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Interaction Between Diuretic Resistance and Intestinal Congestion in Hospitalized Patients With Heart Failure
The 20th Annual Scientific Meeting
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JHFS
S189
HF patients from Jan 2011 through March 2015. 18 patients were required continuous administration of tolvaptan after discharge. The initial dose of tolvaptan of 15 cases (83%) was 7.5 mg/day. The increase of tolvaptan was required for treatment of HF in 10 cases (56%). The frequency of HF readmission was 11 cases (61%) and all-cause death was 9 cases (50%) within one year. In the group which was not survived throughout the year, hypoalbuminemia and NYHA3 at discharge were significantly higher more than the survived group (P < .05, respectively). Conclusion: The prognosis of the HF patients who were needed long-term continuation of tolvaptan was not long, especially the patients with hypoalbuminemia or heavy symptoms at discharge. It may to be necessary to consider palliative care in cases of long-term use of tolvaptan.
performed a bone marrow biopsy that revealed asymptomatic multiple myeloma, and therefore instituted a regimen of bortezomib and dexamethasone.Case2: A 55-yearold woman developed left abdominal pain and was hospitalized the next day. We diagnosed renal infarction on contrast CT. After admission, we found left ventricular dysfunction on the echocardiogram and diagnosed amyloidosis with skin biopsy. We started treatment with tolvaptan and low-dose furosemide,as well as bortezomib and dexamethasone. In both cases tolvaptan was continued as outpatient therapy. Conclusion: There has thus far been no specific treatment for cardiac amyloidosis. In the two cases presented above, tolvaptan has been found to be effective in treating heart failure caused by cardiac amyloidosis.
O25-4
O26-1
Mechanism of Diuresis for Acute Decompensated Heart Failure by Tolvaptan: Assessment by Bioelectrical Impedance Analysis Hidetsugu Nomoto1, Yasuhiro Satoh1, Mayumi Masumura1, Shu Yamashita1, Masahito Suzuki1, Tomoyo Sugiyama1, Tetsuo Oumi1, Masakazu Ohno1, Yoshihide Takahashi1, Mitsuaki Isobe2; 1Department of Cardiology, National Hospital Organization, Disaster Medical Center, Tokyo, Japan; 2Department of Cardiology, Tokyo Medical and Dental University, Tokyo, Japan
Importance of Time-Course Assessment of Durable LV Reverse Remodeling to Identify True Cardiac Resynchronization Therapy Responders Michio Ogano; Department of Cardiovascular Medicine, Shizuoka Medical Center, Shizouka, Japan
Background: Tolvaptan, a vasopressin type 2 receptor antagonists, was reported to unchange the kidney circulation and cause no worsening of renal function (WRF) for acute decompensated heart failure (ADHF) patients. Bio impedance analysis (BIA) can be used to evaluate intravascular volume by calculating as the ratio of extracellular water (ECW) to intracellular water (ICW). We examined mechanism of diuresis of tolvaptan by using BIA. Methods: Study patients were 29 ADHF patients (Age 48–95, men 69%) between April 2013 and May 2016 to whom BIA was done before and after treatment. 15 patients were treated with tolvaptan in addition to conventional diuresis therapy (tolvaptan group, mean daily tolvaptan dosage 5.5 ± 1.9 mg) and 14 patients treated by conventional diuresis therapy (control group, furosemide 22.1 ± 10.5 mg). Results: The numerical value of serum creatinine (Cre) significantly increased from 0.89 ± 0.22 to 1.07 ± 0.29 in C group (P = .0044). And ECW/ICW significantly decreased from 0.696 ± 0.036 to 0.673 ± 0.032 in C group (P = .0044). The values of them showed no significant difference in T group. Furthermore, regression analysis showed negative correlation between δCre and δECW/ICW (δCre = −0.002155 − 5.6681881 × δECW/ ICW, R2 = 0.306035, P = .0019). Conclusion: Our study suggested that WRF by furosemide is caused by reducing intravascular volume, and tolvaptan can decrease excess volume without changing ECW/ICW.
