Impact of cardiac resynchronisation therapy in patients with cardiac sarcoidosis

Background

Implantation of a device is usually required in cardiac sarcoidosis (CS) patients presenting with advanced conduction abnormalities or ventricular arrhythmias. A cardiac resynchronisation therapy (CRT) device is often chosen in patients with concomitant left ventricular systolic impairment. The role of CRT in CS is not well established.

Purpose

To describe the cohort of CS patients with CRT device in situ in our hospital focusing on the short-term effect in serial echocardiography and long-term outcomes on morbidity and mortality.

Methods

All consecutive CS patients with a CRT device in situ were identified in our CS database (2005–2022). A confident CS diagnosis was provided after review of all relevant clinical and imaging baseline data in our CS multi-disciplinary meeting and a consensus decision for CRT-D implantation was made based on international guidelines. All patients were followed up for at least 6 months with serial echocardiography. Serial data regarding symptoms, rhythm disturbance and echocardiographic parameters were obtained and comparisons were performed using Wilcoxon signed rank test.

Results

A total of 51 CS patients with CRT-D were identified (mean age: 57±10 years old). Patients were male predominant (64.7%) and Caucasian in origin (86.2%). Extra-cardiac sarcoidosis was confirmed histologically in 33 (64.7%) patients. The prevalence of smoking, diabetes, hypertension and ischaemic heart disease was 27.5%, 21.6%, 49.0% and 7.8% respectively. At the time of device implantation or during follow-up, 43 (84.3%) patients were found to have active cardiac sarcoidosis on cardiac PET.

Post CRT implantation there was a significant difference in LV ejection fraction (35.9±15.0% vs 42.2±14.1%, p<0.001), LV end-systolic diameter (4.90±1.46 cm vs 4.62±1.32 cm, p=0.012) and LV end-diastolic diameter (5.99±1.18 cm vs 5.66±1.06 cm, p<0.001). No significant changes were observed in the right ventricular function (p=0.09) and severity of mitral regurgitation (p=0.40). There was one patient who experienced acute heart failure decompensation admission within six months of CRT-D implantation. The New York Heart Association (NYHA) class improved in 26 patients (51.0%), worsened in 4 (7.8%) patients and remained the same in 21 (41.2%) patients at 6 months post CRT-implantation. During the mean follow up of 47.6 months, the composite end-point of death and cardiac transplantation was reached in 9 (17.6%) patients (8 deaths and 1 cardiac transplantation). 5 patients had major complications including a large haematoma, a small atrio-septal defect, haemothorax, device associated endocarditis and lead fracture. Minor wound infections were seen in 3 patients and 4 patients received inappropriate shock or anti-tachycardia pacing.

Conclusions

CRT in cardiac sarcoidosis patients is associated with short-term improvement in LV remodelling and functional status but over a four year follow up, morbidity and mortality are common.

Funding Acknowledgement

Type of funding sources: None.

The broad spectrum of cardiovascular adverse events related to immune check point inhibitors

Background

Immunotherapy is one of the latest and most exciting developments in cancer treatment. Immune checkpoint inhibitors (ICI) have shown to have impressive positive results on several tumours such as melanoma, renal cancer and lung cancer, among others. Along with its benefits come the adverse effects which, concerning the heart, myocarditis is the most well-known and feared event. Yet, the spectrum of cardiovascular adverse events (CVAE) is much broader, ranging from heart failure to arrhythmias, but this has not been well documented until know.

Objective

Describe the broad spectrum of CVAE related to ICI

Methods

Observational retrospective, single centre study. We evaluated all the patients that have been referred to the cardio oncology (CO) unit and were under ICI treatment. The referred patients underwent a day case assessment with cardiovascular tests (blood tests, ECG, resting echocardiogram in all cases and MRI, stress echo or CT coronary angiogram if needed). The results were discussed in the multidisciplinary team meeting and the patients were then reviewed by one of the doctors in the team. The conclusions of the assessment were then communicated to the oncology team.

