Impact of right ventricular reserve on exercise capacity and quality of life in patients with left ventricular assist device

Background

Right heart failure following left ventricular assist device (LVAD) implantation is a major complication which significantly impairs functional capacity and quality of life (QoL). Right ventricular (RV) reserve function may limit exercise capacity and QoL in LVAD patients; however, most patients show normal RV haemodynamics at rest.

Purpose

The aim of this study was to investigate whether RV reserve assessed by the changes of RV function during exercise is correlated with exercise capacity and QoL in patients with LVAD.

Methods

We prospectively examined 20 consecutive LVAD patients who were admitted to our university hospital between June 2020 and November 2021 after excluding those who were unable to perform exercise (n=8). All patients underwent invasive exercise right heart catheterisation with simultaneous echocardiography in the supine position. RV stroke work index (RVSWI) was calculated as 0.0136 × stroke volume index × (mean pulmonary artery pressure [mPAP] − right atrial pressure [RAP]) at rest and during exercise. Exercise capacity and QoL were assessed by 6-minute walk distance (6MWD) and peak oxygen consumption (VO2) in cardiopulmonary exercise testing, and the EuroQol visual analogue scale (EQ-VAS), respectively. The patients were divided into two groups according to the median ΔRVSWI (RVSWI change from rest to peak exercise) of 1.45 (interquartile range [IQR] −0.31 to 8.25) g/m2.

Results

Patients were predominantly male (75%) and the median age was 47 (IQR 38–60) years. Patients with lower ΔRVSWI had significantly higher change on RAP (P=0.019), but significantly lower change on mPAP (P<0.001) compared to those with higher ΔRVSWI. There were no significant differences in age, gender, primary aetiology of heart failure, type of LVAD devices, or echocardiographic parameters including tricuspid annular plane systolic excursion, and RVSWI at rest between the groups. ΔRVSWI during exercise were positively correlated with 6MWD (R=0.69, P<0.01) and peak VO2 (R=0.66, P<0.01) (Figure A). In addition, ΔRVSWI during exercise were positively correlated with the EQ-VAS (R=0.48, P=0.031). On the other hand, there was no significant correlation between RVSWI at rest and 6MWD (R=−0.11, P=0.63) and peak VO2 (R=0.13, P=0.95), and the EQ-VAS (R=0.11, P=0.61). During a median follow-up period of 312 (IQR 176–369) days, adverse events occurred in 3 patients (15%), including 1 death and 2 hospitalisations for major bleeding and right heart failure. Kaplan-Meier analysis revealed that the adverse events more frequently occurred in patients with lower ΔRVSWI compared to those with higher ΔRVSWI (Figure B).

Conclusions

ΔRVSWI was positively correlated with 6MWD, peak VO2 and EQ-VAS irrespective of RV function at rest. Our findings suggest that the assessment of RV reserve function using ΔRVSWI would be useful for risk stratification in patients with LVAD.

Funding Acknowledgement

Type of funding sources: None.

Empagliflozin attenuates arrhythmogenesis via inhibition of O-GlcNAcylation in diastolic phase of diabetic cardiomyopathy

Background

Diabetic cardiomyopathy is an important complication of diabetes mellitus (DM) and reported to increase the risk of fatal ventricular arrhythmias. Recent clinical trials showed that empagliflozin (EMPA), a selective sodium-glucose co-transporter 2 (SGLT2) inhibitor, improved cardiovascular outcomes regardless of the presence of diabetes and the traditional cardiovascular risk factors. Despite the promising benefit of EMPA on heart failure treatment, its beneficial effect in the context of anti-arrhythmic therapy has not been fully examined. We therefore aimed to examine anti-arrhythmic effect of acute EMPA treatment especially onto calcium (Ca2+) handling in diabetic cardiomyocytes.

Methods

We assessed echocardiography, hemodynamic study, electrophysiology, Ca2+ handling and protein expression in C57BLKS/J-leprdb/db mice (db/db mice), a leptin receptor-deficient model of obesity and Type 2 diabetes, and their non-diabetic lean heterozygous Leprdb/+ littermates (db/+ mice).

Results

The 16-week-old db/db mice had preserved systolic function but exhibited diastolic dysfunction. In arrhythmia induction using ex-vivo Langendorff-perfused hearts, db/db mice showed a significantly increased premature ventricular complex (PVC) by 2x Ca2+ and 1μM isoproterenol load than control, which was attenuated by EMPA perfusion (1 μM). Diabetic cardiomyocytes showed an increased frequency of spontaneous Ca2+ sparks and waves, and decreased Ca2+ transient amplitude and sarcoplasmic reticulum (SR) Ca2+ content. Ca2+ transient decay tau and time to 50% decay were significantly prolonged in diabetic cardiomyocytes. These data indicating the impaired Ca2+ handling in diabetic cardiomyocytes were normalized by acute administration of EMPA (1 μM), while the administration of NHE inhibitor (Cariporide 10 μM) did not show significant differences. In the protein expression analysis, CaMKII Thr287 autophosphorylation and CaMKII-dependent RyR2 S2814 phosphorylation were significantly increased in diabetic hearts, which were inhibited by short-term (30 min) perfusion of EMPA (1 μM). The expressions of SERCA2a and phospholamban were not significantly different among three groups. Lastly, whole hearts O-GlcNAcylation, one of the important post translational modifications, was significantly reduced by EMPA treatment.

Conclusion

EMPA improved intracellular Ca2+ handling and attenuated arrhythmogenesis in mice with diabetic cardiomyopathy at the diastolic dysfunction phase, suggesting that EMPA may exhibit this anti-arrhythmic effect by normalization of intracellular calcium handling via inhibiting O-GlcNAcylation.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boehringer Ingelheim

Two-dimensional echocardiographic scoring system of the left ventricular filling pressure and clinical outcomes in heart failure with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Japan Society for the Promotion of Science (JSPS)

Introduction

Elevated left ventricular (LV) filling pressure in non-decompensated state is a powerful indicator of worse clinical outcomes in heart failure regardless of LV ejection fraction. However, its detection is often challenging in heart failure with preserved ejection fraction (HFpEF).

Purpose

This study aimed to elucidate the predictive value of recently proposed echocardiographic parameter of LV filling pressure, Visually assessed time difference between the Mitral valve and Tricuspid valve opening (VMT) score in HFpEF.

Methods

We retrospectively analyzed 310 well-differentiated HFpEF patients in stable conditions. Using two-dimensional echocardiographic images, time sequence of opening of mitral valve and tricuspid valve was visually assessed in the apical four-chamber view and scored to 0 to 2 (0: tricuspid valve first, 1: simultaneous, 2: mitral valve first). When the inferior vena cava diameter was dilated, 1 point was added and VMT score was calculated as four grades from 0 to 3. Based on the previous study, VMT≥2 was regarded as a sign of elevated LV filling pressure (Figure 1). LV diastolic function was graded according to the guidelines. The primary endpoint was defined as a composite of cardiac death and heart failure hospitalisation during the two years after echocardiographic examination.

