Mortality risk factors and fulminant sub-phenotype in anaerobic bacteremia: a 10-year retrospective, multicenter, observational cohort study

PURPOSE

During the last decade, the incidence of anaerobic bacteremia (AB) has been increasing. Patients with AB may develop complex underlying diseases, which can occasionally be accompanied by fatal or fulminant outcomes. However, the risk factors for AB-related mortality remain unclear. Herein, we sought to elucidate the risk factors for AB-related mortality.

METHODS

In this multicenter, retrospective, observational study, we enrolled patients with culture-proven AB from six tertiary hospitals in Japan, between January 2012 and December 2021. Data on patient and infection characteristics, laboratory findings, treatment, and outcome were collected, and their associations with mortality were analyzed.

RESULTS

A total of 520 participants were included. The 30-day mortality in the study cohort was 14.0% (73 patients), and malignant tumors were frequently observed comorbidities in 48% of the entire cohort. Multivariable logistic regression analysis showed a Charlson comorbidity score of > 6, serum creatinine level of > 1.17 mg/dL, and hypotension to be independent risk factors for 30-day mortality in AB (odds ratios [ORs] 2.12, 2.25, and 5.12, respectively; p < 0.05), whereas drainage significantly reduced this risk (OR, 0.28; p < 0.0001). Twelve patients (2.3% of the whole cohort and 16.4% of the deceased patients) presented with extremely rapid progression leading to fatal outcome, consistent with "fulminant AB."

CONCLUSIONS

This study identified acute circulatory dysfunction and performance of drainage as independent predictive factors for 30-day AB-related mortality and revealed the existence of a fulminant AB sub-phenotype. Our findings could serve as a practical guide to predict the clinical outcomes of AB.

Pathophysiological role of right ventricular function and interventricular functional mismatch in the development of pulmonary edema in acute heart failure

BACKGROUND

Parameters of cardiac function related to the development of pulmonary edema (PE) in acute heart failure (AHF), including right ventricular (RV) function and a mismatch of interventricular function, are not fully elucidated. The aim of this study was to verify the hypothesis that a relatively preserved RV function compared with left ventricular function may be associated with the development of PE by using two-dimensional speckle tracking echocardiography (2DSTE).

METHODS

Hospitalized patients with AHF at 11 institutions were enrolled. PE was defined as lung congestion on chest X-ray with hypoxemia. Patients with systolic blood pressure ≥140 mmHg on admission were defined to have hypertensive AHF. Echocardiographic analyses, including 2DSTE, were performed prior to discharge. The index of mismatch between RV and left ventricular systolic function was assessed by interventricular longitudinal strain difference (IVLSD) which was defined as RV free wall longitudinal strain and left ventricular global longitudinal strain.

RESULTS

Of 610 patients with AHF, 422 (69.2%) had PE. In patients with PE, IVLSD (p = 0.007) and RV fractional area change ratio (p<0.001) was significantly higher than those in patients without PE. In patients with non-hypertensive AHF, RV fractional area change ratio, age, ischemic etiology, and serum brain natriuretic peptide (BNP) levels were independent predictors of PE. In patients with hypertensive AHF, IVLSD, age, and serum BNP levels were independent predictors of PE.

CONCLUSIONS

Preserved RV function might be one of the underlying mechanisms of the development of PE in AHF. Furthermore, interventricular functional mismatch might be related to the development of PE in hypertensive AHF.

Comparison of Soluble ST2, Pentraxin-3, Galectin-3, and High-Sensitivity Troponin T of Cardiovascular Outcomes in Patients With Acute Decompensated Heart Failure

BACKGROUND

Data regarding a direct comparison of soluble suppression of tumorigenesis-2 (sST2), pentraxin 3 (PTX3), galectin-3 (Gal-3), and high-sensitivity troponin T of cardiovascular outcome in patients with heart failure (HF) are lacking.