Results

From the year 2011 until December 2019, 71 patients receiving immunotherapy were referred to the CO unit. Three patients were excluded because they were referred for having an intracardiac tumour, leaving 68 for analysis. The first patient was referred in 2014 and during the first 3 years only 7 patients were reviewed in the CO unit. The frequency increased dramatically in 2017 to 17, 19 in 2018 and 25 in 2019. 21 patients were receiving Nivolumab, 24 on Ipilimumab, and 23 (34%) on combined therapy. The most frequent tumour was Melanoma (26/68, 38%). Regarding the CVAE: 22 patients (32%) were referred for investigtion of myocarditis. 6 had a diagnosis of definite myocarditis, 5 probable and 4 possible. Other CVAE (20/68, 29%) were the supraventricular arrhythmias including atrial fibrilation (20/68, 29%). 8 patients presented with non-inflammatory heart failure with new LVEF drop, 4 with chest pain, and 4 others with syncope. 1 patient developed pulmonary hypertension.

Conclusions

Myocarditis still remains the most frequent CVAE related to ICI, but the spectrum is broader than initially described. Supraventricular arrhythmias and non-inflammatory LVEF disfunction were very frequent in this series and we suspect that the incidence will increase as cardiologist and oncologists start considering them as probable adverse effects of this treatment.

Funding Acknowledgement

Type of funding source: None

P1507Role of adjuvant carotid ultrasound in women undergoing stress echocardiography for the assessment of suspected angina with no previous history of coronary artery disease

Introduction

Traditional risk assessment tools classify the majority of women at low risk despite cardiovascular disease remaining the leading cause of death in women. Additionally conventional stress testing techniques have poor predictive value in women, due to unique pathophysiological mechanisms causing ischaemia in women, and the lower prevalence of obstructive CAD. The study sought to evaluate the role of adjuvant carotid ultrasound (CU) in women attending for stress echocardiography (SE).

Methods and results

415 women (Mean age 62±10 years, 28% Diabetes Mellitus, Mean BMI 28) attending for SE prospectively underwent CU, to assess Carotid Intima-media thickness (CIMT) and the presence of plaque.

47 women (11%) had inducible wall motion abnormalities, and carotid disease (CD) was present in 46% (Carotid plaque in 41%, 15% CIMT >75th percentile). Women with CD were older (65 vs 58 years, p<0.0001), more likely to have Diabetes (41% vs 21%, p=0.0001) and hypertension (67% vs 36%, p<0.01), and had higher pretest probability of CAD (59% vs 41%, p<0.0001). 40% of women classified as low Framingham, were found to have evidence of CD. Conversely, only 40% of women classified as high Framingham risk, had CD.

The positive predictive value of SE for flow-limiting CAD was 51%, but the presence of carotid plaque improved this to 71% (p<0.01). Of all clinical and test parameters, carotid plaque (p=0.001) and SE result (p=0.01) were the only independent predictors of >70% angiographic.

Conclusion

CU significantly improves the accuracy of SE alone for identifying flow-limiting disease on coronary angiography. Non-invasive assessment of subclinical atherosclerosis using CU offers an individualized disease-guided approach in women, where conventional scoring systems offer modest risk stratification.

Overexpression of Fibrinogen-Like Protein 2 Promotes Tolerance in a Fully Mismatched Murine Model of Heart Transplantation

Fibrinogen-like protein 2 (FGL2) is an immunomodulatory protein that is expressed by regulatory T cells (Tregs). The objective of this study was to determine if recombinant FGL2 (rFGL2) treatment or constitutive FGL2 overexpression could promote transplant tolerance in mice. Although rFGL2 treatment prevented rejection of fully mismatched cardiac allografts, all grafts were rejected after stopping treatment. Next, we generated FGL2 transgenic mice (fgl2(Tg) ) that ubiquitously overexpressed FGL2. These mice developed normally and had no evidence of the autoimmune glomerulonephritis seen in fgl2(-/-) mice. Immune characterization showed fgl2(Tg) T cells were hypoproliferative to stimulation with alloantigens or anti-CD3 and anti-CD28 stimulation, and fgl2(Tg) Tregs had increased immunosuppressive activity compared with fgl2(+/+) Tregs. To determine if FGL2 overexpression can promote tolerance, we transplanted fully mismatched cardiac allografts into fgl2(Tg) recipients. Fifty percent of cardiac grafts were accepted indefinitely in fgl2(Tg) recipients without any immunosuppression. Tolerant fgl2(Tg) grafts had increased numbers and proportions of Tregs and tolerant fgl2(Tg) mice had reduced proliferation to donor but not third party antigens. These data show that tolerance in fgl2(Tg) recipients involves changes in Treg and T cell activity that contribute to a higher intragraft Treg-to-T cell ratio and acceptance of fully mismatched allografts.

