RELATIVE TELOMERE LENGTH OF PERIPHERAL BLOOD LYMPHOCYTES AND STRUCTURAL AND FUNCTIONAL STATE OF THE LEFT VENTRICLE MYOCARDIUM IN CLEAN-UP WORKERS OF THE CHORNOBYL ACCIDENT WHO SUFFERED FROM STENOTIC CORONARY ATHEROSCLEROSIS

The objective was to analyze the relative telomere length (RTL) of peripheral blood lymphocytes depending onmyocardium structural and functional state in emergency workers (EW) of the Chornobyl accident who suffered fromcoronary arteries stenotic atherosclerosis.

MATERIALS AND METHODS

There were examined 60 male EW who operated at the Chornobyl nuclear power plant at1986 and 25 male non-irradiated persons (control group - CG) with coronary heart disease (CHD). Everyone EW andCG patients were almost healthy before the accident. During the period 2016-2021, they underwent a comprehen-sive clinical and laboratory examination, echodopplercardiographic examination and determination of RTL by fluo-rescent hybridization in situ using laser flow cytometry.

RESULTS

EW almost did not differ from CG according to its clinical characteristics, the presence of risk factors,indices of systolic and diastolic heart functions, as well as RTL. The analysis of variance showed that RTL was influ-enced by the fact of irradiation in combination with obesity (p = 0.020). At normal body weight, RTL average valuein CG was significantly higher than in EW (p = 0.023). According to the results of hierarchical cluster analysis of twovariables as RTL and end-diastolic volume normalized by body surface area (EDV/BSA), EW and CG patients togeth-er were divided into two subgroups. The first subgroup (1st cluster) differed from the second (2nd cluster) by signi-ficantly larger average values of left ventricle (LV) EDV and end-systolic volume (ESV) as well as EDV/BSA andESV/BSA, LV myocardial mass (MM) and MM/BSA, reduced ejection fraction (EF). In patients of the 1st cluster telom-eres were significantly shorter than in the 2nd one (10,3 ± 1.7 vs. 14.3 ± 2.0 at p = 0.000). The increase of myocar-dial mass and LV wall thickness caused the development of its hypertrophy. The number of people with hypertrophyLV was significantly higher among patients of the 1st cluster (91.6 vs. 67.2 %, p < 0.001) due to eccentric hypertro-phy LV. Accordingly, concentric hypertrophy LV was more common among patients in the 2nd cluster (24.6 vs. 4.2 %at p < 0.01). Patients of the 1st cluster was characterized by a more severe course of heart failure.

CONCLUSIONS

In patients who suffered from CHD with stenotic atherosclerosis of the coronary arteries and wereexposed to radiation 30-35 years earlier, having normal body weight, there was a reduction in telomere. Hierarchicalcluster analysis proved to be a good tool that allows by the value of RTL and EDV/BSA to separate the group ofpatients with the most severe clinical course of CHD and LV systolic dysfunction among patients with the samepathology.

Hemodynamic Heterogeneity of Reduced Cardiac Reserve Unmasked by Volumetric Exercise Echocardiography

Background: Two-dimensional volumetric exercise stress echocardiography (ESE) provides an integrated view of left ventricular (LV) preload reserve through end-diastolic volume (EDV) and LV contractile reserve (LVCR) through end-systolic volume (ESV) changes. Purpose: To assess the dependence of cardiac reserve upon LVCR, EDV, and heart rate (HR) during ESE. Methods: We prospectively performed semi-supine bicycle or treadmill ESE in 1344 patients (age 59.8 ± 11.4 years; ejection fraction = 63 ± 8%) referred for known or suspected coronary artery disease. All patients had negative ESE by wall motion criteria. EDV and ESV were measured by biplane Simpson rule with 2-dimensional echocardiography. Cardiac index reserve was identified by peak-rest value. LVCR was the stress-rest ratio of force (systolic blood pressure by cuff sphygmomanometer/ESV, abnormal values ≤2.0). Preload reserve was defined by an increase in EDV. Cardiac index was calculated as stroke volume index * HR (by EKG). HR reserve (stress/rest ratio) <1.85 identified chronotropic incompetence. Results: Of the 1344 patients, 448 were in the lowest tertile of cardiac index reserve with stress. Of them, 303 (67.6%) achieved HR reserve <1.85; 252 (56.3%) had an abnormal LVCR and 341 (76.1%) a reduction of preload reserve, with 446 patients (99.6%) showing ≥1 abnormality. At binary logistic regression analysis, reduced preload reserve (odds ratio [OR]: 5.610; 95% confidence intervals [CI]: 4.025 to 7.821), chronotropic incompetence (OR: 3.923, 95% CI: 2.915 to 5.279), and abnormal LVCR (OR: 1.579; 95% CI: 1.105 to 2.259) were independently associated with lowest tertile of cardiac index reserve at peak stress. Conclusions: Heart rate assessment and volumetric echocardiography during ESE identify the heterogeneity of hemodynamic phenotypes of impaired chronotropic, preload or LVCR underlying a reduced cardiac reserve.

