inflammation/immune activation of EAT was higher in PLWH as compared to controls. In EAT of PLWH, immune activation was strongly associated with fibrosis stressing for a dysfunctional EAT. Moreover, the severity of CAD, as addressed by the Gensini score, was associated with collagen 6 expression, a deleterious collagen in the context of EAT fibrosis. We propose that in PLWH, altered EAT immune profile and fibrosis could be responsible for reported accelerated CAD.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): French Agency for Research on AIDS and Viral Hepatitis

Heart Transplant Activity in France during the COVID-19 Outbreak

Purpose

The COVID-19 pandemic has deeply affected organ transplant activity across the world. During the first and second epidemic waves, the Agence de la biomedecine in agreement with the French scientific societies has pursued the heart transplant program where transplant's capacity was ensured. This study aimed to examine the impact of COVID-19 on new listings, waitlist outcomes and transplant activity in France.

Methods

All patients newly registered on the national waiting list for heart transplantation between January and September 2018-2020 were included in the study (n=1 311). The number of new listings and transplants per million population (pmp) in 2018-2019 period and in 2020 COVID era were compared. Cumulative incidence of transplantation and waitlist mortality estimated with the competing risk analysis with transplantation and death or delisting for medical condition as the competing events were compared between the study periods.

Results

In 2020 compared with the 2018-2019 period, the total number of patients newly registered on the waiting list declined 11%, from 6.8 to 5.9 pmp and the number of transplants performed decreased 22%, from 4.6 to 3.5 pmp. While 3-month cumulative incidence of transplantation (Figure 1) decreased from 51% [47-54] to 45% [40-50], a non-significant increase in cumulative incidence of death or delisting for medical condition (9% [7-11] versus 12% [9-15]) (Figure 2) was observed.

Conclusion

In 2020 COVID era, the waitlist and transplant access significantly declined in France without significant change in waitlist mortality.

Identification of trajectories of cardiac allograft vasculopathy after heart transplantation: a nationwide comparison

Background

Cardiac allograft vasculopathy (CAV) is a major contributor of heart transplant recipient's mortality. However, little is known about CAV trajectories at a population level.

Purpose

We aimed to identify the different profiles of CAV trajectories.

Methods

Heart transplant recipients receiving care at 4 academic centers (2004 to 2016) were included. Patients underwent prospective, protocol-based monitoring consisting of repeated coronary angiographies together with systematic assessment of clinical, functional, histological and immunological parameters. The mainoutcome was the CAV trajectories, identified with unsupervised latent class mixed models.

Results

Overall, 1,301 patients were included (609 in France, 206 in Belgium and 486 in the US). The median follow-up post-transplant was 6.6 years (IQR=4.7) with 4,710 coronary angiographies analyzed (3.6±1.6 CAV assessments per patient). In the French development cohort, we identified 4 distinct profiles of CAV trajectories over 10 years that were characterized by i) Patients without CAV at baseline and non-progression (n=317, 52.1%), ii) patients without CAV at baseline and late onset CAV progression (n=52, 8.5%), iii) patients with mild baseline CAV and mild progression (n=151, 24.8%), iv) patients with mild baseline CAV and accelerated CAV progression (n=89, 14.6%, discrimination 0.92). The 4 CAV trajectories were independently validated in the external validation cohorts from Belgium (discrimination=0.92) and the US (discrimination=0.97).

Conclusion

In a large multicentric and highly phenotyped prospective cohort of heart transplant recipients, we identified and validated 4 distinct CAV trajectories corresponding to specific initial CAV grades and subsequent evolutions. Our results provide the basis for a trajectory-based assessment for risk stratification at early-stage post heart transplantation.

Figure 1. Cardiac allograft vasculopathy trajectories in France (n=609), in Belgium (n=206), in USA (n=486). Thick lines represent latent class trajectory; thin lines represent CAV individual patient trajectory.