Copper(II) complexes as catalyst for the aerobic oxidation of o-phenylenediamine to 2,3-diaminophenazine

Two new mononuclear copper(II) complexes [Cu (L) (NO3)2] (1) and [Cu (L) Br2] (2) where (L=bis(1-(pyridin-2-ylmethyl)-benzimidazol-2-ylmethyl)ether) are synthesized and characterized by single-crystal X-ray diffraction analysis, elemental analysis, UV-Visible, IR spectroscopy, EPR and cyclic voltammetry. The complexes exhibit different coordination structures; the E1/2 value of the complex (1) is found to be relatively more cathodic than that of complex (2). X-band EPR spectra at low temperature in DMF supports a tetragonally distorted complex (1) while complex (2) shows three different g values suggesting a rhombic geometry. These complexes were utilized as a catalyst for the aerobic oxidation of o-phenylenediamine to 2,3-diaminophenazine assisted by molecular oxygen. The initial rate of reaction is dependent on the concentration of Cu(II) complex as well as substrate, and was found to be higher for the nitrate bound complex, while presence of acetate anion acts as a mild inhibitor of the reaction, as it is likely to pick up protons generated during the course of reaction. The inhibition suggests that the generated protons are further required in another important catalytic step.

The role of neurohormonal antagonists in hibernating myocardium

Hibernating myocardium is characterized by chronic reduction of myocardial blood flow due to obstructive coronary artery disease, causing reversible left ventricular dysfunction and flow-metabolism mismatch. The condition is unstable and increasing demand may lead to further left ventricular dysfunction or necrosis causing death or worsening heart failure. Recognition of the condition is difficult and requires complex cardiac imaging protocols. Treatment protocols are also poorly defined. This review addresses both the diagnostic and therapeutic aspects of hibernating myocardium.

Independent prognostic value of the extent and severity of systolic wall thickening abnormality at infarct site after thrombolytic therapy

BACKGROUND

The prognostic value of systolic wall thickening abnormality after acute myocardial infarction in the thrombolytic era is not clearly known.

METHODS AND RESULTS

Accordingly, 119 consecutive patients with acute myocardial infarction who underwent thrombolysis were investigated with exercise electrocardiography and rest echocardiography at predischarge evaluation and were followed up for cardiac events. During a mean follow-up period of 19 months, 43 patients had cardiac events. Multivariate analysis with clinical, exercise electrocardiographic, and rest echocardiographic parameters showed that the independent predictors of cardiac events were systolic wall thickening score at the site of infarct (p = 0.02), end-systolic volume (p = 0.03), and exercise time (p = 0.02). The only independent predictor for both recurrent ischemic (death, unstable angina, and reinfarction) and nonischemic events (congestive heart failure and ventricular tachycardia) was systolic wall thickening score at the site of infarct (p = 0.02 and p = 0.007, respectively).

CONCLUSIONS

Systolic wall thickening abnormality at rest is an important independent predictor of cardiac events in patients who have undergone thrombolysis after acute myocardial infarction.

Value of dobutamine stress echocardiography for the detection of multivessel coronary artery disease

Dobutamine stress echocardiography has been shown to accurately detect coronary artery disease (CAD), but it is not clear whether it has the ability to detect multivessel CAD relative to clinical and exercise electrocardiography. Therefore, the aim of this study was to evaluate the ability of dobutamine stress echocardiography to identify multivessel CAD and ascertain its incremental value when combined with clinical and exercise test variables. One hundred twenty-one consecutive patients referred for coronary arteriography on the basis of symptoms and exercise electrocardiography underwent dobutamine stress echocardiography. Significant multivessel CAD was defined as the presence of > or =70% diameter stenosis in > or =2 major epicardial arteries. Stepwise logistic regression analysis was performed using the clinical exercise test and echocardiographic variables. The strongest independent variables predicting the presence of multivessel CAD were systolic wall thickening index at peak stress (p < 0.0001), presence of wall thickening abnormalities in multiple vascular territories (p = 0.001), and a history of acute myocardial infarction (p = 0.04). Furthermore, dobutamine echocardiography significantly enhanced the prediction of multivessel disease when combined with clinical and exercise test variables (p = 0.001). Dobutamine stress echocardiography adds independent and incremental information to clinical and exercise test variables for identifying multivessel CAD.