Results

During the follow-up period, 55 events (18%) occurred, including four cardiac deaths and 51 heart failure hospitalisations. Kaplan-Meier curves demonstrated that VMT≥2 (n = 54) was associated with worse outcomes compared to patients showing VMT ≤ 1 (n = 256) (log-rank test P <0.001). Furthermore, VMT≥2 was associated with worse outcomes when tested in 100 HFpEF patients with atrial fibrillation (log-rank test P = 0.026) (Figure 2). In the adjusted model including age, systolic blood pressure, serum albumin level, and the LV diastolic function grading, VMT≥2 was independently associated with the primary outcome (hazard ratio: 2.23; 95% confidence interval: 1.17 to 4.24, P = 0.014). Additionally, the nested regression model showed that VMT scoring provided an incremental prognostic value over clinically relevant variables (age, sex, the plasma brain natriuretic peptide level, atrial fibrillation) and LV diastolic function grading (chi-square 10.8 vs 16.3, P = 0.035).

Conclusions

In patients with HFpEF, the VMT score was independently and incrementally associated with adverse clinical outcomes. Moreover, it discriminated worse clinical outcome even in HFpEF patients with atrial fibrillation. Abstract Figure. VMT scoring  Abstract Figure. Kaplan-Meier analysis

Pathophysiological mechanism of worsened clinical outcome by lowered left ventricular cardiac power output in heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac power output (CPO) is a measure of cardiac pumping function, and CPO during exercise is known to be a powerful prognostic marker of heart failure. Despite its prognostic significance, pathophysiological mechanism of the association between reduced CPO and worse clinical outcome is unknown. We hypothesized that reduced CPO is associated with worse outcome through the reduced exercise capacity and enhanced ventilatory response.

Methods

Cardiopulmonary exercise testing and exercise stress echocardiography were performed in consecutive 64 patients with chronic heart failure who admitted to our department for the management of heart failure [60 ± 14 years old, left ventricular (LV) ejection fraction 39 ± 16%, ischemic etiology 16%, brain natriuretic peptide 124 pg/ml (51-313)]. Peak oxygen uptake (peak VO2) and the lowest minute ventilation / carbon dioxide production ratio (VE/VCO2) were measured as a parameter of exercise tolerance and that of ventilatory response, respectively. LV ejection fraction was measured by disk summation method at peak exercise. By using Doppler images, E/e" at peak exercise was measured as a marker of LV filling pressure, and CPO normalized by LV mass was obtained as 0.222 × cardiac output × mean blood pressure / LV mass [W/100 g]. Cardiac events defined as hospitalization for heart failure, cardiac death, or implantation of a LV assist device after the examinations were recorded.

Results

CPO at rest was weakly correlated with peak VO2 (r = 0.25, p = 0.046) but not with VE/VCO2. In contrast, CPO at peak exercise was positively correlated with peak VO2 (r = 0.50, p < 0.001) and inversely correlated with VE/VCO2 (r=-0.40, p = 0.002). Moreover, CPO at peak exercise determined both peak VO2 (b = 0.50) and VE/VCO2 (β=-0.54) independently of LV ejection fraction and E/e" at peak exercise. During a median follow-up period of 1211 days, 12 cardiac events were observed. Each of reduced peak VO2 (hazard ratio 0.78, 95% confidence interval 0.66-0.90) and increased VE/VCO2 (hazard ratio 1.10, 95% confidence interval 1.02-1.18) was associated with worse clinical outcome.

Conclusions

In patients with chronic heart failure, CPO during exercise was associated with prognosis of heart failure through the reduced exercise capacity and enhanced ventilatory response.

Validation of the HFA-PEFF and the H2FPEF scores for the diagnosis of heart failure with preserved ejection fraction in Japanese patients:a report from the Japanese multicentre registry

Background

The standard diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF) is based on the following: 1) symptoms of HF, 2) preserved left ventricular (LV) ejection fraction (LVEF, >50%), and 3) presence of LV diastolic dysfunction confirmed by echocardiography or cardiac catheterisation. However, there are limits to the diagnostic accuracy of individual parameters, and what cut-off values should be applied and how they should be combined remain unclear. Diagnostic algorithms for HFpEF such as the HFA-PEFF algorithm and the H2FPEF score have been proposed; however, previous validation studies were conducted in stable chronic HF and did not include an invasive haemodynamic assessment. Thus, the diagnostic accuracy for HFpEF lacked robustness. Moreover, information on their applicability in the Asian population is limited.

Purpose

The aim of this study was to investigate these scores' diagnostic validity for HFpEF in Japanese patients recently hospitalised due to acute decompensated HF.

Methods

We examined patients with HFpEF recently hospitalised with acute decompensated HF whose HFA-PEFF and H2FPEF scores could be calculated at discharge from a nationwide HFpEF-specific multicentre registry (HFpEF group) and control patients who underwent echocardiography to investigate the cause of dyspnoea in our hospital (Non-HFpEF group). We calculated the HFA-PEFF and the H2FPEF scores among the studied population. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were computed to compare the diagnostic accuracy of these scores.

Results

The studied population included 372 consecutive patients (194 HFpEF group and 178 Non-HFpEF group; HFpEF prevalence, 52%). The HFA-PEFF score classified 155 (42%) of all patients into the high likelihood category (5–6 points) and only 19 (5%) into the low likelihood category (0–1 point). A high HFA-PEFF score could diagnose HFpEF with a high specificity of 84% and a positive predictive value (PPV) of 82%, and a low HFA-PEFF score could rule out HFpEF with a high sensitivity of 99% and a negative predictive value (NPV) of 89%. The H2FPEF score classified 86 (23%) of all patients into the high likelihood category (6–9 points) and 84 (23%) into the low likelihood category (0–1 point). HFpEF could be diagnosed with a high H2FPEF score (specificity, 97%; PPV, 94%) or ruled out with a low H2FPEF score (sensitivity, 97%; NPV, 93%). The diagnostic accuracy for the HFA-PEFF and H2FPEF scores was 0.82 (95% confidence interval [CI] 0.78–0.86) and 0.89 (95% CI 0.86–0.93), respectively, by the AUC of the ROC curve (P=0.004) (Figure 1A). In the HFA-PEFF sub-scores, the functional score showed little diagnostic value, while the morphological and biomarker scores showed moderate diagnostic value (Figure 1B).

Conclusions

The H2FPEF score may be more useful than the HFA-PEFF score in diagnosing HFpEF in Japanese patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): a Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (JSPS KAKENHI) Figure 1

Applicability of the AHA/ACC/HRS guideline for implantable cardioverter defibrillator implantation in Japanese patients with cardiac sarcoidosis

Background

Sarcoidosis is a systemic granulomatous disease that affects multiple organs. Cardiac involvement is a key determinant of poor clinical outcomes in the patients with sarcoidosis, as it causes congestive heart failure, conduction abnormalities, ventricular tachycardia and fibrillation (VT/VF), and sudden cardiac death (SCD). Although implantable cardioverter defibrillators (ICDs) are used to prevent SCD from VT/VF in patients with cardiac sarcoidosis (CS), the generalizability of the AHA/ACC/HRS guidelines for the Japanese CS patients remains unclear.

Purpose

We aimed to assess, among Japanese patients with CS, the ICD recommendations from the 2017 AHA/ACC/HRS Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death.

Methods

We examined 188 consecutive patients with CS in two tertiary hospitals between 1979 and 2020. The primary outcome was defined as a composite outcome involving SCD or ventricular arrhythmic events. Ventricular arrhythmic events were defined as either emergency treatment for VF or sustained VT, which included appropriate ICD therapy.