Background: LV reverse remodeling by cardiac resynchronization therapy (CRT) reduces heart failure (HF) hospitalization and ventricular tachyarrhythmias (VTA). However, the relationship between durability of LV reverse remodeling and clinical events is unclear. Methods: We investigated 97 patients undergoing CRT. At 6 month followup after CRT, we identified CRT responder as more than 10% reduction of left ventricular end-systolic volume (LVESV) compared to baseline. Among CRT responders, we measured the LVESV differences between 6 and 12 months after CRT (δLVESV=LVESV12Mo-LVESV 6Mo) and durable CRT responder was defined as δLVESV <0. Results: There were 48 CRT responders at 6 months after implantation. CRT responder showed lower HF hospitalization and VTA than non CRT responder (P = .033) with a 44.0 ± 22.3 months follow-up. At 12 months follow-up after CRT, we identified 27 patients as durable CRT responders. HF hospitalization and VTA were significantly lower in durable CRT responders than that in non-durable CRT responder (P = .005). Durable CRT responder was the only independent determinant associated with HF hospitalization and VTA (hazard ratio 0.088, 95% confidential interval 0.01–0.76, P = .027). Conclusions: Some patients who achieved LV reverse remodeling at 6 month after CRT showed re-progressive LV remodeling. Timecourse assessment of LVESV up to 12 month and evaluation of durable LV reverse remodeling were important to identify true CRT responder.
O26-2 O25-5 Interaction Between Diuretic Resistance and Intestinal Congestion in Hospitalized Patients With Heart Failure Yuki Ikeda, Takayuki Inomata, Teppei Fujita, Toyoji Kaida, Takeru Nabeta, Shunsuke Ishii, Emi Maekawa, Toshimi Koitabashi, Junya Ako; Cardiovascular Medicine, Kitasato University School of Medicine, Japan Background: Intestine-cardiovascular interaction is increasingly recognized as one of key determinants of prognostic factors in heart disease. We aimed to identify the relationship among intestinal wall thickness, blood flow in intestinal vessels, and dose of diuretic agents in hospitalized heart failure (HHF) patients. Methods: In 159 HHF patients, we investigated clinical characteristics including furosemide-equivalent dose of diuretic agents, blood sampling parameters, echocardiography, and abdominal ultrasonography for identification of averaged colon wall thickness (CWT) from ascending to sigmoid colon, blood flow analyses in intestinal vessels (portal vein [PV], superior mesenteric artery [SMA], and inferior mesenteric artery [IMA]). Results: There was positive correlation among furosemide-equivalent dose of diuretic agents, CWT (r = 0.168, P < .05), PV congestion index (PV-CI, r = 0.300, P < .001), PV pulsatile index (PVPI, r = 0.303, P < .001), and PV resistance index (PV-RI, r = 0.326, P < .001). Neither flow volume in PV/SMA/IMA, SMA/IMA-PI, nor SMA/IMA-RI had significant correlation to dose and quantities of diuretic agents (all, P > .05). CWT and PV-CI were positively correlated (r = 0.194, P < .05). Patients with readmission for heart failure had increased CWT and PV-CI than those without (CWT: 3.1 ± 0.9 vs 2.5 ± 0.7 mm, P < .001; PV-CI: 0.050 ± 0.063 vs 0.030 ± 0.027 cm×sec, P < .05). Conclusions: Increased CWT and PV-CI were both related to higher diuretic resistance. Relationship among intestinal wall edema, increased portal congestion, and impairment of diuretic response are suggested.