Assessment of four different cardiac softwares for evaluation of LVEF with CZT-SPECT vs CMR in 48 patients with recent STEMI

PURPOSE

To compare, vs CMR, four softwares: quantitative gated SPECT (QGS), myometrix (MX), corridor 4DM (4DM), and Emory toolbox (ECTb) to evaluate left ventricular ejection fraction (LVEF), end-systolic (ESV), and end-diastolic volumes (EDVs) by gated MPI CZT-SPECT.

METHODS

48 patients underwent MPI CZT-SPECT and CMR 6 weeks after STEMI, LV parameters were measured with four softwares at MPI CZT-SPECT vs CMR. We evaluated (i) concordance and correlation between MPI CZT-SPECT and CMR, (ii) concordance MPI CZT-SPECT/CMR for the categorical evaluation of the left ventricular dysfunction, and (iii) impacts of perfusion defects > 3 segments on concordance.

RESULTS

LVEF: LCC QGS/CMR = 0.81 [+ 2.2% (± 18%)], LCC MX/CMR = 0.83 [+ 1% (± 17.5%)], LCC 4DM/CMR = 0.73 [+ 3.9% (± 21%)], LCC ECTb/CMR = 0.69 [+ 6.6% (± 21.1%)]. ESV: LCC QGS/CMR = 0.90 [- 8 mL (± 40 mL)], LCC MX/CMR = 0.90 [- 9 mL (± 36 mL)], LCC 4DM/CMR = 0.89 [+ 4 mL (± 45 mL)], LCC ECTb/CMR = 0.87 [- 3 mL (± 45 mL)]. EDV: LCC QGS/CMR = 0.70 [- 16 mL (± 67 mL)], LCC MX/CMR = 0.68 [- 21 mL (± 63 mL], LCC 4DM/CMR = 0.72 [+ 9 mL (± 73 mL)], LCC ECTb/CMR = 0.69 [+ 10 mL (± 70 mL)].

CONCLUSION

QGS and MX were the two best-performing softwares to evaluate LVEF after recent STEMI.

The correlation between myocardial perfusion scintigraphy and three-dimensional echocardiography in ejection fraction and cardiac volumes for determination of the nearest filtering parameters