Results

During a median follow-up period of 5.68 (IQR: 4.87–6.70) years, the primary outcome occurred in 44 patients (23%), which included 6 cases of SCD and 38 cases of VT/VF. ICD implant was indicated based on left ventricular ejection fraction (LVEF) of ≤35% (class I recommendation) in 62 patients, with an annualized event rate of 3.93%. A LVEF of >35% with a need for a permanent pacemaker (class IIa recommendation) was observed for 53 patients, with an annualized event rate of 2.54%. A LVEF of >35% with late gadolinium enhancement (LGE) during cardiovascular magnetic resonance (class IIa recommendation) was observed for 62 patients, with an annualized event rate of 2.38% (Figure A). Kaplan-Meier analyses revealed that patients with a class I recommendation for ICD implantation had a significant higher incidence of the primary outcome, compared to patients with a class IIa recommendation and patients with no indication for ICD implantation (P=0.03). However, there were no significant differences in the incidence of the primary outcome between patients with a LVEF of >35% and a need for a permanent pacemaker and patients with a class I recommendation (P=0.08) or patients with a LVEF of ≤35% (P=0.31). Moreover, there was no significant difference in the incidence of the primary outcome between patients with a LVEF of >35% and LGE on cardiovascular magnetic resonance and patients with a class I recommendation (P=0.054) or patients with a LVEF of ≤35% (P=0.22) (Figure B).

Conclusions

The American guideline recommendations for ICD implantation might be applicable to Japanese patients with CS. Implantation of an ICD may need to be considered in these patients if they require a permanent pacemaker or have LGE, regardless of LVEF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science

Association of high serum soluble interleukin 2 receptor levels with risk of adverse events in patients with cardiac sarcoidosis

Background

Sarcoidosis is a systemic granulomatous disease that affects multiple organs. Among these, the presence of cardiac involvement is recognised as a determinant of worse clinical outcomes. Soluble interleukin 2 receptor (sIL-2R) is a potentially useful biomarker in the diagnosis and evaluation of disease severity in patients with sarcoidosis. However, it remains to be seen whether sIL-2R is associated with the severity and activity of disease in patients with cardiac sarcoidosis (CS).

Purpose

The aims of this study were to investigate whether sIL-2R was associated with clinical outcomes and to clarify the relationship between sIL-2R levels and disease activity evaluated by 18F-fluorideoxyglucose in positron emission tomography/computed tomography (18F-FDG PET/CT) in patients with CS.

Methods

We examined 101 consecutive patients with CS who were admitted to our University HospitalbetweenMay 2003 and February 2020. Patients who had no data of serum sIL-2R levels before initiation of immunosuppressive therapy (n=18) were excluded. Ultimately, 83 patients were examined in this study. The primary outcome was a composite of advanced atrioventricular block (AVB), ventricular tachycardia or ventricular fibrillation (VT/VF), heart failure hospitalisation, and all-cause death. Inflammatory activity in the myocardium and lymph nodes were assessed by18F-FDG PET/CT. We used a published program to analyse the cardiac metabolic activity (CMA), and total lymph node glycolysis (TLyG), which are quantitative measures of FDG volume-intensity.

Results

During a median follow-up period of 2.96 (interquartile range 2.24–4.27) years, the primary outcome occurred in 24 patients (29%), including 1 advanced AVB, 13 VT/VF, 5 hospitalisations for heart failure, and 5 all-cause deaths. Kaplan-Meier analyses showed that the primary outcome occurred more frequently in patients with higher sIL-2R levels (>538 U/mL, the median) than in those with lower sIL-2R levels (Figure). A multivariable Cox regression analysis revealed that a higher sIL-2R level was independently associated with an increased subsequent risk of adverse events (hazard ratio 3.71, 95% confidence interval 1.63–8.44, p=0.002), even after adjustments for age, plasma B-type natriuretic peptide, estimated glomerular filtration rate, left ventricular ejection fraction, and late gadolinium enhancement, which are known to be strong determinants of worse clinical outcomes in patients with CS (Table). Furthermore, sIL-2R levels were significantly correlated with TLyG, the inflammatory activity in lymph nodes (r=0.346, p=0.003) but not with CMA, the inflammatory activity in myocardium (r=0.131, p=0.27).

Conclusions

Increased sIL-2R is associated with worse long-term clinical outcomes accompanied by increased systemic inflammatory activity in CS patients. These findings suggest the importance of assessing sIL-2R as a surrogate marker for further risk stratification in these patients.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Japan Society for the Promotion of Science

Influence of left ventricular systolic dysfunction on occurrence of pulsus tardus in patients with aortic stenosis

Funding Acknowledgements

Type of funding sources: None.

Background

The time between left ventricular (LV) and aortic systolic pressure peaks (TLV-Ao) which could reflect pulsus tardus (PT) is reported to be a marker of severity and be associated with poor prognosis in patients with aortic stenosis (AS). Despite its worldwide recognition, physiological mechanism of PT has not been well elucidated. We hypothesized that not only severity of the AS but also LV systolic dysfunction could be associated with occurrence of PT.

Methods

TLV-Ao and mean trans-aortic valvular pressure gradient (mean PG) were measured by simultaneous pressure tracing of left ventricle and basal aorta in 74 AS patients with at least moderate severity (78 ± 8 years old). Effective orifice area index (EOAI) was estimated by using continuity equation from transthoracic echocardiography and severe AS was defined as EOAI ± 0.60 cm²/m². Global longitudinal strain (GLS) was measured by using speckle-tracking method and expressed as an absolute value.

Results

TLV-Ao, mean PG, and EOAI was 87 ± 30 msec, 51 ± 21 mmHg, and 0.51 ± 0.14 cm² respectively. A weak correlation was observed between EOAI and TLV-Ao (Figure). In 9 out of 17 moderate AS patients (A in Figure), TLV-Ao was prolonged over the previously reported cut-off value (≥66 msec), on the other hand, it was not prolonged in 11 out of 57 severe AS patients (D in Figure). When the patients were divided by TLV-Ao of 66 msec, mean PG was not different between patients with prolonged TLV-Ao and those without in moderate AS patients (Figure, A vs B; NS), whereas GLS was significantly reduced in prolonged TLV-Ao group (P = 0.0383). In patients with severe AS, mean PG was significantly higher (P < 0.0001) in patients with prolonged TLV-Ao than in those without (Figure, C vs D), whereas GLS was comparable between the groups. In overall patients, multivariable analysis revealed that not only mean PG (β=0.54) but also GLS (β=-0.23) was an independent determinant of TLV-Ao.

Conclusion

The occurrence of pulsus tardus could be associated not only with severity of the AS but also with LV systolic dysfunction in patients with AS.

Abstract Figure

Presence and significance of mid-systolic notch on right ventricular outflow tract velocity envelopes in pulmonary hypertension due to heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

 A mid-systolic notch (MSN) of the right ventricular outflow tract (RVOT) pulsed-wave Doppler envelope, which is recognized as a characteristic finding in pre-capillary pulmonary hypertension (PH), is often observed in heart failure (HF) patients. However, clinical significance of MSN formation in HF has not been elucidated.

