Circulation: Heart Failure最新文献

Background: Pulmonary hypertension (PH) is classified as precapillary, isolated postcapillary pulmonary hypertension (IpcPH), combined postcapillary and precapillary (CpcPH), or exercise PH. IpcPH associated with left heart disease can lead to pulmonary vascular remodeling and eventually CpcPH. Conversely, precapillary PH may be diagnosed in the presence of cardiovascular comorbidities, including left heart disease. Atrial functional impairment is a frequent finding in cardiopulmonary disease, reflecting both intrinsic atrial cardiomyopathy and congestion. Consequently, we sought to investigate this across the PH spectrum.

Methods: Patients referred to both right heart catheterization and cardiovascular magnetic resonance imaging were enrolled in this monocentric registry. Patients were classified by right heart catheterization according to current guideline recommendations. Cardiovascular magnetic resonance assessment included left/right ventricular and left atrial (LA)/right atrial volumes and deformation imaging.

Results: The study population consisted of N=209 patients (n=55 normal, n=72 precapillary, n=27 CpcPH, n=15 IpcPH, n=34 exercise, and n=6 unclassified PH). N=126 patients underwent additional exercise stress right heart catheterization. Median LA reservoir function was lowest and similar in IpcPH (10.0%) and CpcPH (10.0%), which were significantly impaired compared with normal hemodynamics (30.8%, both P<0.001), precapillary (28.2%, both P<0.001), and exercise PH (26.9%, IpcPH: P=0.039, CpcPH: P=0.048). LA reservoir function and left ventricular global longitudinal strain showed good diagnostic performance to identify patients with left cardiac involvement evident at rest (pulmonary capillary wedge pressure ≥15 mm Hg; area under the curve, 0.81 versus 0.77; P=0.20), whereas LA reservoir function emerged superior for identification of exercise stress induced pulmonary capillary wedge pressure ≥25 mm Hg (area under the curve, 0.79 versus 0.70, P=0.039).

Conclusions: LA functional impairment is a sign of left heart involvement in patients with PH. Left atrial reservoir function emerged superior for the identification of left heart disease unmasked during exercise stress compared with left ventricular global longitudinal strain. Consequently, LA strain may become an innovative method to detect early-stage left heart disease in PH.

Background: The performance of estimated glomerular filtration rate (eGFR) among patients with heart failure (HF) may be worse than in the general population due to a higher prevalence of confounding factors affecting creatinine and cystatin C. Studies in this area are scarce and not stratified by type of HF. We evaluated the performance of current creatinine and cystatin C equations (eGFRcr, eGFRcys, and eGFRcrcys) compared with measured GFR (mGFR) among patients with HF stratified by ejection fraction.

Methods: We pulled data on Mayo Clinic patients with an mGFR performed for clinical indications from 2011 to 2023, with serum creatinine and cystatin C measured within 7 days and an echocardiogram performed up to 1 year before the mGFR date. HF was identified by the presence of International Classification of Diseases codes within 1 year before the mGFR and subgrouped into ejection fraction (EF) ≥50% (HFEF≥50%, n=182) or <50% (HFEF<50%, n=115) and compared with no-HF controls (n=1871). CKD-EPI (and EKFC) eGFRcr, eGFRcys, and eGFRcrcys equations were calculated and compared for bias (mGFR minus eGFR) and accuracy (1-P30, proportion of people with ≥30% difference between eGFR and mGFR). CIs were generated by bootstrapping.

Results: The HF groups were characterized by older age, higher proportion of males, more diabetes, higher creatinine, and higher cystatin C than controls. In terms of bias, eGFRcr overestimated mGFR to a greater extent in both HF groups compared with controls, whereas eGFRcys and eGFRcrcys showed similar bias in both HF groups and controls. In the HF groups, cystatin C-based equations were more accurate than eGFRcr, particularly within HFEF<50% (1-P30 of 28% and 34% for CKD-EPI eGFRcys and eGFRcrcys, respectively, versus 60% for eGFRcr), whereas eGFRcrcys was more accurate in controls. The CKD-EPI and EKFC equations were overall convergent, showing similar results.

Conclusions: Among patients with HF, eGFRcr demonstrates inferior performance (more bias and less accuracy) compared with cystatin C-based eGFRs, with this effect being more pronounced in those with HFEF<50%.

The Get With The Guidelines-Heart Failure program was developed in 2005 with the goal of bringing evidence-based guidelines in heart failure management into widespread clinical practice. The program includes workshops, webinars, tool kits, chart abstraction, performance benchmarking, and achievement awards to drive quality improvement at participating hospitals. Two decades after its inception, the program has grown to include over 600 participating institutions across the United States. Linking registry data to Centers for Medicare and Medicaid Services claims has also allowed for the evaluation of longitudinal outcomes. Get With The Guidelines-Heart Failure has helped improve the quality of care for patients and has contributed substantially to the understanding of clinical science and optimal management of heart failure. This narrative review provides an overview of the indelible impact of the Get With The Guidelines-Heart Failure program on quality heart failure care over the past 20 years and highlights future challenges and directions.

Background: This study evaluates clinical trends and mid-term waitlist and posttransplant outcomes following the 2018 heart allocation policy change.