End-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF) are cardiac volumes that have crucial roles in diagnosis of cardiovascular diseases (CVD) in patients. There are differences between these mentioned parameters in echocardiography (Echo) and myocardial perfusion scintigraphy (MPS) in clinical practice. In this study, we determined the nearest filtering parameters in the analysis of MPS data in comparison with three-dimensional echocardiography (3DE). All of patients were in this study, and 3DE and MPS were performed for all patients at rest phase in the same day. MPS images were analyzed through quantitative gated single photon emission computer tomography (SPECT) software with Butterworth filter which was a fixed order (order = 5) and variable cutoffs (COs) of 0.3, 0.35, 0.4, 0.45, and 0.5. The EDV, ESV, and EF values were measured by 3DE and MPS and compared. Based on the above different COs, the ESVs of MPS were 15.5 ± 18 mL, 18 ± 20 mL, 21 ± 22.5 mL, 22 ± 23 mL, and 22.5 ± 23.5 mL, respectively, while ESV of 3DE was 44.4 ± 23.5 mL. It was observed as a significant difference between MPS and 3DE for ESV. The EDVs of MPS were 61.3 ± 24.5 ml, 64 ± 26.5 ml, 68 ± 29.5 ml, 72 ± 31 ml, and 76 ± 32.2 ml, respectively, while EDV of 3DE was 105 ± 30 ml, which was significantly different between two methods. The EFs of MPS were 79% ± 14%, 76% ± 13%, 73.5% ± 12%, 73.5% ± 11%, and 74% ± 11%, respectively. The EF of 3DE was 58.4% ± 10% ml. It was statistically significant difference in values of EF between SPECT analysis parameters and 3DE. It was interesting when the COs increased from 0.3 to 0.5; the cardiac volumes increased while the EF decreased. The measured ESV and EDV values were lower in females than males while the EFs of females were higher than males. Finally, we demonstrate that the nearest Cos for measuring of EF and cardiac volumes for analysis of MPS data in comparison with 3DE are 0.45 and 0.5, respectively.

Bioabsorbable Intracoronary Matrix for Prevention of Ventricular Remodeling After Myocardial Infarction

BACKGROUND

Bioabsorbable cardiac matrix (BCM) is a novel device that attenuates adverse left ventricular (LV) remodeling after large myocardial infarctions in experimental models.

OBJECTIVES

This study aimed to analyze whether BCM, compared with saline control, would result in less LV dilation and fewer adverse clinical events between baseline and 6 months.

METHODS

In an international, randomized, double-blind, controlled trial, 303 subjects with large areas of infarction despite successful primary percutaneous coronary intervention (PCI) of ST-segment elevation myocardial infarction (STEMI) were randomized 2:1 to BCM or saline injected into the infarct-related artery 2 to 5 days after primary PCI. The primary outcome was mean change from baseline in LV end-diastolic volume index (LVEDVI) at 6 months. Secondary outcomes included change in Kansas City Cardiomyopathy Questionnaire score, 6-minute walk time, and New York Heart Association functional class at 6 months. The primary safety endpoint was a composite of cardiovascular death, recurrent MI, target-vessel revascularization, stent thrombosis, significant arrhythmia requiring therapy, or myocardial rupture through 6 months.

RESULTS

In total, 201 subjects were assigned to BCM and 102 to saline control. There was no significant difference in change in LVEDVI from baseline to 6 months between the groups (mean change ± SD: BCM 14.1 ± 28.9 ml/m(2) vs. saline 11.7 ± 26.9 ml/m(2); p = 0.49). There was also no significant difference in the secondary endpoints. The rates of the primary safety outcome were similar between the 2 groups (BCM 11.6% vs. saline 9.1%; p = 0.37).

CONCLUSIONS

Intracoronary deployment of BCM 2 to 5 days after successful reperfusion in subjects with large myocardial infarction did not reduce adverse LV remodeling or cardiac clinical events at 6 months. (IK-5001 for the Prevention of Remodeling of the Ventricle and Congestive Heart Failure After Acute Myocardial Infarction [PRESERVATION I]; NCT01226563).

Whatever Happened to Measuring Ventricular Contractility in Heart Failure?

Attempts have been made to assess and measure ventricular contractility in patients and whether it can be used to identify heart failure. Due to the assumption that if the contractility of all the muscle fibres in a heart were lower, could it be called heart failure? Early attempts involved the assumption of a model of muscle that had a contractile unit in series with an elastic element, but this was found to be incorrect. Further attempts applied the series elastic model but this model also proved challenging. However, one method has assessed changes in contractility in a given patient, in response to an intervention, but could not compare contractility in a patient with heart failure with a normal person. End-systolic pressure-volume (ESPV) is regarded as a more correct index of contractility and this method was used to confirm changes in contractility from beat to beat during AF, showing results that end-systolic volume varied and indicating a shift of ESPV from beat to beat. This review will discuss the difficulty in measurement, the complicated nature of myocardial fibre orientation and hypertrophy, and whether myocardial contractility failure precipitates increased global heart failure.