Methods

 Consecutive 233 HF patients who underwent right heart catheterization and echocardiography within 24 hours were enrolled. Isolated post-capillary PH (IpcPH) was defined as mean pulmonary arterial pressure (mPAP) >20 mmHg, mean pulmonary artery wedge pressure (mPAWP) >15 mmHg, and pulmonary vascular resistance (PVR) <3 Wood units and combined pre- and post-capillary PH (CpcPH) was as mPAP >20 mmHg, mPAWP >15 mmHg, and PVR ≥3 Wood units. Pulmonary arterial capacitance (PAC) was calculated as stroke volume / pulmonary arterial pulse pressure [mL/mmHg]. MSN was defined as formation of notch within first half of the RVOT pulsed-wave Doppler envelope.

Results

 Prevalence of IpcPH, CpcPH, and without PH were 87 (37%), 45 (19%), and 101 (43%), respectively and MSN was observed in 8 (9%) of IpcPH, 17 (38%) of CpcPH, and 1 (1%) of patients without PH. Among the hemodynamic and echocardiographic parameters, mPAP and PAC independently determined occurrence of MSN in all the multivariable models (Table). Interestingly, when the PH patients were dimidiated according to median PAC (3.2 mL/mmHg), 25 out of 102 PH patients (25%) with low PAC showed MSN whereas any of PH patients with high PAC did not (Figure).

Conclusion

 MSN was frequently observed in HF patients showing CpcPH. Combination of elevated pressure and reduced compliance of the pulmonary circulation could determine occurrence of MSN in HF.

Determinants of MSN occurrence Univariable analysis Multivariable analysis Model 1 Model 2 Model 3 Model 4 variables OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p LV ejection fraction 0.97 (0.94-0.99) 0.007 1.00 (0.96-1.03) 0.795 LV mass index 1.00 (1.00-1.02) 0.143 PAW pressure 1.13 (1.08-1.18) <0.001 0.92 (0.82-1.03) 0.135 Mean PA pressure 1.14 (1.09-1.19) <0.001 1.08 (1.02-1.14) 0.006 1.15 (1.04-1.27) 0.004 1.08 (1.00-1.17) 0.030 1.07 (1.01-1.14) 0.025 Mean RA pressure 1.14 (1.06-1.22) <0.001 1.00 (0.90-1.11) 0.978 Pulmonary vascular resistance 1.97 (1.45-2.67) <0.001 1.20 (0.88-1.63) 0.225 Pulmonary arterial capacitance 0.27 (0.15-0.48) <0.001 0.49 (0.26-0.92) 0.010 0.44 (0.23-0.85) 0.004 0.47 (0.24-0.93) 0.011 0.49 (0.26-0.93) 0.011 Abstract Figure.

High-density lipoprotein cholesterol does not predict future cardiovascular events in patients treated with statins for secondary prevention: an observation from the REAL-CAD study

Background

The relation between high-density lipoprotein cholesterol (HDL-C) level after statin therapy and cardiovascular events in patients with stable coronary artery disease remains unclear.

Purpose

We sought to determine the association of the HDL-C level after statin therapy with cardiovascular events in stable coronary artery disease patients.

Methods

This study was a post-hoc analysis of the Randomized Evaluation of Aggressive or Moderate Lipid Lowering Therapy with Pitavastatin in Coronary Artery Disease (REAL-CAD) study, which is randomised, open-label, blinded endpoint, physician-initiated, superiority clinical trial. Enrollment was from January 2010 to March 2013, and follow-up was through January 2016. From the main study, we excluded the patients without either HDL-C data at baseline or 6 months, with occurrence of the primary outcome at 6 months and reported poor adherence for pitavastatin. The primary outcome of interest was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal ischemic stroke, or unstable angina requiring emergent admission after 6 months from randomisation, consistent with the primary analysis of the trial. We constructed landmark Cox proportional hazards regression models with the 18 selected clinically relevant risk-adjusting variables during the entire follow-up period starting at 6 months after randomisation. Absolute and relative changes of HDL-C level were defined as (6 months value – baseline value) and (absolute change / baseline value) × 100, respectively.

Results

Among 14,774 participants in the REAL-CAD study, 9,221 patients were included in this analysis (7652 [83.0%] male; median [IQR] age, 70 [63–75] years; median [IQR] HDL-C, 49 [42–57] mg/dL; median [IQR] low-density lipoprotein cholesterol [LDL-C], 88 [75–101] mg/dL). During a median follow-up period of 4.0 (IQR 3.2–4.7) years, the primary outcome occurred in 417 (4.5%) patients. There was no significant difference in crude and adjusted cumulative incidence of the primary outcome among the quartiles of HDL-C level at 6 months (Figure 1). The adjusted risks of all the HDL-C related variables (baseline value, 6 months value, absolute and relative changes) for the primary outcome were not significant (Figure 2). Furthermore, the adjusted hazard ratio (HR) as HDL-C level at 6 months increased by 10 mg/dL remained non-significant for the primary outcome for each on-treatment LDL-C level at 6 months (<70 mg/dL [HR 0.97, 95% CI 0.82–1.15], 70–100 mg/dL [HR 1.10, 95% CI 0.98–1.24], and ≥100 mg/dL [HR 0.94, 95% CI 0.78–1.13]). There was also no significant association between HDL-C level at 6 months and the primary outcome both in the low (1 mg/day [HR 1.02, 95% CI 0.91–1.14], increased by 10 mg/dL) dose and high (4 mg/day [HR 1.04, 95% CI 0.91–1.19]) dose pitavastatin groups

Conclusion

After statin therapy with modestly controlled LDL-C, HDL-C level has little prognostic value in patients with stable coronary artery disease.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Comprehensive Support Project for Clinical Research of Lifestyle-Related Disease of the Public Health Research Foundation

The role of right ventricular late gadolinium enhancement scoring by cardiac magnetic resonance imaging in cardiac sarcoidosis

Background

The right ventricular (RV) function is a significant predictor of the prognosis and exercises tolerance in patients with left ventricular dysfunction. The previous study reported that RV late gadolinium enhancements (LGE) as assessed by cardiac magnetic resonance (CMR) imaging were present in 16% of pulmonary sarcoidosis. Although RV LGE is associated with a poor prognosis, a semi-quantitative assessment of RV LGE was not been established so far. Moreover, the frequency of RV dysfunction (RVD) in cardiac sarcoidosis (CS) and predictors of RVD are unclear.

Purpose

Our aim of this study is to establish RV LGE semi-quantitative scores and to clarify the rate and predictors of RVD in CS.

Methods

Forty-four consecutive patients with CS who underwent CMR imaging (median age, 63 [IQR 54–71] years old; 10 males) were studied. They were diagnosed as definitive based on the Heart Rhythm Society expert consensus statement. Two patients were excluded due to no long axial view. Thus, a total of 42 patients were included in this study. RV LGE was semi-quantitatively evaluated using the original score developed by ours. RV was classified into RV outflow tract (OT), basal, middle and apex. RVOT and apex are assigned 1 segment for each, and basal and middle are assigned 4 segments include anterior, septal, inferior and lateral (Figure1). In total, 10 segments were evaluated. RV LGE scores were analysed independently by the two operators. The RV ejection fraction was assessed in a long axial view without an RVOT (20 phases, 12 slices). We divided the cohort into the non-RVD group (RVEF ≥45%) and the RVD group (RVEF <45%) and compared the RV scores between the two groups.