METHODS AND RESULTS

A total of 616 hospitalized patients with HF were evaluated prospectively. Biomarker data were obtained in the stable predischarge condition. sST2 levels were associated with age, sex, body mass index, inferior vena cava diameter, B-type natriuretic peptide (BNP), PTX3, C-reactive protein, and Gal-3 levels. During follow-up, 174 (28.4%) primary composite end points occurred, including 58 cardiovascular deaths and 116 HF rehospitalizations. sST2 predicted the end point after adjustment for 13 clinical variables (hazard ratio 1.422; 95% confidence interval [CI] 1.064 to 1.895, P = .018). The association between sST2 and the end point was no longer statistically significant after adjustment for BNP (P = .227), except in the subgroup of patients with preserved ejection fraction (hazard ratio 1.925, 95% CI 1.102-3.378, P = .021). Gal-3 and high-sensitivity troponin T predicted the risk for the end point after adjustment for age and sex, but were not significant after adjustment for clinical variables. The prognostic value of PTX3 was not observed (age and sex adjusted, P = .066).

CONCLUSIONS

This study did not show significant additional value of biomarkers to BNP for risk stratification, except sST2 in patients with preserved ejection fraction.

The Usefulness and Limitations of Impedance Cardiography for Cardiac Resynchronization Therapy Device Optimization

Identifying the optimal atrioventricular (AV) or interventricular (VV) delay is beneficial for patients using cardiac resynchronization therapy (CRT) devices. Ultrasonic echocardiography (UCG) has been the most commonly used method; however, it requires high technical knowledge. Impedance cardiography (ICG) can calculate stroke volume by measuring changes in transthoracic electric impedance. This study sought to assess the clinical utility of ICG in comparison with that of UCG for the optimization of CRT devices.Patients who underwent CRT device implantation were retrospectively analyzed. One week after implantation, optimization of AV delay (AVD) was performed in every patient with ICG (AVD-ICG) and UCG (AVD-UCG). VV delay (VVD) was then determined according to the optimal AVD using these two methods.Forty-two patients were enrolled. Average AVD-ICG was significantly shorter than AVD-UCG (128 ± 49 versus 146 ± 41 milliseconds, P = 0.018). Five patients (12%) had the same optimized AVD with two methods, and the difference between AVD-ICG and AVD-UCG was ≤ 20 milliseconds in 19 patients (45%). In the multivariate analysis, the presence of postoperative mitral regurgitation (MR) was an independent predictor of AVD-ICG/AVD-UCG mismatch, defined as a difference over 20 milliseconds (odds ratio = 10.71; 95% confidence interval = 1.72 to 66.72; P = 0.018). The results of optimized VVD were similar using both methods.ICG might be a promising tool for the rapid optimization of CRT devices. However, in patients with moderate-to-severe MR, ICG may not be able to optimize AVD.

Clinical significance of the presence of puff-chandelier ruptures detected by nonobstructive aortic angioscopy

OBJECTIVE

This study aimed to investigate the prevalence and prognostic significance of atherosclerotic aortic plaques (AAPs) or specific AAP types detected by nonobstructive angioscopy (NOA) in patients who underwent percutaneous coronary intervention (PCI).

BACKGROUND

Although recent studies have reported the presence of various patterns of AAPs, identified by NOA, the clinical significance of the presence of AAPs remains elusive.

METHODS

In this retrospective, multicenter cohort study, a total of 167 patients who underwent PCI and intra-aortic scans with NOA were studied. The association between AAPs and the incidence of major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, stroke, and clinically driven unplanned revascularizations, was assessed.

RESULTS

AAPs were detected in 126 patients (75%) who underwent NOA. MACEs occurred in 28 (17%) patients during the follow-up (median 2.9 years [range 2.1-3.8]). Among all types of AAPs, only puff-chandelier rupture (PCR) showed a significant difference in frequency between patients with and those without MACEs: 21 (75%) and 49 (35%), respectively (p < .001). Multivariable Cox proportional hazard analysis revealed that PCR (hazard ratio [HR] 3.73, 95% confidence interval [CI] 1.57-8.87, p = .004) and chronic kidney disease (HR 2.97, 95% CI 1.37-6.44, p = .010) were independent predictors of MACEs. Kaplan-Meier analysis revealed that PCR was significantly associated with more frequent MACEs.