Funding Acknowledgement

Type of funding source: None

Trajectories of Cardiac Allograft Vasculopathy After Heart Transplantation and association with mortality: a population-based study

Background

Cardiac allograft vasculopathy (CAV) is a major contributor of heart transplant recipient's mortality. However, the associations between CAV trajectories and mortality remains poorly described.

Purpose

We aimed to identify the different evolutive profiles of CAV and to determine the respective association with all-cause mortality.

Methods

Heart transplant recipients receiving care at 4 academic centers were included. Patients underwent prospective, protocol-based monitoring consisting of repeated coronary angiographies together with systematic assessment of clinical, functional, histological and immunological parameters. The mainoutcome was a prediction for CAV trajectories using unsupervised latent class mixed models. We then identified their association with all-cause mortality (NCT04117152).

Results

Overall, 1,301 patients were included (815 and 486 in the development and validation cohorts, respectively). The median follow-up post-transplant was 6.6 years (IQR=4.7) with 4,710 coronary angiographies analyzed (3.6±1.6 CAV assessments per patient). We identified 4 distinct profiles of CAV trajectories over 10 years that were characterized by i)Patients without CAV at baseline and non-progression (n=823, 63.3%), ii) patients without CAV at baseline and late onset CAV progression (n=79, 6.1%), iii) patients with mild baseline CAV and mild progression (n=261, 20.1), iv) patients with mild baseline CAV and accelerated CAV progression (n=138, 10.6%, discrimination 0.95). The 4 CAV trajectories showed gradient for all-cause mortality (p<0.001). Trajectories #3 and #4 were associated with higher mortality rates (10-year patient survival of 73.43% [95% CI 65.18–80.02] and 51.89% [95% CI 38.76–63.51], respectively) as compared with trajectories #1, and #2 that were characterized by 10-year patient survival of 80.01 [95% CI 76.38–84.82] and 83.49% [95% CI 71.34–90.80], respectively (p<0.001).

Conclusion

In a large multicentric and highly phenotyped prospective cohort of heart transplant recipients, we identified 4 robust CAV trajectories. These different profiles were associated with distinct prognosis. Our results provide the basis for a trajectory-based assessment of heart transplant patients for early patient risk stratification and patient monitoring.

Figure 1. Overall 10-year survival probability according to the CAV trajectory in the overall cohort (n=1,301). The left part represents the main profiles CAV grades identified with latent class mixed models. Thick lines represent latent class trajectory; thin lines represent CAV individual patient trajectory. The right part represent the Kaplan Meier curves of the different trajectories.

Funding Acknowledgement

Type of funding source: None

Determinants of trajectories of cardiac allograft vasculopathy after heart transplantation: a population based study

Background

Cardiac allograft vasculopathy (CAV) is a major contributor of heart transplant recipient's mortality. Little is known about determinants of CAV trajectories at a population level.

Purpose

We aimed to identify the respective contribution of immune and non-immune factors in the different evolutive profiles of CAV.

Methods

Heart transplant recipients receiving care at 2 academic centers (2004 to 2016) were included. Patients underwent prospective, protocol-based monitoring consisting of repeated coronary angiographies together with systematic assessment of clinical, functional, histological and immunological parameters. The outcome was CAV trajectories, identified with unsupervised latent class mixed models. The independent, predictive factors of CAV trajectories were investigated with multinomial regressions (NCT04117152).

Results

Overall, 815 patients were included. The median follow-up post-transplant was 7.7 years (IQR=5.14) with 2,742 coronary angiographies analyzed. We identified 4 distinct profiles of CAV trajectories over 10 years that were characterized by i) Patients without CAV at baseline and non-progression (n=459, 56.3%), ii) patients without CAV at baseline and late onset CAV progression (n=62, 7.6%), iii) patients with mild baseline CAV and mild progression (n=188 23.1%), iv) patients with mild baseline CAV and accelerated CAV progression (n=106, 13.0%, discrimination 0.92). Six early independent predictors of CAV trajectories were identified: donor age (p<0.001), donor male gender (p<0.001), donor tobacco consumption (p=0.001), recipient post-transplant dyslipidemia (p=0.009), preexisting or de novo class II anti-HLA donor-specific antibodies (p=0.004) and episode of acute cellular rejection ≥2R during the first year post transplantation (p=0.028).