Cor pulmonale parvus in chronic obstructive pulmonary disease and emphysema: the MESA COPD study

BACKGROUND

The classic cardiovascular complication of chronic obstructive pulmonary disease (COPD) is cor pulmonale or right ventricular (RV) enlargement. Most studies of cor pulmonale were conducted decades ago.

OBJECTIVES

This study sought to examine RV changes in contemporary COPD and emphysema using cardiac magnetic resonance (CMR) imaging.

METHODS

We performed a case-control study nested predominantly in 2 general population studies of 310 participants with COPD and control subjects 50 to 79 years of age with ≥10 pack-years of smoking who were free of clinical cardiovascular disease. RV volumes and mass were assessed using magnetic resonance imaging. COPD and COPD severity were defined according to standard spirometric criteria. The percentage of emphysema was defined as the percentage of lung regions <-950 Hounsfield units on full-lung computed tomography; emphysema subtypes were scored by radiologists. Results were adjusted for age, race/ethnicity, sex, height, weight, smoking status, pack-years, systemic hypertension, and sleep apnea.

RESULTS

Right ventricular end-diastolic volume (RVEDV) was reduced in COPD compared with control subjects (-7.8 ml; 95% confidence interval: -15.0 to -0.5 ml; p = 0.04). Increasing severity of COPD was associated with lower RVEDV (p = 0.004) and lower RV stroke volume (p < 0.001). RV mass and ejection fraction were similar between the groups. A greater percentage of emphysema also was associated with lower RVEDV (p = 0.005) and stroke volume (p < 0.001), as was the presence of centrilobular and paraseptal emphysema.

CONCLUSIONS

RV volumes are lower without significant alterations in RV mass and ejection fraction in contemporary COPD, and this reduction is related to the greater percentage of emphysema on computed tomography.

Intracoronary cardiosphere-derived cells after myocardial infarction: evidence of therapeutic regeneration in the final 1-year results of the CADUCEUS trial (CArdiosphere-Derived aUtologous stem CElls to reverse ventricUlar dySfunction)

OBJECTIVES

This study sought to report full 1-year results, detailed magnetic resonance imaging analysis, and determinants of efficacy in the prospective, randomized, controlled CADUCEUS (CArdiosphere-Derived aUtologous stem CElls to reverse ventricUlar dySfunction) trial.

BACKGROUND

Cardiosphere-derived cells (CDCs) exerted regenerative effects at 6 months in the CADUCEUS trial. Complete results at the final 1-year endpoint are unknown.

METHODS

Autologous CDCs (12.5 to 25 × 10(6)) grown from endomyocardial biopsy specimens were infused via the intracoronary route in 17 patients with left ventricular dysfunction 1.5 to 3 months after myocardial infarction (MI) (plus 1 infused off-protocol 14 months post-MI). Eight patients were followed as routine-care control patients.

RESULTS

In 13.4 months of follow-up, safety endpoints were equivalent between groups. At 1 year, magnetic resonance imaging revealed that CDC-treated patients had smaller scar size compared with control patients. Scar mass decreased and viable mass increased in CDC-treated patients but not in control patients. The single patient infused 14 months post-MI responded similarly. CDC therapy led to improved regional function of infarcted segments compared with control patients. Scar shrinkage correlated with an increase in viability and with improvement in regional function. Scar reduction correlated with baseline scar size but not with a history of temporally remote MI or time from MI to infusion. The changes in left ventricular ejection fraction in CDC-treated subjects were consistent with the natural relationship between scar size and ejection fraction post-MI.

CONCLUSIONS

Intracoronary administration of autologous CDCs did not raise significant safety concerns. Preliminary indications of bioactivity include decreased scar size, increased viable myocardium, and improved regional function of infarcted myocardium at 1 year post-treatment. These results, which are consistent with therapeutic regeneration, merit further investigation in future trials. (CArdiosphere-Derived aUtologous stem CElls to reverse ventricUlar dySfunction [CADUCEUS]; NCT00893360).