CONCLUSION

The detection of PCR in the aorta using NOA was significantly associated with an increased risk of subsequent adverse events after PCI.

Incremental Prognostic Value of Right Ventricular Strain in Patients With Acute Decompensated Heart Failure

BACKGROUND

Although 2-dimensional strain analyses based on speckle tracking echocardiography have been used to detect myocardial deformation, the prognostic impact of 2-dimensional strain is unclear in patients with acute decompensated heart failure (HF). We investigated whether left ventricular and right ventricular (RV) strain parameters assessed by speckle tracking echocardiography provide incremental prognostic information in hospitalized patients because of acute decompensated HF.

METHODS AND RESULTS

Six hundred eighteen patients (age, 72±13 years; 38% women; ejection fraction, 46±16%) hospitalized for acute decompensated HF underwent clinical and echocardiographic evaluation just before discharge. We performed strain analyses of left ventricular global longitudinal strain and left ventricular global circumferential strain. We also analyzed RV longitudinal strain only from the free wall (RV-fwLS) and from all segments of the RV global longitudinal strain wall by using Tomtec software. The primary composite end point was cardiovascular death and readmission for HF. There were 34.8% cardiac events during a median follow-up of 427 days. In multivariate Cox models, among echocardiographic parameters, only impaired RV-fwLS (≥-13.1%; hazard ratio, 1.51; 95% CI, 1.12-2.04; P=0.01) was independently associated with cardiac events. Adding RV-fwLS to clinical risk evaluation (age, New York Heart Association class III/IV, blood urea nitrogen, and brain natriuretic peptide) markedly improved prognostic utility and consequently increased net reclassification improvement by 0.30 ( P=0.01).

CONCLUSIONS

RV-fwLS is an independent predictor of cardiac events in acute decompensated HF and provides greater prognostic power than standard echocardiographic parameters.

Clinical utility of the 2016 ASE/EACVI recommendations for the evaluation of left ventricular diastolic function in the stratification of post-discharge prognosis in patients with acute heart failure

Aims

Left ventricular diastolic dysfunction (LVDD) has prognostic significance in heart failure (HF). We aimed to assess the impact of LVDD grade stratified by the updated 2016 echocardiographic algorithm (DD2016) on post-discharge outcomes in patients admitted for acute HF and compare with the previous 2009 algorithm (DD2009).

Methods and results

The study included 481 patients hospitalized for acute decompensated HF. Comprehensive echocardiography and LVDD evaluation were performed just before hospital discharge. The primary endpoint was a composite of cardiovascular death and readmission for HF. The concordance between DD2016 and DD2009 was moderate (κ = 0.44, P < 0.001); the reclassification rate was 39%. During the follow-up (median: 15 months), 127 (26%) patients experienced the primary endpoint. In the Kaplan–Meier analysis, Grade III in DD2016 showed a lower event-free survival rate than Grades I and II (log rank, P < 0.001 and P = 0.048, respectively) and was independently associated with a higher incidence of the primary endpoint than Grade I [hazard ratio 1.89; 95% confidence interval (CI) 1.17–3.04; P = 0.009]. Grade II or III in DD2016, reflecting elevation of left ventricular (LV) filling pressure, added an incremental predictive value of the primary endpoint to clinical variables irrespective of LV ejection fraction. DD2016 was comparable to DD2009 in predicting the endpoint (net reclassification improvement = 11%; 95% CI −7% to 30%, P = 0.23).

Conclusion

Despite simplification of the algorithm for LVDD evaluation, the prognostic value of DD2016 for post-discharge cardiovascular events in HF patients was maintained and not compromised in comparison with DD2009.