Conclusion

In a large multicentric and highly phenotyped prospective cohort of heart transplant recipients, we identified 4 robust CAV trajectories and their respective immune and non-immune determinants. Our results provide the basis for a trajectory-based assessment of heart transplant patients for early patient risk stratification and patient monitoring.

Factors associated CAV trajectories in multivariate analyses in the derivation cohort. This table shows the association of clinical, immunological, functional and structural parameters associated with CAV trajectories in multivariate multinomial regression analysis. The trajectory of reference was trajectory #1, including patients with no CAV at baseline and stable CAV grade over time.

Funding Acknowledgement

Type of funding source: None

Determinants of sudden cardiac death after heart transplantation

Background

Heart transplant recipients are at high-risk of sudden cardiac death (SCD). However, risk factors of SCD in heart recipients remained poorly described.

Objective

To assess the predictors of SCD beyond the first-year post-transplant.

Methods

We enrolled consecutive patients transplanted between 2004 and 2017 in two French referral centers. We excluded patients deceased during the first year. Patients underwent an evaluation at the day of transplantation and during the first year, comprising clinical, biological, histological, immunological (circulating anti-HLA DSA) and interventional (cardiac allograft vasculopathy assessment) parameters. Echocardiographies were routinely performed in all included patients according to a prespecified protocol. According to the last consensus, SCD was defined as an unexpected out-of-hospital cardiac arrest without obvious non-cardiac cause, in the first hour after initiation of symptoms. Cox model analysis was used to determine the parameters associated with sudden death risk.

Results

A total of 913 patients were included. The median follow-up post-HT was 5.9 years (IQR=2.9–8.5). Among the 213 deaths after one year, 44 patients (21%) died from SCD. In this population, the incidence rate of SCD was 0,82 per 100 person-year (95% CI: 0,51–2,05). Among the 60 parameters tested in univariate analysis, we identified 2 independent factors of sudden death after 1 year post-HT: left ventricular ejection fraction (LVEF) ≤55% any time after transplantation ( HR 4.07, 95% CI 1.94–8.53, p<0.001) and the presence of circulating anti-HLA DSA at the time of transplantation (HR 2.79, 95% CI 1.37–5.68, p=0.005). The incidence rate of SCD was 2.17 per 100 person-year (95% CI: 1.42; 4.60) and 1.21 per 100 person-year (95% CI: 0.80; 2.58) in patients with FEVG<55% (n=73) and in patients with pre-formed DSA (n=260), respectively.

Conclusion

In a large multicentric and highly phenotyped cohort of heart transplant recipients, we identified two independent factors associated with SCD beyond the first year. This study provides fresh evidence of SCD assessment for improving risk stratification of HT recipients.

Funding Acknowledgement

Type of funding source: None

Incidence of sudden cardiac death after heart transplantation

Background

Sudden cardiac death (SCD) is a major contributor to the rate of mortality after heart transplantation. However, little is known about the incidence of SCD in heart recipients.

Objective

To assess the incidence of SCD after heart transplantation.

Methods

We enrolled consecutive patients transplanted between 2004 and 2017 in two French referral centers. We defined 7 main groups of causes of deaths: SCD, cardiovascular (including Cardiac allograft vasculopathy), infection, primary graft dysfunction, graft failure (including late graft dysfunction, rejection), malignancy and others. Causes of deaths were independently adjudicated by two senior cardiologists based on the analysis of death certificates and medical records. Discrepancies were resolved by discussion until a consensus was made. SCD was defined as an unexpected out-of-hospital cardiac arrest without obvious non-cardiac cause, in the first hour after initiation of symptoms.