The C-terminus of the long AKAP13 isoform (AKAP-Lbc) is critical for development of compensatory cardiac hypertrophy

The objective of this study was to determine the role of A-Kinase Anchoring Protein (AKAP)-Lbc in the development of heart failure, by investigating AKAP-Lbc-protein kinase D1 (PKD1) signaling in vivo in cardiac hypertrophy. Using a gene-trap mouse expressing a truncated version of AKAP-Lbc (due to disruption of the endogenous AKAP-Lbc gene), that abolishes PKD1 interaction with AKAP-Lbc (AKAP-Lbc-ΔPKD), we studied two mouse models of pathological hypertrophy: i) angiotensin (AT-II) and phenylephrine (PE) infusion and ii) transverse aortic constriction (TAC)-induced pressure overload. Our results indicate that AKAP-Lbc-ΔPKD mice exhibit an accelerated progression to cardiac dysfunction in response to AT-II/PE treatment and TAC. AKAP-Lbc-ΔPKD mice display attenuated compensatory cardiac hypertrophy, increased collagen deposition and apoptosis, compared to wild-type (WT) control littermates. Mechanistically, reduced levels of PKD1 activation are observed in AKAP-Lbc-ΔPKD mice compared to WT mice, resulting in diminished phosphorylation of histone deacetylase 5 (HDAC5) and decreased hypertrophic gene expression. This is consistent with a reduced compensatory hypertrophy phenotype leading to progression of heart failure in AKAP-Lbc-ΔPKD mice. Overall, our data demonstrates a critical in vivo role for AKAP-Lbc-PKD1 signaling in the development of compensatory hypertrophy to enhance cardiac performance in response to TAC-induced pressure overload and neurohumoral stimulation by AT-II/PE treatment.

Evolution of reperfusion post-infarction ventricular remodeling: new MRI insights

BACKGROUND

Our current understanding is that left ventricular (LV) remodeling after acute myocardial infarction (AMI) is caused by expansion of the infarcted myocardium with thinning of the wall and eccentric hypertrophy of the remote myocardium. To study the geometric changes in the remodeling process after reperfused AMI we used cardiac magnetic resonance imaging (CMR).

METHODS

Nine juvenile swine underwent a 120-min occlusion of the left circumflex coronary artery followed by reperfusion. CMR was performed at 3 and 36 days post-infarction. Global and regional LV remodeling was assessed including geometric changes of infarcted and remote myocardium; infarct longitudinal length (mm), mean circumferential length (mm), total infarct surface (mm(2)), end-diastolic wall thickness (EDWT) (mm) and transmural extent of infarction (TEI).

RESULTS

From 3 days to 36 days post-infarction end-diastolic volume increased by 43% (p<0.01). Infarct mass decreased by 36% (p<0.01), mainly by reduction of EDWT with 26%, while mean infarct circumferential length and longitudinal infarct length did not change. Remote myocardial mass increased by 23%, which was the result of an increase in its circumferential length from 95 ± 10 mm to 113 ± 11 mm (p<0.01), with no change in its EDWT. In contrast, EDWT in the infarct, peri-infarct and border zone decreased.

CONCLUSIONS

Contrary to the widely held view the present, using CMR measurements, shows that post-infarction remodeling was not associated with expansion of the infarcted myocardium. These findings suggest that eccentric hypertrophy of the remote myocardium, but not expansion of the infarct region, is responsible for left ventricular dilatation after AMI.

Selective heart rate reduction with ivabradine unloads the left ventricle in heart failure patients

OBJECTIVES

The study aimed to determine whether isolated heart rate (HR) reduction with ivabradine reduces afterload of patients with systolic heart failure.

BACKGROUND

The effective arterial elastance (Ea) represents resistive and pulsatile afterload of the heart derived from the pressure volume relation. HR modulates Ea, and, therefore, afterload burden.

METHODS

Among the patients with systolic heart failure (ejection fraction ≤35%) randomized to either placebo or ivabradine in the SHIFT (Systolic Heart Failure Treatment With the If Inhibitor Ivabradine Trial), 275 patients (n = 132, placebo; n = 143, ivabradine 7.5 mg twice a day) were included in the echocardiographic substudy. Ea, total arterial compliance (TAC), and end-systolic elastance (Ees) were calculated at baseline and after 8 months of treatment. Blood pressure was measured by arm cuff; stroke volume (SV), ejection fraction, and end-diastolic volume were assessed by echocardiography.