Prognostic Value of Phase-Contrast Cine-Magnetic Resonance Imaging-Derived Global Coronary Flow Reserve in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome Treated With Urgent Percutaneous Coronary Intervention

BACKGROUND

Phase-contrast cine-magnetic resonance imaging (PC-CMR) of the coronary sinus (CS) is a promising approach for quantifying coronary sinus flow (CSF) and global coronary flow reserve (G-CFR). We evaluated the prognostic value of G-CFR using PC-CMR in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).Methods and Results:The study prospectively enrolled 116 NSTE-ACS patients who underwent uncomplicated urgent PCI within 48 h of symptom onset. Post-PCI (median, 20 days) PC-CMR images of the CS were acquired to assess absolute CSF at rest and during maximum hyperemia. The association of G-CFR with major adverse cardiac events (cardiac death, nonfatal myocardial infarction, late revascularization, or hospitalization for congestive heart failure) was investigated. Rest and maximal hyperemic CSF and corrected G-CFR were 1.27 [interquartile range, 0.79-1.73] mL/min/g, 2.95 [2.02-3.84] mL/min/g, and 2.42 [1.69-3.34], respectively. At a median follow-up of 17 months, cardiac event-free survival was significantly worse in patients with a corrected G-CFR <2.33 (log-rank χ²=19.5, P<0.001). Cox proportional-hazards analysis showed that corrected G-CFR (hazard ratio, 0.434, 95% CI, 0.270-0.699, P<0.001) and NT-pro BNP at admission (hazard ratio, 1.0001, 95% CI, 1.0000-1.0001, P=0.007) were independent predictors of adverse cardiac events during follow-up.

CONCLUSIONS

In NSTE-ACS patients successfully revascularized within 48 h of onset, post-PCI PC-CMR-derived G-CFR provided significant prognostic information independent of infarct size and conventional risk scores.

Geriatric nutritional risk index predicts all-cause deaths in heart failure with preserved ejection fraction

AIMS

The objective of the study was to evaluate whether the geriatric nutritional risk index (GNRI) at discharge may be helpful in predicting the long-term prognosis of patients hospitalized with heart failure (HF) with preserved ejection fraction (HFpEF, left ventricular ejection fraction ≥50%), a common HF phenotype in the elderly.

METHODS AND RESULTS

Overall, 110 elderly HFpEF patients (≥65 years) from the Ibaraki Cardiovascular Assessment Study-HF (n = 838) were enrolled. The mean age was 78.5 ± 7.2 years, and male patients accounted for 53.6% (n = 59). All-cause mortality was compared between the low GNRI (<92) with moderate or severe nutritional risk group and the high GNRI (≥92) with no or low nutritional risk group. Cox proportional hazard regression models were constructed to evaluate the influence of the GNRI on all-cause death with the following covariates using forward stepwise selection: age, sex, nutritional status based on the GNRI as a categorical variable, history of HF hospitalization, haemoglobin level, estimated glomerular filtration rate, log brain natriuretic peptide levels (logBNP), history of hypertension, log C-reactive protein levels, left ventricular ejection fraction, left ventricular mass index, and the New York Heart Association functional classification (I/II or III class). The prognostic value of the GNRI was compared with that of serum albumin using C-statistics. The GNRI was added to the logBNP, serum albumin or the body mass index was added to the logBNP, and the C-statistic was compared using DeLong's test. Cox regression analysis revealed that age and a low GNRI were independent predictors of all-cause death (P < 0.05, n = 103; hazard ratio = 1.095, 95% confidence interval = 1.031-1.163, for age, and hazard ratio = 3.075, 95% confidence interval = 1.244-7.600, for the GNRI). DeLong's test for the two correlated receiver operating characteristic curves [area under the receiver operating characteristic curve (AUROC) of serum albumin, 0.71; AUROC of the GNRI, 0.75] demonstrated significant differences between the groups (P = 0.038). Adding the GNRI to the logBNP increased the AUROC for all-cause death significantly (0.71 and 0.80, respectively; P = 0.040, n = 105). The addition of serum albumin or the body mass index to the logBNP did not significantly increase the AUROC for all-cause death (P = 0.082 and P = 0.29, respectively).

CONCLUSIONS

Nutritional screening using the GNRI at discharge is helpful to predict the long-term prognosis of elderly HFpEF patients.