Results

The RVD was present in 31% of the entire cohort. The presence of RV LGE was significantly higher in the RVD group than the non-RVD group (83% vs. 43%, p=0.037). RV LGE score in the RVD group was significantly higher than that in the non-RVD group (2.83±1.95 vs. 0.83±1.21, p=0.001). The septal lesions in basal and middle levels accounted for 54% in all segments. RVEF showed a significant inverse correlation with RV LGE score (r=−0.57, p<0.0001). In the ROC curve for RVD, the RV LGE score of more than 2 and equal could discriminate RVD from non-RVD with AUC of 0.813 (Sensitivity = 0.77, Specificity = 0.76, p=0.003).

Conclusion

RVD was observed in 31% of patients with definitive CS. The septal lesions were the most frequent in the RV LGE site, which suggests that the longitudinal abnormal motion of RV is a significant predictor of the RVD in patients with CS. RV LGE score is a valuable method to assess RVD.

RV LGE score

Funding Acknowledgement

Type of funding source: None

Suppression of ventricular arrhythmia by mitochondrial calcium uptake via mitochondrial calcium uniporter in the ischemic heart failure mice

Background

In heart failure (HF), diastolic calcium (Ca) leak from sarcoplasmic reticulum (SR) via ryanodine receptor (RyR) causes delayed after depolarization (DAD), leading ventricular arrhythmias (VAs). Recent study reported that Ca uptake into mitochondria via mitochondrial calcium uniporter (MCU) suppress Ca waves (CaWs) and DAD in catecholaminergic polymorphic ventricular tachycardia, in which diastolic Ca leak is thought to be a major cause of VAs as in HF. However, such anti-arrhythmic effect of mitochondrial Ca uptake via MCU remains unclear in HF.

Purpose

We sought to investigate whether mitochondrial Ca uptake via MCU decreases CAWs and VAs incidence in ischemic HF mice.

Methods

Ten-week-old male C57BL/6J mice were divided into 2 groups; sham operation mice (Sham) or HF mice (HF) in which myocardial infarction was induced by left coronary artery ligation. After 4–6 weeks, cardiomyocyte or mitochondria was isolated respectively from the myocardium of Sham and the non-infarct myocardium of HF. Influence of MCU activation on Ca dynamics, VA inducibility and left ventricular hemodynamics were evaluated using Kaemenpferol, a MCU activator. Intracellular Ca dynamics and mitochondrial Ca uptake were measured in isolated cardiomyocytes loaded with Fluo-4 AM on an epifluorescence microscopy and by estimating the extra-mitochondrial Ca reduction with Fluo-5N on a spectrofluoro-photometer, respectively. VAs was induced by programmed stimulation in the Langendorff perfused hearts. Left ventricular (LV) pressure was measured using a microtip transducer catheter. Finally, the effect of intravenous administration of Kaempferol (5mg/kg) on hemodynamic parameters was examined 30 minutes after administration in Sham and HF.

Results

HF mice showed left ventricular dysfunction, as well as the increased heart and lung weights compared to Sham. MCU protein expression in cardiomyocytes did not differ between Sham and HF. Kaempferol increased mitochondrial Ca uptake in the isolated mitochondria both in Sham and HF. The number of the diastolic CaWs was higher in HF compared to Sham. Such increased number of CaWs in HF was attenuated by 10 μM Kaempferol, which was, however, abolished by a MCU blocker Ruthenium Red. The incidence of induced VA was significantly higher in HF than Sham, which was suppressed by Kaempferol. In vivo measurements, intravenous administration of Kaempferol did not show significant changes in hemodynamic parameters in Sham and HF mice.

Conclusions

Mitochondrial Ca uptake via MCU suppresses CaWs and VAs, but did not change LV hemodynamics in HF. Whereas traditional antiarrhythmic drugs have limited use in heart failure patients, a novel strategy that promotes Ca uptake into mitochondria might be a new and safer option for treating VAs in HF.

Funding Acknowledgement

Type of funding source: None

Simple echocardiographic scoring system to estimate left ventricular filling pressure based on visual assessment of time sequence of mitral and tricuspid valve opening

Introduction

In the presence of elevated left ventricular (LV) filling pressure, mitral valve (MV) becomes to open early and precedes tricuspid valve (TV) opening in early diastole. Accordingly, time-delay of right ventricular inflow relative to LV inflow assessed by dual Doppler system was recently reported as a parameter of LV filling pressure. We assumed that visually-assessed time-delay of TV relative to MV opening could be a simple and alternative marker of elevated LV filling pressure.

Purpose

This study aimed to elucidate the clinical usefulness of the 2-dimensional echocardiographic scoring system, Visual assessment of time-difference between Mitral and Tricuspid valve opening (VMT) score, in patients with heart failure (HF).

Methods

We analyzed 119 consecutive HF patients who underwent echocardiography and cardiac catheterization within a day. Elevated LV filling pressure was defined as mean pulmonary arterial wedge pressure (PAWP) ≥15 mmHg. LV diastolic function was graded according to the ASE/EACVI recommendations. Time sequence of opening of MV and TV was visually assessed in the apical 4-chamber view and scored to 3 grades (0: TV opening first, 1: simultaneous, 2: MV opening first). When the inferior vena cava diameter was >21 mm and collapsed <20% during normal respiration, 1 point was added and VMT score was calculated as 4 grades from 0 to 3. We also investigated 113 patients without worsening HF at VMT scoring for cardiac events defined as worsening HF, LV assist device implantation, or cardiac death for 1 year after the echocardiography.

Results

VMT was scored as 0 in 20 patients, 1 in 50 patients, 2 in 37 patients, and 3 in 12 patients. PAWP was elevated in patients with VMT score of 2 and 3 (0: 10±5, 1: 12±4, 2: 22±8, 3: 28±4 mmHg, ANOVA P<0.001) (Figure). In overall patients, VMT≥2 predicted elevated PAWP with accuracy of 86%. When the accuracy was tested in patients with reduced (<40%, HFrEF) and preserved LV ejection fraction (≥40%) respectively, the accuracy was excellent in HFrEF (96% and 77%, respectively). Importantly, VMT≥2 also had good accuracy of 82% for elevated PAWP in 33 patients in whom recommendations usually cannot grade diastolic function due to monophasic LV inflow. In the sequential Cox models, the addition of VMT score to the model including the plasma brain natriuretic peptide (BNP) level and LV diastolic grading improved the predictive power for elevated PAWP (P<0.001). During the follow-up, 20 cardiac events were observed (6 worsening HF, 9 LV assist device implantation and 5 cardiac death). Kaplan-Meier analysis showed that the patients with VMT≥2 were at higher risk of cardiac events than those with VMT≤1 (log-rank test P<0.001) (Figure).