O25-6 Tolvaptan Therapy for Cardiac Amyloidosis; Two Case Reports Hideki Saito, Yusuke Mizuno; Cardiology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan Objective: There has thus far been no drug that is effective in treating cardiac amyloidosis. We here report two cases of cardiac amyloidosis in which tolvaptan was effective.Case presentation:Case1:A 58-year-old man noticed shortness of breath for three months and leg edema for two months before being admitted this hospital. He was treated with azosemide for a diagnosis of chronic heart failure. A skin biopsy revealed amyloidosis, and cardiac involvement was diagnosed as well. We started treatment with tolvaptan and low-dose furosemide, and the congestion improved. We also
Baseline Echocardiographic Features Associated With Improvement in Significant Mitral Regurgitation After Cardiac Resynchronization Therapy—START Study Sub-Analysis Tetsuari Onishi, Hiroya Kawai, Yasue Tsukishiro; Cardiology, Himeji Cardiovascular Center, Himeji, Japan Background: The aim of this study was to investigate baseline parameters associated with improvement in significant mitral regurgitation (MR) after CRT in advanced heart failure patient. Methods: We prospectively studied 180 consecutive CRT patients with NYHA class III/IV. Quantitative echocardiography was performed before and 6 months after CRT. MR was quantified by jet area to left atrial area ratio. Results: Of 150 patients met the inclusion criteria, 75 patients had significant MR at baseline. After CRT, 26 patients of them had an improvement in MR after CRT. There was a significant difference in baseline LV dimensions and volumes in end-diastole and endsystole, deceleration time of early diastole wave in transmitral flow, previous myocardial infarction (MI), maximum time delay of radial strain (RS-TD) between patients groups with and without significant MR after CRT. Logistic multivariate analysis revealed LV end-systolic volume (ESV), previous MI, and RS-TD were independent predictors of. The novel scoring system which put 1 point for each: the absence of previous MI, LVESV less than 121 ml, and RS-TD more than 280ms, was strongly predictive for the improvement in significant MR after CRT (Odds ratio: 0.26, P = .0001). Conclusion: The absence of previous MI, not too much dilated LV and definite radial dyssynchrony associated with improvement in MR have the potential to predict MR reduction following CRT.
O26-4 High Brain Natriuretic Peptide Level and Renal Dysfunction Were Poor Prognostic Predictors After Cardiac Resynchronization Therapy Kazuhisa Nisimura, Shuntaro Ikeda, Hiroshi Kawakami, Haruhiko Higashi, Teruyoshi Uetani, Takayuki Nagai, Katsuji Inoue, Jun Suzuki, Takafumi Okura, Jitsuo Higaki; Department of Cardiology, Pulmonary, Hypertension and Nephrology This aim of this study was to clarify the prognostic factors of cardiac resynchronization therapy (CRT). (Methods) One hundred-eight patients were received CRT (mean years: 67 years). Left ventricular (LV) function was assessed by echocardiography at baseline and 6 months after CRT. CRT responder was defined as the reduction of LV end-systolic volume (LVESV) < 15% at 6 months after CRT. (Results) Seventy-two patients (67%) were identified as CRT responders. Among age, body mass index, baseline QRS width, CLBBB morphology, baseline LVEF, LVESV, serum brain natriuretic peptide (BNP) level, estimated glomerular filtration rate (eGFR), and
•
JHFS
S189
HF patients from Jan 2011 through March 2015. 18 patients were required continuous administration of tolvaptan after discharge. The initial dose of tolvaptan of 15 cases (83%) was 7.5 mg/day. The increase of tolvaptan was required for treatment of HF in 10 cases (56%). The frequency of HF readmission was 11 cases (61%) and all-cause death was 9 cases (50%) within one year. In the group which was not survived throughout the year, hypoalbuminemia and NYHA3 at discharge were significantly higher more than the survived group (P < .05, respectively). Conclusion: The prognosis of the HF patients who were needed long-term continuation of tolvaptan was not long, especially the patients with hypoalbuminemia or heavy symptoms at discharge. It may to be necessary to consider palliative care in cases of long-term use of tolvaptan.
performed a bone marrow biopsy that revealed asymptomatic multiple myeloma, and therefore instituted a regimen of bortezomib and dexamethasone.Case2: A 55-yearold woman developed left abdominal pain and was hospitalized the next day. We diagnosed renal infarction on contrast CT. After admission, we found left ventricular dysfunction on the echocardiogram and diagnosed amyloidosis with skin biopsy. We started treatment with tolvaptan and low-dose furosemide,as well as bortezomib and dexamethasone. In both cases tolvaptan was continued as outpatient therapy. Conclusion: There has thus far been no specific treatment for cardiac amyloidosis. In the two cases presented above, tolvaptan has been found to be effective in treating heart failure caused by cardiac amyloidosis.