Impact of regional functional ischemia on global coronary flow reserve in patients with stable coronary artery disease

BACKGROUND

Global coronary flow reserve (g-CFR) provides powerful prognostic information. The relationship between g-CFR and the regional physiological indices of fractional flow reserve (FFR), coronary flow reserve (r-CFR), and the index of microcirculatory resistance remains undetermined. This study aimed to assess the relationship between regional and global physiological indices and determinants of cardiovascular magnetic resonance imaging (CMR)-derived g-CFR.

METHODS

A total of 151 patients with single de novo intermediate to stenotic epicardial lesions referred for diagnostic invasive coronary angiography who underwent phase-contrast cine CMR of the coronary sinus (CS) were included. g-CFR was calculated as the ratio of hyperemic and resting CS flow (CSF). Regional and global physiological parameters were compared, and determinants of g-CFR were assessed.

RESULTS

There was a weak linear relationship between FFR and g-CFR (R²=0.04, p=0.013), while r-CFR and g-CFR, or combinations of the other regional-global indices were not significantly correlated. When patients were divided into two groups by FFR of 0.80, there were also no significant differences in global physiological indices between the groups (FFR≤0.80 vs. FFR>0.80; g-CFR: 2.73 vs. 2.61, p=0.48; hyperemic CSF: 3.32 vs. 3.52ml/min/g, p=0.84). Higher high-sensitivity cardiac troponin-I (hs-cTnI) and higher resting CS flow were independently associated with impaired g-CFR, and the combination could efficiently identify patients with g-CFR<2.0.

CONCLUSIONS

Given weak relationship among global and regional physiological indices, these indices may provide complementary efficacy for prognostication in patients with single-vessel stable coronary artery disease. Combination of hs-cTnI and resting CS flow could estimate g-CFR without pharmacological hyperemic induction.

Impact of Elective Percutaneous Coronary Intervention on Global Absolute Coronary Flow and Flow Reserve Evaluated by Phase-Contrast Cine-Magnetic Resonance Imaging in Relation to Regional Invasive Physiological Indices

Background:

Few studies have documented changes in global absolute coronary blood flow and global coronary flow reserve after percutaneous coronary intervention (PCI) in relation to regional physiological measures. Phase-contrast cine-magnetic resonance of the coronary sinus is a promising approach to quantify global absolute coronary blood flow. We aimed to assess the impact of elective PCI on global absolute coronary blood flow and global coronary flow reserve by quantifying coronary sinus flow (CSF) using phase-contrast cine-magnetic resonance in relation to regional physiological indices.

Methods and Results:

We prospectively studied 54 patients with stable angina undergoing elective PCI for a single proximal lesion. Phase-contrast cine-magnetic resonance was used to assess CSF and CSF reserve at rest and during maximum hyperemia, before and after PCI. Regional physiological indices were obtained during PCI. A complete data set was obtained in 50 patients. Hyperemic CSF increased significantly after PCI (pre-PCI, 230.2 [167.4–282.8] mL/min; post-PCI, 267.4 [224.1–346.2] mL/min; P <0.01), although 12 patients (24.0%) showed a decrease, despite successful PCI and improved fractional flow reserve. CSF reserve numerically, albeit not statistically significant ( P =0.19), increased from 2.65 (1.95–3.96) to 2.98 (2.13–4.32). Patients with decreased CSF after PCI were associated with significantly greater pre-PCI hyperemic CSF, lower global coronary vascular resistance, lower regional microcirculatory resistance, and higher fractional flow reserve (all P <0.01).

Conclusions:

Fractional flow reserve–guided PCI in patients with single de novo lesions was associated with increased absolute hyperemic CSF, although 24% of patients showed decreased hyperemic CSF, despite successful and uncomplicated PCI. The present approach combining regional and global physiological assessments may provide a novel insight into the dynamic behavior of the coronary hemodynamics and microvascular function after PCI.