Conclusions

The VMT score was a simple and accurate marker of elevated LV filling pressure and has an incremental benefit over BNP and LV diastolic function grading. Moreover, it could be a novel prognostic marker in patients with HF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Activation of invariant natural killer T cells ameliorates doxorubicin-induced cardiotoxicity in mice

Objective

Doxorubicin (DOX) is one of the most important anticancer agents and widely used to treat cancers but clinical utility of DOX is limited for its dose-dependent cardiotoxicity. The precise mechanism of DOX-induced cardiotoxicity is still not fully understood but it has been reported that cardiac inflammation is involved in the cardiotoxicity. Invariant natural killer T (iNKT) cells, a unique subset of T lymphocytes that recognize glycolipid antigens and secrete a large amount of both Th1 and Th2 cytokines on activation, have been shown to play crucial roles in the regulation of immune responses. However, it remains unclear whether iNKT cells are involved in DOX-induced cardiotoxicity.

Methods and results

Male C57BL/6J mice were administered DOX (20mg/kg body weight; n=28) or vehicle (Vehicle; n=6). DOX-administered mice were further divided into 2 groups; those treated with α-galactosylceramide (αGC, 0.1μg/g body weight; DOX-αGC; n=14), which specifically activates iNKT cells, or those treated with PBS (DOX-PBS; n=14) by intraperitoneal injections (twice; 4 days before and 3 days after DOX administration).An echocardiography conducted at 14 days after DOX/Vehicle administration revealed that LV fractional shortening was significantly reduced in the DOX-PBS compared to the Vehicle (49.3±0.8% vs. 59.2±1.7%, P<0.05), and this decrease was completely attenuated in the DOX-αGC (57.7±1.3%, P<0.05 vs. DOX-PBS)without affecting LV end-diastolic diameter. Flow cytometric analysis revealed that the ratio of iNKT cells to mononuclear cells infiltrated into the heart tissue was significantly increased in the DOX+αGC compared to the Vehicle and the DOX+PBS (1.00±0.09% vs. 0.54±0.09% and 0.71±0.07%, P<0.05). Immuno-histochemistry revealed that the infiltration number of Iba1+macrophages in the heart tissue was significantly elevated in the DOX+αGC compared to the Vehicle and the DOX+PBS (55.4±3.2 cells/mm2 vs. 21.7±2.0 cells/mm2 and 37.5±5.9 cells/mm2, P<0.05) The ratio of fibrosis area to the heart tissue was markedly higher in the DOX-PBS than in Vehicle (4.3±0.5% vs. 2.2±0.1%, P<0.05), and this increase was completely attenuated in the DOX-αGC (2.8±0.1%, P<0.05 vs.DOX-PBS).Real-time PCR analysis revealed that mRNA expressions of M2 macrophage markers (Arginase 1 and Retnla) and IL-4 were significantly enhanced in the DOX+αGC compared to the DOX+PBS (Arginase 1: 2.5±0.4 vs. 1.6±0.3 [relative ratio to the Vehicle], P=0.08; Retnla: 2.4±0.5 vs. 1.1±0.2 [relative ratio to the Vehicle], P<0.05; IL-4: 1.0±0.3 vs. 8.94±2.8 [relative ratio to the DOX+PBS], P<0.05), while those of M1 macrophage markers (iNOS and MCP-1) did not change among all groups.

Conclusions

Activation of iNKT cells ameliorates DOX-induced cardiotoxicity in mice via enhanced M2 macrophage polarization with the upregulation of IL-4 and reducing cardiac fibrosis. iNKT cell activation can be a novel preventive strategy against DOX-induced cardiotoxicity.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Japan Agency for Medical Research and Development (18lm0203001j0002) and JSPS KAKENHI (18K15834).

Long-term prognostic significance of dispersion of ventricular repolarization in patients with cardiac sarcoidosis

Background

Although the presence of cardiac involvement is recognised as a determinant of worse clinical outcomes in sarcoidosis patients, the determinants of adverse outcomes in patients with cardiac sarcoidosis (CS) have not been well understood. T-peak to T-end interval (TpTe) on the surface electrocardiogram (ECG) was proposed as a marker of dispersion of ventricular repolarisation. Prolonged TpTe to QT interval ratio (TpTe/QT) represents a period of potential vulnerability to reentrant ventricular arrhythmias. Notably, prolonged TpTe/QT has been associated with increased risk of mortality in hypertrophic cardiomyopathy, congenital long-QT syndrome, and Brugada syndrome. However, its prognostic implication in patients with CS is unclear.

Purpose

We sought to investigate whether TpTe/QT was associated with long-term clinical outcomes in patients with CS.

Methods

A total of 108 consecutive CS patients between August 1986 and March 2019 in two academic hospitals who had ECG data before initiation of immunosuppressive therapy were examined. We excluded patients who received pacemaker (n=15) or cardiac resynchronization therapy (n=3) at the time of ECG. Ultimately, 90 CS patients were included in this study. All standard 12-lead ECGs were recorded at 25 mm/s with an amplification of 10 mm/mV. TpTe was measured from the peak of T wave to the end of T wave which defined as the intersection of the tangent to the down slope of the T wave and the isoelectric line. Lead V5 was selected for the analyses. If V5 is not suitable for analyses, V4 was selected. The primary outcome was the composite of advanced atrioventricular block (AVB), ventricular tachycardia or ventricular fibrillation (VT/VF), heart failure hospitalisation and all-cause death.

Results

During a median follow-up period of 4.70 (interquartile range [IQR] 2.06–7.23) years, adverse events occurred in 21 patients (23.3%), including 2 advanced AVB, 12 VT/VF, 4 heart failure hospitalisation and 3 all-cause death. Events group had higher TpTe/QT compared to no events group (0.231 [IQR 0.193–0.261] vs. 0.282 [IQR 0.263–0.304] P<0.001). Kaplan-Meier analyses revealed that the primary outcome, especially VT/VF or sudden cardiac death more frequently occurred in patients with higher TpTe/QT (≥0.242, the median) compared to those with lower TpTe/QT (Figure 1). Multivariable Cox regression analysis showed that higher TpTe/QT was independently associated with increased subsequent risk of adverse events (hazard ratio 1.09, 95% confidence interval [CI] 1.02–1.17, P=0.014) even after adjustment for age, sex and left ventricular ejection fraction. Furthermore, the optimal cut-off value of TpTe/QT for the discriminatory of primary outcome was 0.257, and c-index was 0.77 (95% CI 0.64–0.89).

Conclusions

Higher TpTe/QT was associated with worse long-term clinical outcomes in patients with CS. Our findings indicate the importance of assessing TpTe/QT for risk stratification in patients with CS.

Figure 1

Funding Acknowledgement

Type of funding source: None

Early and noninvasive diagnosis using serological antigen biomarkers in chronic invasive fungal rhinosinusitis

Background: Chronic invasive form of fungal rhinosinusitis (FRS) is characterized by the invasion of fungal organisms into the sinonasal mucosa in the background of diabetes mellitus and corticosteroid treatment. Although the histopathology has traditionally been used to make a proven diagnosis of invasive fungal infections, the dependence on tissue samples and the slow turnaround time hamper the early confirmation of such infections. Methodology: This is a retrospective case series conducted over 6 years. All patients with a chronic course and immunosuppressive background of FRS diagnosed by radiologic imaging and treated with endoscopic sinus surgery were eligible for inclusion. Data were collected through medical records, including basic characteristics, symptoms and signs, imaging findings, laboratory investigations, pathology, treatment, and outcomes. Results: Fifteen patients with chronic course and immunosuppressive background of FRS diagnosed by radiologic imaging were identified. High values of 1,3-b-D-glucan (BDG) assay were recognized in 5 patients, whereas the other 10 patients with negative findings in the BDG assay showed sinus mycetomas. All the 5 patients showing significant elevations of serum BDG showed positive findings in the polymerase chain reaction (PCR), but only 2 patients were positive in the histopathology. The findings of the BDG assay were consistent with those of the PCR method, which was superior in sensitivity to the histopathology. Conclusion: We first applied BDG assay as a diagnostic tool for chronic invasive FRS. The BDG assay may be useful to distinguish chronic invasive FRS, including its early stage, from noninvasive mycetoma, contributing to timely treatment.