RESULTS

At baseline Ea, TAC, HR, and Ees did not differ significantly between ivabradine- and placebo-treated patients. After 8 months of treatment, HR was significantly reduced in the ivabradine group (p < 0.0001) and was accompanied by marked reduction in Ea (p < 0.0001) and improved TAC (p = 0.004) compared with placebo. Although contractility remained unchanged, ventricular-arterial coupling was markedly improved (p = 0.002), resulting in a higher SV (p < 0.0001) in the ivabradine-treated patients.

CONCLUSIONS

Isolated HR reduction by ivabradine improves TAC, thus reducing Ea. Because Ees is unaltered, improved ventricular-arterial coupling is responsible for increased SV. Therefore, unloading of the heart may contribute to the beneficial effect of isolated HR reduction in patients with systolic heart failure.

Functional iron deficiency and diastolic function in heart failure with preserved ejection fraction

BACKGROUND

Functional iron deficiency (FID) is an independent risk factor for poor outcome in advanced heart failure with reduced EF, but its role in heart failure with preserved EF (HFPEF) remains unclear. We aimed to investigate the impact of FID on cardiac performance determined by pressure-volume loop analysis in HFPEF.

METHODS

26 HFPEF patients who showed an increase in LV stiffness by pressure-volume (PV) loop analysis obtained by conductance-catheterization, performed exercise testing, echocardiographic examination including tissue Doppler and determination of iron metabolism: serum iron, ferritin and transferrin saturation. HFPEF patients who provided ferritin <100 μg/l or ferritin of 100-299 μg/l in combination with transferrin saturation <20% were defined as having FID. In 14 patients the expression of transferrin receptor was determined from available endomyocardial biopsies.

RESULTS

Fifteen out of 26 HFPEF patients showed FID without anemia. Compared to control subjects and HFPEF patients without FID, HFPEF patients with FID showed an up-regulation of the myocardial transferrin receptor expression (p<0.05). No differences between HFPEF patients with and without iron deficiency were found in heart dimensions, systolic and diastolic function obtained by PV-loop and echocardiography analysis. According to the linear regression analysis, LV stiffness was correlated with peak oxygen uptake (r=-0.636, p<0.001) but not with the ferritin level or transferrin saturation. No relation was found between FID and exercise capacity. The association of LV stiffness with exercise performance was independent from the level of iron deficiency.

CONCLUSION

In non-anemic HFPEF patients, cardiac dysfunction and impaired exercise capacity occur independently of FID.

An exploratory study on coronary sinus lead tip three-dimensional trajectory changes in cardiac resynchronization therapy

BACKGROUND

Prediction of response to cardiac resynchronization therapy (CRT) is still an unsolved major issue. The interface between left ventricular mechanics, coronary sinus (CS) lead, and pacing delivery has been little investigated.

OBJECTIVE

To investigate CS lead tip movements at baseline and during biventricular pacing (BiV) in the hypothesis that they could provide some insights into left ventricular mechanical behavior in CRT.

METHODS

Three-dimensional reconstruction of CS lead tip trajectory throughout the cardiac cycle using a novel fluoroscopy-based method was performed in 22 patients with chronic heart failure (19 men; mean age 70 ± 10 years). Three trajectories were computed: before (T-1) and immediately after (T0) BiV start-up and after 6 months (T1). CRT response was the echocardiographic end-systolic volume reduction ≥15% at T1. Metrics describing trajectory at T0, T-1, and T1 were compared between 9 responders (R) and 13 nonresponders (NR).

RESULTS

At T-1 trajectories demonstrated heterogeneous shapes and metrics, but at T0 the variations in the ratio between the two main axes (S1/S2) and in the eccentricity were statistically different between R and NR, pointing out a trajectory's change toward a significantly more circular shape at BiV start-up in R. Remarkably, R and NR could be completely separated by means of the percent variation in S1/S2 from T-1 to T0 (R: 47.5% [31.5% to 54.1%] vs. NR: -25.6% [-67% to -6.5%]). This single marker computed at T0 would have predicted CRT response at T1.