Utility of Nutritional Screening in Predicting Short-Term Prognosis of Heart Failure Patients

Controlling nutritional status (CONUT) uses 2 biochemical parameters (serum albumin and cholesterol level), and 1 immune parameter (total lymphocyte count) to assess nutritional status. This study examined if CONUT could predict the short-term prognosis of heart failure (HF) patients.A total of 482 (57.5%) HF patients from the Ibaraki Cardiovascular Assessment Study-HF (n = 838) were enrolled (298 men, 71.7 ± 13.6 years). Blood samples were collected at admission, and nutritional status was assessed using CONUT. CONUT scores were defined as follows: 0-1, normal; 2-4, light; 5-8, moderate; and 9-12, severe degree of undernutrition. Accordingly, 352 (73%) patients had light-to-severe nutritional disturbances. The logarithmically transformed plasma brain natriuretic peptide (log BNP) concentration was significantly higher in the moderate-severe nutritional disturbance group (2.92 ± 0.42) compared to the normal group (2.72 ± 0.45, P < 0.01). CONUT scores were significantly higher in the in-hospital death patients [4 (3-8), n = 14] compared with patients who were discharged following symptom alleviation [3 (1-5), n = 446, P < 0.05]. With the exception of transferred HF patients (n = 22), logistic regression analysis that incorporated the CONUT score and the log BNP, showed that a higher CONUT score (P = 0.019) and higher log BNP (P = 0.009) were predictors of in-hospital death, and the median duration of hospital stay was 20 days.Our results demonstrate the usefulness of CONUT scores as predictors of short-term prognosis in hospitalized HF patients.

Effect of Dipeptidyl Peptidase-4 Inhibitors on Cardiovascular Outcome and Cardiac Function in Patients With Diabetes and Heart Failure - Insights From the Ibaraki Cardiac Assessment Study-Heart Failure (ICAS-HF) Registry

BACKGROUND

Although experimental animal studies report many pleiotropic effects of dipeptidyl peptidase-4 inhibitors (DPP-4i), their prognostic value has not been demonstrated in clinical trials.Methods and Results:Among 838 prospectively enrolled heart failure (HF) patients hospitalized for acute decompensated HF, 79 treated with DPP-4i were compared with 79 propensity score-matched non-DPP-4i diabetes mellitus (DM) patients. The primary endpoint was all-cause mortality; the secondary endpoint was a composite of cardiovascular death and hospitalization. During follow-up (423±260 days), 8 patients (10.1%) in the DPP-4i group and 13 (16.5%) in the non-DPP-4i group died (log-rank, P=0.283). The DPP-4i group did not have a significantly higher rate of all-cause mortality (log-rank, P=0.283), or cardiovascular death or hospitalization (log-rank, P=0.425). In a subgroup analysis of HF with preserved ejection fraction (HFpEF; n=75), the DPP-4i group had a significantly better prognosis than the non-DPP-4i group regarding the primary endpoint (log-rank, P=0.021) and a tendency to have better prognosis regarding the secondary endpoint (log-rank, P=0.119). In patients with HF with reduced EF (n=83), DPP-4i did not result in better prognosis.

CONCLUSIONS

DPP-4i did not increase the risk of adverse clinical outcomes in patients with DM and HF. DPP-4i may be beneficial in HFpEF.

Nutritional screening based on the controlling nutritional status (CONUT) score at the time of admission is useful for long-term prognostic prediction in patients with heart failure requiring hospitalization

The objective of the study was to clarify whether controlling nutritional status (CONUT) is useful for predicting the long-term prognosis of patients hospitalized with heart failure (HF). A total of 482 (57.5%) HF patients from the Ibaraki Cardiovascular Assessment Study-HF (N = 838) were enrolled (298 men, 71.7 ± 13.6 years). At admission, blood samples were collected and nutritional status assessed using CONUT. CONUT scores were defined as follows: 0-1, normal; 2-4, light; 5-8, moderate; and 9-12, severe undernutrition. Accordingly, 352 (73%) patients had light-to-severe nutritional disturbances. In the follow-up period [median 541.5 (range 354-786) days], 109 deaths were observed. A Kaplan-Meier analysis revealed that all-cause deaths occurred more frequently in HF patients with nutritional disturbances [n = 93 (26.4%)] than in those with normal nutrition [n = 16 (12.3%); log-rank p < 0.001]. The Cox proportional hazard analyses revealed that a per point increase in the CONUT score was associated with an increased risk of all-cause death (hazard ratio 1.142; 95% confidence interval, 1.044-1.249) after controlling simultaneously for age, sex, previous history of HF hospitalization, log brain natriuretic peptide, and use of therapeutic agents at admission (tolvaptan and aldosterone antagonists). This study suggests that nutritional screening using CONUT scores is helpful in predicting the long-term prognosis of patients hospitalized with HF in a multicenter registry setting.