O25-4
O26-1
Mechanism of Diuresis for Acute Decompensated Heart Failure by Tolvaptan: Assessment by Bioelectrical Impedance Analysis Hidetsugu Nomoto1, Yasuhiro Satoh1, Mayumi Masumura1, Shu Yamashita1, Masahito Suzuki1, Tomoyo Sugiyama1, Tetsuo Oumi1, Masakazu Ohno1, Yoshihide Takahashi1, Mitsuaki Isobe2; 1Department of Cardiology, National Hospital Organization, Disaster Medical Center, Tokyo, Japan; 2Department of Cardiology, Tokyo Medical and Dental University, Tokyo, Japan
Importance of Time-Course Assessment of Durable LV Reverse Remodeling to Identify True Cardiac Resynchronization Therapy Responders Michio Ogano; Department of Cardiovascular Medicine, Shizuoka Medical Center, Shizouka, Japan
Background: Tolvaptan, a vasopressin type 2 receptor antagonists, was reported to unchange the kidney circulation and cause no worsening of renal function (WRF) for acute decompensated heart failure (ADHF) patients. Bio impedance analysis (BIA) can be used to evaluate intravascular volume by calculating as the ratio of extracellular water (ECW) to intracellular water (ICW). We examined mechanism of diuresis of tolvaptan by using BIA. Methods: Study patients were 29 ADHF patients (Age 48–95, men 69%) between April 2013 and May 2016 to whom BIA was done before and after treatment. 15 patients were treated with tolvaptan in addition to conventional diuresis therapy (tolvaptan group, mean daily tolvaptan dosage 5.5 ± 1.9 mg) and 14 patients treated by conventional diuresis therapy (control group, furosemide 22.1 ± 10.5 mg). Results: The numerical value of serum creatinine (Cre) significantly increased from 0.89 ± 0.22 to 1.07 ± 0.29 in C group (P = .0044). And ECW/ICW significantly decreased from 0.696 ± 0.036 to 0.673 ± 0.032 in C group (P = .0044). The values of them showed no significant difference in T group. Furthermore, regression analysis showed negative correlation between δCre and δECW/ICW (δCre = −0.002155 − 5.6681881 × δECW/ ICW, R2 = 0.306035, P = .0019). Conclusion: Our study suggested that WRF by furosemide is caused by reducing intravascular volume, and tolvaptan can decrease excess volume without changing ECW/ICW.
Background: LV reverse remodeling by cardiac resynchronization therapy (CRT) reduces heart failure (HF) hospitalization and ventricular tachyarrhythmias (VTA). However, the relationship between durability of LV reverse remodeling and clinical events is unclear. Methods: We investigated 97 patients undergoing CRT. At 6 month followup after CRT, we identified CRT responder as more than 10% reduction of left ventricular end-systolic volume (LVESV) compared to baseline. Among CRT responders, we measured the LVESV differences between 6 and 12 months after CRT (δLVESV=LVESV12Mo-LVESV 6Mo) and durable CRT responder was defined as δLVESV <0. Results: There were 48 CRT responders at 6 months after implantation. CRT responder showed lower HF hospitalization and VTA than non CRT responder (P = .033) with a 44.0 ± 22.3 months follow-up. At 12 months follow-up after CRT, we identified 27 patients as durable CRT responders. HF hospitalization and VTA were significantly lower in durable CRT responders than that in non-durable CRT responder (P = .005). Durable CRT responder was the only independent determinant associated with HF hospitalization and VTA (hazard ratio 0.088, 95% confidential interval 0.01–0.76, P = .027). Conclusions: Some patients who achieved LV reverse remodeling at 6 month after CRT showed re-progressive LV remodeling. Timecourse assessment of LVESV up to 12 month and evaluation of durable LV reverse remodeling were important to identify true CRT responder.
O26-2 O25-5 Interaction Between Diuretic Resistance and Intestinal Congestion in Hospitalized Patients With Heart Failure Yuki Ikeda, Takayuki Inomata, Teppei Fujita, Toyoji Kaida, Takeru Nabeta, Shunsuke Ishii, Emi Maekawa, Toshimi Koitabashi, Junya Ako; Cardiovascular Medicine, Kitasato University School of Medicine, Japan Background: Intestine-cardiovascular interaction is increasingly recognized as one of key determinants of prognostic factors in heart disease. We aimed to identify the relationship among intestinal wall thickness, blood flow in intestinal vessels, and dose of diuretic agents in hospitalized heart failure (HHF) patients. Methods: In 159 HHF patients, we investigated clinical characteristics including furosemide-equivalent dose of diuretic agents, blood sampling parameters, echocardiography, and abdominal ultrasonography for identification of averaged colon wall thickness (CWT) from ascending to sigmoid colon, blood flow analyses in intestinal vessels (portal vein [PV], superior mesenteric artery [SMA], and inferior mesenteric artery [IMA]). Results: There was positive correlation among furosemide-equivalent dose of diuretic agents, CWT (r = 0.168, P < .05), PV congestion index (PV-CI, r = 0.300, P < .001), PV pulsatile index (PVPI, r = 0.303, P < .001), and PV resistance index (PV-RI, r = 0.326, P < .001). Neither flow volume in PV/SMA/IMA, SMA/IMA-PI, nor SMA/IMA-RI had significant correlation to dose and quantities of diuretic agents (all, P > .05). CWT and PV-CI were positively correlated (r = 0.194, P < .05). Patients with readmission for heart failure had increased CWT and PV-CI than those without (CWT: 3.1 ± 0.9 vs 2.5 ± 0.7 mm, P < .001; PV-CI: 0.050 ± 0.063 vs 0.030 ± 0.027 cm×sec, P < .05). Conclusions: Increased CWT and PV-CI were both related to higher diuretic resistance. Relationship among intestinal wall edema, increased portal congestion, and impairment of diuretic response are suggested.