P2634Prognostic value of admission left ventricular outflow tract velocity time integral in hospitalized heart failure patients with preserved ejection fraction: a report from the JASPER registry

Background

There are little effective treatment strategies for heart failure with preserved ejection fraction (HFpEF) to achieve a reduction of morbidity and mortality. Thus, accurate prognostication of patients with HFpEF could help improve their outcomes by identifying high-risk patients who might potentially benefit from intensive inpatient and outpatient monitoring and early referral for advanced HFpEF therapy. The left ventricular outflow tract velocity time integral (LVOT-VTI) is a representative non-invasive parameter for evaluating stroke volume, which can be a determinant of adverse outcomes in hospitalized patients with heart failure. However, the prognostic implication of admission LVOT-VTI for hospitalized HFpEF patients is undetermined.

Purpose

The aim of the present study was to investigate whether admission LVOT-VTI could predict poor clinical outcomes in hospitalized patients with HFpEF.

Methods

We examined consecutive 535 hospitalized HFpEF patients (left ventricular ejection fraction ≥50%) due to acute decompensated heart failure from the JASPER (JApanese heart failure Syndrome with Preserved Ejection fRaction) multicenter registry, obtained between November 2012 and March 2015. Patients without accessible LVOT-VTI data on admission were excluded. Finally, 214 patients were examined. The primary outcome of interest was composite of all-cause death and rehospitalization due to heart failure.

Results

Mean age was 78±11 years, 100 were male, and median plasma brain-type natriuretic peptide level was 400 (interquartile range [IQR] 223–711) pg/ml. During a median follow-up period of 688 (IQR 162–810) days, adverse events occurred in 83 patients (39%), including 47 (22%) all-cause death, 51 (24%) rehospitalization due to heart failure. The c-index of LVOT-VTI for predicting the composite of adverse events was 0.59 (95% CI 0.51 to 0.67), and the optimal cut-off value of LVOT-VTI was 15.8 cm. Low LVOT-VTI (≤15.8 cm) was significantly associated with higher adverse events compared to high LVOT-VTI (>15.8 cm) (Figure). Multivariable Cox regression analysis revealed that lower LVOT-VTI was an independent determinant of adverse events (HR 0.94, 95% CI 0.91 to 0.98, P=0.005) even after adjustment for pre-specified confounders including age, sex, systolic blood pressure, serum sodium, albumin, plasma brain-type natriuretic peptide and renal function.

Figure 1

Conclusions

Lower admission LVOT-VTI was an independent determinant of worse clinical outcomes in hospitalized HFpEF patients, indicating that LVOT-VTI on admission could be a useful marker for risk stratification in these patients.

4089Prognostic value of cardiac metabolic activity assessed by 18F-FDG PET in patients with cardiac sarcoidosis

Background

Sarcoidosis is a systemic granulomatous disease that affects multiple organs. Among these,the presenceof cardiac involvementis recognized as a determinant of worse clinical outcomes. 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is a valuable modality for detecting active inflammatory lesions associated with cardiac sarcoidosis (CS). Generally,the maximum standardized uptake value (SUV) is suitable for evaluating disease activity in CS, but this quantitative method had limitations because it does not integrate both volume and intensity of FDG uptake simultaneously. Cardiac metabolic activity (CMA), which is quantitative measures of FDG volume-intensity, could be a diagnostic tool in the evaluation of CS. However, its prognostic implication in patients with CS is unclear.

Purpose

We sought to investigate whether CMA assessed by FDG-PET was associated with long-term worse clinical outcomes in patients with CS.

Methods

A total of 76 consecutive patients suspected CS who underwent FDG-PET between January 2010 and April 2018 in our university hospital were registered. We excluded patients whodid not meet the Japanese Ministry of Health and Welfare 2007 criteria (n=9) and those who received oral corticosteroids at the time of FDG-PET (n=5). Ultimately, 62 CS patients with definitively diagnosed were included in this study.We used a dedicated software to analyze SUV. Cardiac metabolic volume (CMV) was defined as the volume within the boundary determined by the threshold (SUV mean of blood pool × 1.5). CMA was calculated by multiplying CMV by SUV mean. The primary outcome of interest was the composite of advanced atrioventricular block, ventricular tachycardia, ventricular fibrillation, heart failure hospitalization, and all-cause death.

Results

During a median follow-up period of 1287 (IQR 806–1809) days after the first FDG-PET, the adverse events occurred in 12 patients (19%). Events group had significantly higher CMA compared to no events group (83 [IQR 11–330] vs. 354 [IQR 70–577]) (Figure A). Based on ROC analysis, the optimal cut-off value of CMA for the discrimination of the adverse events was 244 ml, and c-index was 0.71 (95% CI, 0.55–0.87). Patients with high CMA (≥244 ml, n=23) had lower LVEF, and higher prevalence of New York Heart Association functional class III or IV, and higher plasma BNP level compared to those with low CMA (<244 ml, n=39). Kaplan-Meier analysis revealed that composite adverse events more frequently occurred in patients with high CMA compared to those with low CMA (Figure B).Univariable Cox regression analysis showed that higher CMA was associated with increased subsequent risk of adverse events (HR 1.47, 95% CI 1.06–2.24).

Conclusions

Higher CMA assessed by FDG-PET was associated with worse clinical long-term outcomes in patients with CS, suggesting that measurement of the volume-intensity of abnormal FDG uptake may be useful for risk stratification in patients with CS.

P1623Activation of invariant natural killer T cells by alpha-galactosylceramide ameliorates doxorubicin-induced cardiotoxicity in mice

Objective

Doxorubicin (DOX) is an effective antineoplastic agent commonly used to treat many types of cancer but its clinical use is limited because of cardiotoxicity, which might proceed to irreversible cardiac dysfunction in a dose-dependent manner. The precise mechanism of DOX-induced cardiotoxicity is still not fully elucidated but it has been reported that cardiac inflammation is involved in the cardiotoxicity. Invariant natural killer T (iNKT) cells, a unique subset of T lymphocytes that recognize glycolipid antigens and secrete a large amount of Th1 and Th2 cytokines on activation, have been shown to play crucial roles in the regulation of immune responses. However, it remains unclear whether iNKT cells are involved in DOX-induced cardiotoxicity.