Optimal cut-off value of reverse remodeling to predict long-term outcome after cardiac resynchronization therapy in patients with ischemic cardiomyopathy

BACKGROUND

Whether the optimal cut-off value of left ventricular (LV) reverse remodeling is different in patients with ischemic cardiomyopathy (ICM) vs. non-ischemic cardiomyopathy (NICM) is unclear. This study aimed to clarify this value in patients with ICM and NICM.

METHODS AND RESULTS

LV reverse remodeling was defined as a reduction in LV end-systolic volume (LVESV) at 6 months after cardiac resynchronization therapy (CRT). The clinical endpoint was the combination of cardiac death and first hospitalization for worsening heart failure. Ninety-one of 372 patients had ICM. Event-free survival rates did not differ between ICM and NICM groups (66.8% vs. 78.9%; p=0.12). Receiver operating characteristics analysis revealed a 9% reduction in ESV as the optimal cut-off value to predict the composite endpoint in patients with ICM and a 15% reduction in patients with NICM. Multivariate analysis revealed that reductions in ESV of ≥15% and ≥9% were independent predictors of the composite endpoint, as were left bundle branch block (LBBB) and B-type natriuretic peptide (BNP) at 6 months after CRT. In combination with LBBB and BNP, reduction in ESV ≥9% had a higher, but not significant, C-statistics value than ESV ≥15% (0.854, 95% CI 0.729-0.940 vs. 0.801, 95% CI 0.702-0.908, p=0.07).

CONCLUSION

The optimal cut-off value of a reduction in LVESV was lower in patients with ICM than in patients with NICM.

Enhancement patterns detected by multidetector computed tomography are associated with microvascular obstruction and left ventricular remodelling in patients with acute myocardial infarction

AIMS

This study evaluated the clinical value of myocardial contrast-delayed enhancement (DE) with multidetector computed tomography (MDCT) for detecting microvascular obstruction (MVO) and left ventricular (LV) remodelling revealed by DE magnetic resonance imaging after acute myocardial infarction (AMI).

METHODS AND RESULTS

In 92 patients with first AMI, MDCT without iodine reinjection was performed immediately following successful percutaneous coronary intervention (PCI). Delayed-enhancement magnetic resonance imaging performed in the acute and chronic phases was used to detect MVO and LV remodelling (any increase in LV end-systolic volume at 6 months after infarction compared with baseline). Patients were divided into two groups according to the presence (n = 33) or absence (n = 59) of heterogeneous enhancement (HE). Heterogeneous enhancement was defined as concomitant presence of hyper- and hypoenhancement within the infarcted myocardium on MDCT. Microvascular obstruction and LV remodelling were detected in 49 (53%) and 29 (32%) patients, respectively. In a multivariable analysis, HE and a relative CT density >2.20 were significant independent predictors for MVO [odds ratio (OR) 13.5; 95% confidence interval (CI), 2.15-84.9; P = 0.005 and OR 12.0; 95% CI, 2.94-49.2; P < 0.001, respectively). The presence of HE and relative CT density >2.20 showed a high positive predictive value of 93%, and the absence of these two findings yielded a high negative predictive value of 90% for the predictive value of MVO. Heterogeneous enhancement was significantly associated with LV remodelling (OR 6.75; 95% CI, 1.56-29.29; P = 0.011).

CONCLUSION

Heterogeneous enhancement detected by MDCT immediately after primary PCI may provide promising information for predicting MVO and LV remodelling in patients with AMI.