O25-6 Tolvaptan Therapy for Cardiac Amyloidosis; Two Case Reports Hideki Saito, Yusuke Mizuno; Cardiology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan Objective: There has thus far been no drug that is effective in treating cardiac amyloidosis. We here report two cases of cardiac amyloidosis in which tolvaptan was effective.Case presentation:Case1:A 58-year-old man noticed shortness of breath for three months and leg edema for two months before being admitted this hospital. He was treated with azosemide for a diagnosis of chronic heart failure. A skin biopsy revealed amyloidosis, and cardiac involvement was diagnosed as well. We started treatment with tolvaptan and low-dose furosemide, and the congestion improved. We also
Baseline Echocardiographic Features Associated With Improvement in Significant Mitral Regurgitation After Cardiac Resynchronization Therapy—START Study Sub-Analysis Tetsuari Onishi, Hiroya Kawai, Yasue Tsukishiro; Cardiology, Himeji Cardiovascular Center, Himeji, Japan Background: The aim of this study was to investigate baseline parameters associated with improvement in significant mitral regurgitation (MR) after CRT in advanced heart failure patient. Methods: We prospectively studied 180 consecutive CRT patients with NYHA class III/IV. Quantitative echocardiography was performed before and 6 months after CRT. MR was quantified by jet area to left atrial area ratio. Results: Of 150 patients met the inclusion criteria, 75 patients had significant MR at baseline. After CRT, 26 patients of them had an improvement in MR after CRT. There was a significant difference in baseline LV dimensions and volumes in end-diastole and endsystole, deceleration time of early diastole wave in transmitral flow, previous myocardial infarction (MI), maximum time delay of radial strain (RS-TD) between patients groups with and without significant MR after CRT. Logistic multivariate analysis revealed LV end-systolic volume (ESV), previous MI, and RS-TD were independent predictors of. The novel scoring system which put 1 point for each: the absence of previous MI, LVESV less than 121 ml, and RS-TD more than 280ms, was strongly predictive for the improvement in significant MR after CRT (Odds ratio: 0.26, P = .0001). Conclusion: The absence of previous MI, not too much dilated LV and definite radial dyssynchrony associated with improvement in MR have the potential to predict MR reduction following CRT.
O26-4 High Brain Natriuretic Peptide Level and Renal Dysfunction Were Poor Prognostic Predictors After Cardiac Resynchronization Therapy Kazuhisa Nisimura, Shuntaro Ikeda, Hiroshi Kawakami, Haruhiko Higashi, Teruyoshi Uetani, Takayuki Nagai, Katsuji Inoue, Jun Suzuki, Takafumi Okura, Jitsuo Higaki; Department of Cardiology, Pulmonary, Hypertension and Nephrology This aim of this study was to clarify the prognostic factors of cardiac resynchronization therapy (CRT). (Methods) One hundred-eight patients were received CRT (mean years: 67 years). Left ventricular (LV) function was assessed by echocardiography at baseline and 6 months after CRT. CRT responder was defined as the reduction of LV end-systolic volume (LVESV) < 15% at 6 months after CRT. (Results) Seventy-two patients (67%) were identified as CRT responders. Among age, body mass index, baseline QRS width, CLBBB morphology, baseline LVEF, LVESV, serum brain natriuretic peptide (BNP) level, estimated glomerular filtration rate (eGFR), and