Not an Adequate Management of PT-INR, but Platelet Count Fluctuation can Predict Near Future Thromboembolic Events in Patients With LVAD

S156 Journal of Cardiac Failure Vol. 22 No. 9S September 2016 SY4-1 Beneficial Impact of Nicorandil on Mortality in Patients With Ischemic Heart Failure Akiomi Yoshihisa, Yasuchika Takeishi; Department of Cardiovascular Medicine, Fukushima Medical University, Japan Background: Effective treatments in heart failure (HF) patients with ischemic etiology have not been fully established. Nicorandil, combination of nitrate component and sarcolemmal ATP-sensitive potassium channel opener, is a potent vasodilator of coronary and peripheral vessels and has been used as an antianginal agent. Therefore, we examined impacts of nicorandil on mortality in ischemic HF patients. Methods and Results: We analyzed 334 HF patients with ischemic etiology. These patients were divided into 2 groups: nicorandil group (n = 116) and non-nicorandil group (n = 218). Baseline characteristics including age, gender, NYHA class, left ventricular ejection fraction, B-type natriuretic peptide, estimated glomerular filtration rate, presence of hypertension, diabetes, dyslipidemia, atrial fibrillation, chronic kidney disease, anemia and smoking did not differ between the two groups. In the Kaplan-Meier analysis (mean follow-up period 963 days), all-cause mortality was significantly lower in the nicorandil group than in the non-nicorandil group (24.1% vs. 35.8%, P = .018). In the Cox proportional hazard analysis after adjusting for potential confounding factors, use of nicorandil was an independent predictor of mortality in HF patients with ischemic etiology (hazard ratio 0.618, 95% confidence interval 0.400–0.953, P = .030). Conclusion: Nicorandil is potentially effective for reducing mortality in patients with ischemic heart failure.

SY4-2 Transvascular Left Ventricular Unloading in the Acute Phase of Myocardial Infarction Markedly Reduces Infarct Size and Prevents Future Heart Failure Keita Saku1, Takahiro Arimura2, Genya Sunagwa2, Takamori Kakino3, Takafumi Sakamoto4, Takuya Kishi1, Tomomi Ide2, Hiroyuki Tsutsui2, Kenji Sunagawa1; 1Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan; 2 Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; 3Cardiovascular Medicine, Kitakyushu Municipal Medical Center, Kitakyushu, Japan; 4Cardiovascular Medicine, Oita Prefectural Hospital, Oita, Japan Background: Left ventricular assist device (LVAD) unloads left ventricle (LV) and reduces myocardial oxygen consumption (MVO2). The total LVAD unloading (tVAD) where LV no longer ejects markedly decreases MVO2. Since an imbalance between oxygen supply and demand is the fundamental pathophysiology in the formation of infarcted myocardium, we examined whether t-VAD using transvascular LVAD (Impella®) in myocardial infarction (MI) could reduce infarct size and prevent future heart failure. Methods: In 16 anesthetized dogs, we ligated the coronary arteries for 180 min and then reperfused. We initiated the LVAD unloading from 60 min after the onset of ischemia to 90 min after reperfusion. We allocated animals into 3 groups, no support (IR, N = 8), p-VAD (the partial LVAD unloading, N = 6) and t-VAD (N = 6). Four weeks after MI, we compared LV function and the infarct size. Results: t-VAD normalized LV end-systolic elastance (IR: 6.5 ± 3.2 and t-VAD: 12.8 ± 5.1 mmHg/ ml, P < .05) and reduced LV end-diastolic pressure (IR: 16.5 ± 2.7 and t-VAD: 4.4 ± 1.5 mmHg, P < .05). t-VAD markedly reduced the infarct size by more than 80% (IR: 12.4 ± 3.7, p-VAD: 8.1 ± 3.2, t-VAD: 2.1 ± 1.6%, P < .05). Conclusion: Transvascular LV unloading for acute MI strikingly reduces infarct size and prevents heart failure. In the session, we will also discuss the impact of more powerful MVO2 suppression on MI size by providing the data of combination treatment of LVAD with bradycardic agent, ivabradine.

SY4-3 Prognostic Impact of Residual Coronary Stenosis in Patients With Ischemic Heart Failure After Percutaneous Coronary Intervention Kiyotaka Hao1, Jun Takahashi1, Satoshi Miyata2, Yasuhiko Sakata1, Hiroaki Shimokawa1; 1 Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; 2Department of Evidenced-based Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan Background: It remains to be elucidated whether residual coronary stenosis (RS) impacts on the prognosis in ischemic heart failure (IHF) patients. Methods: We examined 3,313 stage B/C/D IHF patients with a history of percutaneous coronary intervention in our Chronic Heart Failure Analysis and Registry in the Tohoku District-2 (CHART-2) Study and divided them according to the presence or absence of RS. Results: The patients with RS (n = 2,172) were characterized, as compared with those without RS (n = 1,141), by a lower proportion of female, higher prevalence of diabetes, dyslipidemia and smoking, and higher levels of brain natriuretic peptide, whereas the proportion of stage C/D HF and left ventricular ejection fraction were comparable between the two groups. During the 3.2 ± 1.3 years, all-cause and cardiovascular mortalities of the patients with RS were significantly higher compared with those without it (log-rank test, P = .001 and P = .028, respectively). Importantly, RS was associated with higher all-cause and cardiovascular mortalities in the patients with stage C/D (P = .001 and P = .042, respectively), whereas, in stage B subjects, those mortalities were comparable irrespective of the presence or absence of RS. These results were further confirmed by additional propensity score matching. Conclusions: Prognostic impact of RS in IHF patients may vary de-

pending on the severity of HF and stage C/D IHF patients with RS could benefit from further revascularization.