Prognostic significance of persistent restrictive filling pattern after cardiac resynchronization therapy

BACKGROUND

Cardiac resynchronization therapy (CRT) may improve left ventricular (LV) diastolic dysfunction as well as systolic dysfunction. Diastolic dysfunction is a key for prognosis in patients with heart failure; therefore, we aimed to clarify the impact of CRT on diastolic function and prognosis.

METHODS

In 67 patients who underwent CRT, LV diastolic function was assessed by pulsed Doppler transmitral flow pattern at baseline and 1 week after CRT, and classified into restrictive filling pattern (RFP) and non-RFP groups. Volume responders were defined by reduction of LV end-systolic volume >15% at 6 months after CRT. The clinical endpoint comprised death from any cause or unplanned hospitalization for a major cardiovascular event (MACE).

RESULTS

During the follow-up period (479 ± 252 days), 26 patients (38.8%) had reached the endpoint of MACE. In Cox proportional hazard analyses, RFP at 1 week after CRT was associated with the endpoints independently of age and New York Heart Association (NYHA) class IV at baseline. Thirty (44.8%) patients were identified as volume responders, who had better prognosis than non-responders. Patients were classified into 4 groups based on their filling pattern at 1 week after CRT and volume responses. The worst prognosis was observed in the RFP and non-responder group, and the best was observed in the non-RFP and responder group. For the remaining 2 groups with intermediate prognosis, the RFP and responder group showed poorer prognosis compared to the non-RFP and non-responder group.

CONCLUSIONS

Persistent RFP after CRT may be a strong prognostic predictor, which should be treated with more intensive therapy to improve the prognosis of patients following CRT.

Cardiac resynchronization therapy in a patient with a failing systemic right ventricle

Systemic right ventricular dysfunction is 1 of the late complications of the atrial switch operation for transposition of the great arteries. It has been reported that cardiac resynchronization therapy (CRT) for the failing systemic right ventricle (RV) improves symptoms and systolic function. However, patient selection for CRT in congenital heart disease is still challenging because the clinical standard for CRT in these patients is not established. We describe a case of successful implantation of a CRT device for a failing systemic RV aided by multimodality imaging and cardiac hemodynamic studies.

Efficacy, safety, and outcomes of catheter ablation of atrial fibrillation in patients with heart failure with preserved ejection fraction

OBJECTIVES

This study sought to investigate the efficacy and safety of catheter ablation for atrial fibrillation (AF) in patients with heart failure with preserved ejection fraction (HFPEF).

BACKGROUND

AF is a precipitating factor for clinical deterioration of HFPEF.

METHODS

Catheter ablation for AF was performed in a consecutive 74 patients with compensated HFPEF (left ventricular [LV] ejection fraction >50%). AF-free probability after catheter ablation and factors relating to maintenance of sinus rhythm were investigated. LV strain and strain rate were assessed by echocardiography at baseline and over 12 months after ablation.

RESULTS

During a 34 ± 16-month follow-up period, single- and multiple-procedure drug-free success rates were 27% (n = 20) and 45% (n = 33), respectively. Multiple procedures and pharmaceutically assisted success rate was 73% (n = 54). No major complications occurred during follow-up. Multivariate Cox regression analyses revealed that AF type (other than long-standing persistent AF) and lack of hypertension were independently associated with maintenance of sinus rhythm (hazard ratio [HR]: 1.81, 95% confidence interval [CI]: 1.03 to 3.17, p = 0.04; HR: 0.49, 95% CI: 0.24 to 0.96, p = 0.04, respectively). LV systolic indices (LV ejection fraction, LV strain/strain rate at systole) and diastolic indices (E/E', ratio of LV strain rate at diastole with early transmitral flow) were improved only in patients maintaining sinus rhythm at follow-up.

CONCLUSIONS

Our results suggest that AF can be effectively and safely treated with a composite of repeat procedures and pharmaceuticals in patients with HFPEF. However, the current study was a single-arm analysis; therefore, larger randomized control studies are needed to verify the benefit of AF ablation in this cohort.