Inotropic stress with arbutamine is superior to vasodilator stress with dipyridamole for the detection of reversible ischemia with Tc-99m sestamibi single-photon emission computed tomography

BACKGROUND

There is a paucity of data comparing the relative merits of inotropic and vasodilator stress Tc-99m sestamibi single-photon emission computed tomography (SPECT) for the detection of coronary artery disease and reversible ischemia.

METHODS AND RESULTS

Twenty-seven patients referred for diagnostic coronary arteriography underwent separate day dipyridamole and arbutamine Tc-99m sestamibi SPECT imaging with simultaneous two-dimensional echocardiography. The sensitivity of arbutamine and dipyridamole Tc-99m sestamibi for the detection of coronary artery disease was 100% (21 of 21) and 90% (19 of 21), respectively, with a specificity of 66% (4 of 6) for both. Coronary artery disease was detected in all six patients with single vessel disease by both stress modalities. The sensitivity for prediction of multivessel disease was 66% (10 of 15) for arbutamine and 46% (7 of 15) for dipyridamole stress. Arbutamine stress induced a greater extent and severity of perfusion abnormality at peak stress (peak perfusion score 25 +/- 6.2 and 21 +/- 5.9 for arbutamine and dipyridamole, respectively, p = 0.001) and reversible perfusion defects (difference between peak stress and rest scores 8.8 +/- 5.5 and 5.2 +/- 4.4 for arbutamine and dipyridamole, respectively, p = 0.001). Furthermore a significantly higher percentage of reversible defects induced by arbutamine stress was associated with wall thickening abnormality on simultaneous echocardiography, which is a more specific marker of myocardial ischemia (88% and 24% for arbutamine and dipyridamole, respectively, p = 0.002).

CONCLUSION

Inotropic stress may be superior to vasodilators for the determination of the extent and severity of myocardial involvement and reversible ischemia by Tc-99m sestamibi SPECT.

Detection of coronary artery disease with myocardial contrast echocardiography: comparison with 99mTc-sestamibi single-photon emission computed tomography

BACKGROUND

The purpose of this study was to determine whether myocardial contrast echocardiography (MCE) can be used to detect coronary artery disease (CAD) during rest and pharmacological stress in humans through the use of venous injections of contrast.

METHODS AND RESULTS

Thirty patients with known or suspected CAD underwent MCE and 99mTc-sestamibi single-photon emission computed tomography (SPECT) at baseline and after dipyridamole (0.56 mg x kg(-1)) infusion. Ten myocardial segments (5 each in the apical two- and four-chamber views) from the two sets of images using both methods were scored for myocardial perfusion as follows: 1=normal, 0.5=mildly reduced, and 0=severely reduced. The information from baseline and postdipyridamole images was then used to determine whether an abnormal segment was irreversible (similar abnormal perfusion at baseline and after dipyridamole) or reversible (perfusion better at baseline compared with after dipyridamole). Concordance between segmental scores was 92% (kappa=.99) for both methods. Concordance between normal perfusion and reversible or irreversible segmental defects was 90% (kappa=.80). Agreem between the two methods for each of the three vascular territories in each patient was 90% (kappa=.77), while agreement for the presence or absence of CAD in each patient was 86% (kappa=.86). In the 4 patients with disagreement, the perfusion scores were 0.5 for SPECT and 1.0 for MCE.

CONCLUSIONS

This study shows that MCE, with venous injection of contrast, can define the presence of CAD during rest and pharmacological stress. The location of perfusion abnormalities and their physiologic relevance (reversible or irreversible) by MCE is similar to that provided by SPECT. MCE, therefore, holds promise for the noninvasive assessment of myocardial perfusion in humans.