Methods: The United Network for Organ Sharing registry was queried to analyze adult waitlisted and transplanted patients undergoing isolated heart transplantation. Two analyses were conducted: (1) waitlist and (2) posttransplant outcomes. For the waitlist analysis, candidates were stratified into seasonally matched prepolicy (October 18, 2012-June 30, 2017) and postpolicy (October 18, 2018-June 30, 2023) groups, with a 1-year follow-up period. Waitlist outcomes included 1-year cumulative incidences of transplantation, delisting due to death/clinical deterioration, and all-cause survival from the initial waitlisting. For the posttransplant analysis, recipients were stratified into seasonally matched prepolicy (October 18, 2014-June 30, 2018) and postpolicy (October 18, 2018-June 30, 2020) groups, with a 4-year follow-up period. Posttransplant outcomes included 4-year survival. Propensity score-matching and multivariable Cox regression were used for risk adjustment.

Results: Under the 2018 allocation system, there was a continued shift toward the use of older donors, longer graft ischemic times, and shorter waitlist durations. In the waitlist analysis, 30 620 waitlisted candidates were analyzed, with 14 908 (48.7%) listed after the policy change. The postpolicy candidates had a higher 1-year cumulative incidence of transplantation (subhazard ratio, 2.06 [95% CI, 2.00-2.12]; P<0.001) and a lower 1-year cumulative incidence of delisting (subhazard ratio, 0.58 [95% CI, 0.53-0.63]; P<0.001) compared with the prepolicy candidates. In addition, the postpolicy candidates had significantly improved 1-year survival from initial waitlisting compared with the prepolicy candidates (90.0% versus 86.8%; P<0.001). In the posttransplant analysis, 13 712 recipients were analyzed, with 4597 (33.5%) transplanted following the policy change. The 4-year post-transplant survival was similar between the groups (83.3% versus 82.8%; P=0.593). Furthermore, the comparable 4-year post-transplant survival persisted in the propensity score-matched comparison and multivariable Cox regression.

Conclusions: Despite the changes in donor and recipient profiles following the 2018 allocation system change, this mid-term reassessment demonstrates its success in significantly improving waitlist survival, while maintaining comparable posttransplant survival.

Background: Sarcopenia is associated with adverse outcomes in patients with end-stage heart failure. Muscle mass can be quantified via manual segmentation of computed tomography images, but this approach is time-consuming and subject to interobserver variability. We sought to determine whether fully automated assessment of radiographic sarcopenia by deep learning would predict heart transplantation outcomes.

Methods: This retrospective study included 164 adult patients who underwent heart transplantation between January 2013 and December 2022. A deep learning-based tool was utilized to automatically calculate cross-sectional skeletal muscle area at the T11, T12, and L1 levels on chest computed tomography. Radiographic sarcopenia was defined as skeletal muscle index (skeletal muscle area divided by height squared) in the lowest sex-specific quartile.

Results: The study population had a mean age of 53±14 years and was predominantly men (75%) with a nonischemic cause of cardiomyopathy (73%). Mean skeletal muscle index was 28.3±7.6 cm²/m² for women versus 33.1±8.1 cm²/m² for men (P<0.001). Cardiac allograft survival was significantly lower in heart transplant recipients with versus without radiographic sarcopenia at T11 (90% versus 98% at 1 year, 83% versus 97% at 3 years, log-rank P=0.02). After multivariable adjustment, radiographic sarcopenia at T11 was associated with an increased risk of cardiac allograft loss or death (hazard ratio, 3.86 [95% CI, 1.35-11.0]; P=0.01). Patients with radiographic sarcopenia also had a significantly increased hospital length of stay (28 [interquartile range, 19-33] versus 20 [interquartile range, 16-31] days; P=0.046).

Conclusions: Fully automated quantification of radiographic sarcopenia using pretransplant chest computed tomography successfully predicts cardiac allograft survival. By avoiding interobserver variability and accelerating computation, this approach has the potential to improve candidate selection and outcomes in heart transplantation.

Background: The atria play an important role in the pathophysiology of heart failure with preserved ejection fraction. Decreased left atrial strain is associated with worse clinical outcomes. The impact of no-implant interatrial shunting on atrial structure and function has not been described.

Methods: We characterized the left atrial (LA) and right atrial strain-pressure relationship at rest and during exercise, before and after creation of a no-implant interatrial shunt. We included patients with New York Heart Association class II, III, or ambulatory IV heart failure with a left ventricular ejection fraction ≥40% and elevated LA wedge pressure during supine ergometry (≥25 mm Hg). Exercise hemodynamics and echocardiographic measurements were analyzed at baseline, 1 month and 6 months (echo only) following transcatheter, transeptal creation of a 7 mm no-implant interatrial shunt.

Results: A total of 33 patients were enrolled/included in the study. At 1 month, LA pressure at rest was significantly reduced from 19.7±7.0 to 17.2±5.0 mm Hg (P=0.044), and from 39.7±10.5 to 33.6±11.1 mm Hg (P=0.002) during exercise. Reductions in LA pressure were associated with a mean decrease of 55.4 mm Hg/W·kg in LA work (P<0.001). Echo measurements demonstrated significant improvements in LA reservoir strain of +4.0% (P=0.015) and +4.1% (P=0.046) at 1 and 6 months, respectively. Modest improvements were observed in LA conduit and contractile strain, with a similar overall trend in right atrial strain measurements. These findings were associated with a significant reduction in LA volumes and an increase in right atrial volume. There was no change in right atrial pressure or measures of right ventricular function.

Conclusions: Hemodynamic and strain assessment in patients with heart failure with preserved ejection fraction suggests that a no-implant interatrial shunt can significantly improve the pressure-function relationship of the LA.

Registration: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT04583527, NCT04838353, and NCT05501652.