Results

A total of 1,363 patients were included. The median follow-up post-transplant was 3.99 years (IQR=0.49–7.49). 450 patients (33%) deceased during the first year. The leading cumulative causes of death in the first year after transplantation were infection, primary graft failure, multiple organ failure during the period in intensiv car unit. Beyond the post-operativ high-risk period of the first year, the leading cumulative cause of death was SCD: among the 213 deaths that occurred beyond the first year, 44 patients (21%) died from SCD. In this period, the incidence rate of SCD reached 0,82 per 100 person-year (95% CI: 0.51–2.05).

Conclusion

In a large multicentric and highly phenotyped cohort of heart transplant recipients, the leading cumulative cause of death beyond the first-year post transplant was sudden cardiac death. Our results open discussion on management of heart recipient, such as the implementation of cardioverter-defibrillators.

Figure 1. Cumulative incidence of causes of death in heart transplant recipients beyond the first year (n=913).

Funding Acknowledgement

Type of funding source: None

P3855Incidence, risk factors and impact of readmission for heart failure after successful transcatheter aortic valve replacement

Background

Incidence and correlates of readmission for heart failure in all-comers, after successful transcatheter aortic valve replacement (TAVR) remain unclear.

Objective

We sought to evaluate the incidence, risk factors and clinical impact of readmission for HF after successful TAVR in an unselected patient population.

Methods

All patients who underwent successful TAVR in two high-volume French tertiary centers from February 2010 to December 2016 were prospectively included and followed-up for one year. Cox multivariate model was used to assess risk factors of readmission for heart failure, evaluated a time-updated covariate and mortality.

Results

A total of 1139 patients (mean age 82.4±7.7 years, 52.2% male) were included. Readmission for heart failure occurred in 99 (8.7%) patients. Risk factors of readmission for HF were chronic pulmonary disease (adjHR 1.8; 95% CI [1.2–2.8], p=0.008), chronic kidney disease (adjHR 1.7; 95% CI [1.1–2.6], p=0.01), diabetes mellitus (adjHR 1.7; 95% CI [1.1–2.5], p=0.01), prior atrial fibrillation (adjHR 1.6; 95% CI [1.1–2.4], p=0.02) and post-TAVR left ventricular ejection fraction (LVEF) ≤35% (adjHR 2.1 95% CI 1.2–3.7, p=0.009). Readmission for HF was strongly associated with mortality (Figure) along with increased STS score (adjHR 1.07 95% CI 1.03–1.12, p=0.002), prior atrial fibrillation (adjHR 2.13 95% CI 1.53–2.96, p<0.001) and shock during the index hospitalization (adjHR 2.68 95% CI 1.48–4.87, p=0.001).

Figure 1

Conclusion

Readmission for heart failure occurs in one out of ten patients after successful TAVR and is strong risk factor of mortality. Comorbidities and post-TAVR LVEF≤35% are the main correlates of readmission for heart failure.

Acknowledgement/Funding

ACTION study group

P5575Acute left ventricular mechanics changes after TAVR: the afterload concept revisited

Background

Recent studies have emphasized the prognostic value of mild left ventricular ejection fraction (LVEF) impairment in severe aortic stenosis. However, despite adaptive mechanisms to pressure overload, subtle impaired systolic function could be worsened by increased afterload and partly reversible immediately after its correction.

Objectives

The aim was to evaluate the short terms effects of transcatheter aortic valve replacement (TAVR) on LV systolic function assessed by global longitudinal strain (GLS). We hypothesized that abrupt decrease of LV afterload after TAVR could lead to immediate improvement of LV systolic function.

Methods

Patients referred to our Department for TAVR were included from January 2018 to July 2018 in this observational prospective single center study. Transthoracic echocardiography (TTE) was performed immediately before and 1–5 days after TAVR by the same operator and reviewed in a blind fashion.