Methods and results

Male C57BL/6J mice were administered DOX (20mg/kg body weight single intraperitoneal injection; n=28) or vehicle (Vehicle; n=6). DOX-administered mice were further divided into 2 groups; α-galactosylceramide (αGC, 0.1μg/g body weight twice intraperitoneal injection; DOX-αGC; n=14), which specifically activates iNKT cells, or phosphate-buffered saline alone (PBS; DOX-PBS; n=14) 4 days before and 3 days after DOX administration. Survival rate at 14 days after DOX/Vehicle administration was significantly lower in DOX-PBS than in Vehicle (71% vs. 100%, P<0.05), and this decrease was completely attenuated in DOX-αGC (100%, P<0.05 vs. DOX-PBS). Echocardiography at 14 days after DOX/Vehicle administration revealed that left ventricular (LV) fractional shortening was significantly reduced in DOX-PBS compared to Vehicle (49.3±0.8% vs. 59.2±1.7%, P<0.05), and this decrease was completely attenuated in DOX-αGC (57.7±1.3%, P<0.05 vs. DOX-PBS) without affecting LV end-diastolic diameter. Picro-sirius red staining revealed that the ratio of fibrosis area to the cardiac tissue was markedly higher in DOX-PBS than in Vehicle (4.3±0.5% vs. 2.2±0.1%, P<0.05), and this increase was completely attenuated in DOX-αGC (2.8±0.1%, P<0.05 vs. DOX-PBS). Real-time PCR analysis revealed that mRNA expression of anti-inflammatory Th2 cytokine IL-4 was enhanced by 7.9-folds in DOX-αGC compared to DOX-PBS, though the difference did not reach statistically significance (P=0.09).

Conclusions

Activation of iNKT cells by αGC ameliorates DOX-induced cardiotoxicity in mice via up-regulation of anti-inflammatory IL-4 and reducing cardiac fibrosis. iNKT cell activation may be a novel therapeutic strategy against DOX-induced cardiotoxicity.

Acknowledgement/Funding

Japan Agency for Medical Research and Development (18lm0203001j0002) and JSPS KAKENHI (18K15834)

P767Survey of palliative sedation at the end-of-life in terminally ill heart failure patients - a five year experience in national cardiovascular center

Background

Palliative sedation is a therapeutic option when symptom relief is difficult to achieve at the end-of-life. However, little is known regarding palliative sedation in terminally ill heart failure (HF) patients.

Purpose

To survey the practice of palliative sedation in terminally ill HF patients at a tertiary referral cardiovascular center, and to investigate the efficacy and safety of sedative agents in HF patients.

Methods

We retrospectively reviewed consecutive patients who were referred to palliative care team at our institution between September 2013 and August 2018. Patients who were hospitalized for HF and died during hospitalization despite optimal medical therapy were selected and defined as terminally ill HF. We investigated the practice of palliative sedation in terminally ill HF patients and analysed the vital signs and sedation scale before starting sedative agents and about 1 hour afterward.

Results

Among 95 terminally ill HF patients, 37 were prescribed palliative sedation at the end-of-life (Picture). Of 37 patients (mean age: 70 years, median B-type natriuretic peptide: 1018 pg/ml, median creatinine: 3.0 mg/dl, intravenous inotrope: 81%), 25 were prescribed dexmedetomidine, and 12 were prescribed midazolam as first agent for sedation. Patient's backgrounds were comparable between the two groups. Richmond Agitation-Sedation Scale was significantly reduced (P<0.01), whereas blood pressure and heart rate were not altered after treatments in both groups. In midazolam group, significant decreases were noted regarding respiratory rate (P=0.01) and oxygen saturation (P=0.02); however, these parameters were not changed in dexmedetomidine group (Table).

Table 1. Vital signs and sedation scale Dexmedetomidine group (n=25) Midazolam group (n=12) Baseline After P value Baseline After P value Richmond Agitation-Sedation Scale 1 (0, 1) −1 (−2, 0) <0.01 1 (0, 1) −2 (−3, −1) <0.01 Vital signs   Systolic blood pressure (mmHg) 90±15 89±16 0.51 89±21 84±23 0.33   Diastolic blood pressure (mmHg) 52±13 54±11 0.34 60±14 56±23 0.48   Heart rate (beats per minute) 95±20 91±22 0.17 90±21 90±19 0.70   Respiratory rate (breaths per minute) 22±5 20±5 0.24 21±5 17±2 0.01   Oxygen saturation (%) 97±3 96±6 0.59 96±5 94±5 0.02

Picture. Study flowchart

Conclusions

Dexmedetomidine and midazolam were commonly used in real-word practice for HF patients at the end-of-life. Although impact on respiratory system differed by treatments, both agents could be prescribed effectively and safely in terminally ill HF patients.

Impact of B-type natriuretic peptide (BNP) on development of atrial fibrillation in people with Type 2 diabetes

AIMS

To examine if a simple biomarker can identify people with diabetes who are at high risk of atrial fibrillation.

METHODS

A retrospective cohort study was conducted at a single centre in people with Type 2 diabetes referred to our department between January 2000 and December 2007. In 517 consecutive people without any history, signs or symptoms of atrial fibrillation at baseline, the association between baseline B-type natriuretic peptide level and future atrial fibrillation incidence was examined, with adjustments for other potentially confounding factors.

RESULTS

A total of 28 people were diagnosed with new-onset atrial fibrillation during a median 6-year follow-up. When people were categorized into three groups according to B-type natriuretic peptide clinical thresholds (20 and 100 pg/ml), hazard ratios for the development of atrial fibrillation in the middle and highest B-type natriuretic peptide groups were 2.8 and 9.4, respectively, compared with the lowest B-type natriuretic peptide group. Time-dependent receiver-operating curve analysis identified a threshold for B-type natriuretic peptide to detect atrial fibrillation development of 52.8 pg/ml (sensitivity 75.2%, specificity 68.8%). The B-type natriuretic peptide predictive value was independent of and similar to that of left atrial size and ventricular dimension.

CONCLUSION

In people with Type 2 diabetes, high baseline B-type natriuretic peptide levels were significantly associated with future atrial fibrillation development.

Impact of intra-arterial chemotherapy including internal carotid artery for advanced paranasal sinus cancers involving the skull base

Background:

The most significant problem of intra-arterial chemotherapy for advanced paranasal sinus carcinomas and residual cancers supplied by internal carotid artery (ICA) and involving the skull base is the lack of salvage therapies.

Objective:

The objective of the study was to evaluate the usefulness of intra-arterial chemotherapy including ICA infusion for treating advanced paranasal sinus carcinomas, which have invaded the skull base.

Methods:

Forty-six patients with advanced paranasal sinus carcinomas supplied by ICA were treated by intra-arterial chemotherapy using CDDP and sodium thiosulphate (STS) as a neutraliser of CDDP toxicity. After evaluating CT angiography, 150 mg m⁻² of CDDP was superselectively administered weekly to each feeding artery including ICA four times.

Results:

The 10-year overall survival rate and progression-free survival rate were 70.7 and 60.2%, respectively. Compared with control group without infusing ICA, recurrences at anterior skullbase or anterior ethomoid sinus were significantly diminished. Of 32 patients in which the orbital apex had been invaded, 29 patients were treated with successful preservation of orbital contents. The CT angiography could efficiently determine all feeding arteries supplying the cancers. Consequently, chemotherapy could be administered on schedule, and side effects were minimal and acceptable.

Conclusions:

This new method has promising applications in the treatment of advanced paranasal sinus carcinomas involving the skull base.