SY5-6 Prognosis of Hospitalized Octogenarians With Heart Failure and its Contributing Factors Satoru Abe1, Hiroaki Obata2, Akifumi Uehara1, Kanako Oishi1, Hiroshi Watanabe1, Akihiro Yokoyama1, Masayuki Onishi1, Norio Higuma1, Tohru Watanabe1, Tohru Izumi1; 1 Division of Medicine, Niigataminami Hospital, Niigata, Japan; 2 Division of Rehabilitation, Niigataminami Hospital, Niigata, Japan Introduction: For octogenarians, hospitalization for heart failure often results in death. However, the clinical characteristics have not been clarified yet. Patients and methods: A retrospective evaluation and cross-sectional analysis were performed in superelderly (aged >80 years) hospitalized for congestive heart failure. Diagnosis was based on the Diagnosis Procedure Combination coding system, and treatment methods were in accordance with the Japan Circulation Society guidelines. Clinical outcomes were judged at the time of hospital discharge. Results: In 1 year, 87 cases were registered. The male-to-female ratio was 39:48; and the mean age, 89.8 years. Fourteen patients had repeated hospitalization. The mean hospital stay was 36.6 days. The clinical outcomes upon discharge were divided into subgroups as follows: died in the hospital, n = 34; needed additional nursing care, n = 23; and able to walk, n = 30. The differences in age, sex, and B-type natriuretic peptide level between the subgroups were not significant. Low blood pressure and atrial fibrillation were candidate contributing factors for mortality. In terms of the level of pre-hospital activities of daily living, the patients required care. The octogenarians who were ambulatory upon discharge were those who were referred because of infectious diseases and loss of cognitive impairment. Conclusion: The prognosis of hospitalized octogenarians with heart failure and, seemingly, the contributing factors were dependent on the aforementioned subgroups.

SY6-2 Heart Transplantation Following Mechanical Circulatory Support Longer Than Two Years Satoshi Saito1, Hironori Murakami1, Youji Takiguchi1, Takeshi Katsube1, Minojri Tateishi1, Nobuhiro Umehara1, Shinichi Nunoda2, Kenji Yamazaki1; 1Department of Cardiovascular Surgery; 2Department of Therapeutic Strategy for Severe Heart Failure Background: The heart transplantation is available for only a minority of patients because of the severe shortage of donors. The bridge to transplantation with mechanical circulatory support is mandatory for over 2 years in Japan. The objective of this study is to evaluate the current status of bridge to transplantation and the results of heart transplantation. Methods and Results: Twenty patients with mean age of 38.7 underwent the heart transplantation in our institute. The diagnosis included DCM in 18, DHCM in 1, and Drug induced CM in 1 patient. Eighteeneen patients (89%) were supported by the LVAD (2 para-corporeal and 16 implantable) for the mean duration of 960 days. The major adverse events during the LVAD supports includes TE events and cable infections. The modified Lower-Shumway (61%) and bicaval(39%) technique was performed with the mean ischemic time of 238.4 minutes. There was one hospital mortality(5.0%) and all 19survivors were followed up for 70.1 months and 16 (89%)have been successfully returned to social activities. Conclusion: The long term results of the heart transplantation is satisfactory and the duration of BTT is extremely longer. The implantable LVAS enables to achieve the successful bridge to heart transplantation. The further increase of donors is expected to reduce the waiting period and the device related adverse events.

SY6-3 Not an Adequate Management of PT-INR, but Platelet Count Fluctuation can Predict Near Future Thromboembolic Events in Patients With LVAD Kenichi Hiasa, Takeo Fujino, Shujiro Inoue, Taiki Higo, Tomomi Ide; Department of Cardiovascular Medicine, Kyushu University, Fukuoka, Japan Background: Left ventricular assist device (LVAD) have the advantage over the optimal medical therapy for the severe heart failure, however, it is required for heart transplantation to overcome some obstacles as follows: device-related cerebral thromboembolism, intracranial hemorrhage, GI bleeding and infection. Purpose: The aim of this study is to investigate the predictive value of several coagulation and physiological parameters for the cerebral thromboembolic events(CTEs) in the patients treated with LVAD. Methods: We analyzed the relation between symptomatic CTEs and coagulation markers for 30 days just before the onset of CTEs. We also evaluated both electro- and echo-cardiographic parameters as follows; presence or absence of atrial fibrillation, opening of aortic valve, cardiac output calculated from RV stroke volume, aortic and intracardiac thrombus. Results: Not the absolute value, but degree of reduction and standard deviation of platelet count and CRP elevation showed the significant difference in the cerebral infarction group, by contrast PT-INR stayed within the target therapeutic range. D-dimmer, TAT, echocardiographic parameters did not correlate the CTEs. Conclusion: Careful attention to the fluctuation of platelets counts and CRP elevation should be paid in the management of anticoagulation therapy in the patients treated with LVAD, even if PT-INR stayed within the target therapeutic range.