CONCLUSIONS

Preliminary data showed that CS lead tip trajectory changes induced by BiV were related to mechanical resynchronization.

Directed epicardial assistance in ischemic cardiomyopathy: flow and function using cardiac magnetic resonance imaging

BACKGROUND

Heart failure after myocardial infarction (MI) is a result of increased myocardial workload, adverse left ventricular (LV) geometric remodeling, and less efficient LV fluid movement. In this study we utilize cardiac magnetic resonance imaging to evaluate ventricular function and flow after placement of a novel directed epicardial assist device.

METHODS

Five swine underwent posterolateral MI and were allowed to remodel for 12 weeks. An inflatable bladder was positioned centrally within the infarct and secured with mesh. The device was connected to an external gas exchange pump, which inflated and deflated in synchrony with the cardiac cycle. Animals then underwent cardiac magnetic resonance imaging during active epicardial assistance and with no assistance.

RESULTS

Active epicardial assistance of the infarct showed immediate improvement in LV function and intraventricular flow. Ejection fraction significantly improved from 26.0% ± 4.9% to 37.3% ± 4.5% (p < 0.01). End-systolic volume (85.5 ± 12.7 mL versus 70.1 ± 11.9 mL, p < 0.01) and stroke volume (28.5 ± 4.4 mL versus 39.9 ± 3.1 mL, p = 0.03) were also improved with assistance. End-diastolic volume and regurgitant fraction did not change with treatment. Regional LV flow improved both qualitatively and quantitatively during assistance. Unassisted infarct regional flow showed highly discoordinate blood movement with very slow egress from the posterolateral wall. Large areas of stagnant flow were also identified. With assistance, posterolateral wall blood velocities improved significantly during both systole (26.4% ± 3.2% versus 12.6% ± 1.2% maximum velocity; p < 0.001) and diastole (54.3% ± 9.3% versus 24.2% ± 2.5% maximum velocity; p < 0.01).

CONCLUSIONS

Directed epicardial assistance can improve LV function and flow in ischemic cardiomyopathy. This novel device may provide a valuable alternative to currently available heart failure therapies.

Ventricular-arterial coupling, remodeling, and prognosis in chronic heart failure

OBJECTIVES

The objective of this study was to compare the physiological determinants of ejection fraction (EF)-ventricular size, contractile function, and ventricular-arterial (VA) interaction-and their associations with clinical outcomes in chronic heart failure (HF).

BACKGROUND

EF is a potent predictor of HF outcomes, but represents a complex summary measure that integrates several components including left ventricular size, contractile function, and VA coupling. The relative importance of each of these parameters in determining prognosis is unknown.

METHODS

In 466 participants with chronic systolic HF, we derived quantitative echocardiographic measures of EF: cardiac size (end-diastolic volume [EDV]); contractile function (the end-systolic pressure volume relationship slope [Eessb] and intercept [V0]); and VA coupling (arterial elastance [Ea]/Eessb). We determined the association between these parameters and the following adverse outcomes: 1) the combined endpoint of death, cardiac transplantation, or ventricular assist device (VAD) placement; and 2) cardiac hospitalization.

RESULTS

Over a median follow-up of 3.4 years, there were 76 deaths, 52 transplantations, 14 VAD placements, and 684 cardiac hospitalizations. EF was independently associated with death, transplantation, and VAD placement (adjusted hazard ratio [HR]: 3.0; 95% confidence interval [CI]: 1.8 to 5.0 comparing third and first tertiles), as were EDV (HR: 2.6; 95% CI: 1.5 to 4.2); V0 (HR: 3.6; 95% CI: 2.1 to 6.1); and Ea/Eessb (HR: 2.1; 95% CI: 1.3 to 3.3). EDV, V0, and Ea/Eessb were also associated with risk of cardiac hospitalization. Eessb was not significantly associated with any adverse outcomes in adjusted analyses.

CONCLUSIONS

Left ventricular size, V0, and VA coupling are associated with prognosis in systolic HF, but end-systolic elastance (Eessb) is not. Assessment of VA coupling via Ea/Eessb is an additional noninvasively derived metric that can be used to gauge prognosis in human HF.