Results

35 symptomatic patients with severe aortic stenosis referred for TAVR (age 84±5 y, 18 male, NYHA 2–3, orifice area 0.7±0.2 cm2, LVEF 66±13%, GLS −15.1±4.7%) were included. Only 9/35 (26%) had a LVEF ≤60%. Overall, no significant change in LVEF (65±14%; p=0.55) or GLS (−16.1±4.8%; p=0.11) occurred immediately after TAVR despite a dramatic decrease in transoartic mean pressure gradient (44±15 mm Hg versus 6±3 mmHg; p<0.0001). However in the subgroup of patients with LVEF ≤60%, a significant increase in GLS after TAVR was observed (−9.6±4.1% versus −12.1±3.3%; p=0.0039).

Improvement in GLS according to the LVEF

Conclusion

Following TAVR, an early improvement in LV systolic function assessed by GLS was observed only in patients with pre-existing mild LV systolic dysfunction. Further studies should evaluate whether this improvement is associated with better long term outcome.

P3737Predictors, feasibility and outcomes of coronary interventions up to 3 years after TAVI with a balloon-expandable valve. Results from a large European multicenter registry

Background/Introduction

Coronary artery disease (CAD) and aortic stenosis often coexist. Transcatheter aortic valve implantation (TAVI) is emerging as a favorable treatment for younger and lower surgical risk patients. The need for coronary angiography (CA) and percutaneous coronary intervention (PCI) after TAVI will thus increase.

Purpose

We retrospectively evaluated the outcome of PCI performed after TAVI with the balloon-expandable SAPIEN 3 transcatheter heart valve in the SOURCE 3 European registry.

Methods

Cardiovascular (CV) mortality was computed at 3 years for patients with PCI and for those without. Univariate and Cox multivariate models were developed to assess the potential impact of PCI on CV mortality.

Results

Out of 1939 TAVI patients, 44 (2.3%) underwent PCI within 3 years after TAVI (mean interval from TAVI: 428±341 days). Patients with PCI were 80.9 years old and 63.6% were male. They had higher baseline logistic EuroSCORE (22.6% vs. 18.3%, p=0.007), higher rate of prior CAD diagnosis (72.7% vs. 51.0%, p=0.005), prior PCI (45.5% vs. 33.6%, p=0.108) and previous CABG (25.0% vs. 11.0%, p=0.013) than other patients of the cohort. Coronary access (ability to cannulate selectively the coronaries) was feasible in 100% of patients; PCI was successful in all but one case. The univariate model showed that CV mortality was slightly higher in patients undergoing PCI compared with those without PCI (Hazard Ratio: 1.86 [0.96–3.59], p=0.07); CV mortality rate was even lower with the multivariate model (HR: 1.39, p=0.52).

Conclusions

Interventions of CA and PCI after TAVI with a balloon-expandable valve was feasible and successful in all but one case in this large European registry. There was a trend towards a worse CV mortality at 3 years in patients needing PCI, which did not reach statistical significance likely because of the low incidence of PCI in our TAVI population.

Acknowledgement/Funding

The SOURCE 3 registry is sponsored by Edwards Lifesciences

Heart transplantation as rescue treatment of left main stem occlusion by a recurrent aortic pseudoaneurysm

A 58 year-old man was admitted in our ICU for cardiogenic shock and electrical storm. His medical history was marked by a triple redo valvular surgery complicated by a recurrent aortic pseudoaneurysm of the ascending aorta. Coronary angiogram and heart CT scan diagnosed an extensive anterior myocardial infarction related to an extrinsic compression of the left main stem by this massive and calcified pseudoaneurysm. Angioplasty or new cardiac surgery options were rejected by the heart team. Despite an unusual indication, the patient was registered on the heart transplant list, and underwent it successfully.