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Rapid Reductions in Mitral Regurgitation Fraction by CPAP and ASV in Heart Failure Patients with Reduced Ejection Fraction
S54 Journal of Cardiac Failure Vol. 23 No. 10S October 2017 servo-ventilation (ASV) as a treatment to obstructive sleep apnea which was sufficiently suppressed by continuous positive airway pressure (CPAP). Use of ASV for HF patients with predominant CSA has been limited because of negative and potentially harmful results from current clinical trial. This case reminds us to reevaluation of SDB or reconsideration of treatment option for SDB following CRT-D implantation in HF with reduced ejection fraction and predominant CSA.
treatment, and fatal cardiovascular events in ASV therapy did not show higher rate in real world compared with SMT.
O42-6 Rapid Reductions in Mitral Regurgitation Fraction by CPAP and ASV in Heart Failure Patients with Reduced Ejection Fraction Takao Kato1, Takatoshi Kasai1,2, Shoichiro Yatsu1, Hiroki Matsumoto1,2, Azusa Murata1, Shoko Suda1, Masaru Hiki1, Hiroyuki Daida1; 1Department of Cardiovascular Medicine, Juntendo University; 2Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine Background: Rapid reductions in functional mitral regurgitation (MR) by continuous positive airway pressure (CPAP) and adaptive-servo ventilation (ASV) in heart failure patients with reduced ejection fraction (HFrEF) remain unclear. Methods: Twenty HFrEF patients (14 men) with functional MR underwent echocardiography during 10minute CPAP (4 and 8 cmH2O) and ASV. MR fraction was defined as the ratio of MR to the left atrial area. The forward stroke volume (SV) index was calculated from the time-velocity integral, cross-sectional area of the aortic annulus. Results: MR fraction significantly reduced due to CPAP of 8 cmH2O (0.30 ± 0.12) and ASV (0.29 ± 0.12), compared with the baseline phase (0.37 ± 0.12) and CPAP of 4 cmH2O (0.34 ± 0.12) (P < .001). The forward SV index did not change in any of the sessions (P = .888). However, in men, the forward SV index increased as the applied airway pressure increased, whereas in women, it did not (P = .006). Additionally, patients with a high left ventricular end-systolic volume index and those with a low forward SV index at baseline showed increases in the forward SV index, as the applied airway pressure increased (P = .034 and .017, respectively). Conclusion: In HFrEF patients with functional MR, positive airway pressure can alleviate functional MR without changing forward SV. However, in men with dilated LV and those with low baseline SV, MR alleviation was accompanied by an increase in forward SV.
O42-7 Prognostic Impact of Sleep-disordered Breathing and Its Treatment on Clinical Outcomes in Patients Hospitalized Following Acute Decompensated Heart Failure Hiroki Matsumoto1,2, Takatoshi Kasai1,2, Shoko Suda1,2, Shoichiro Yatsu1, Azusa Murata1, Jun Shitara1, Megumi Shimizu1, Takao Kato1, Masaru Hiki1, Hiroyuki Daida1; 1 Department of Cardiology, Juntendo University Graduate School of Medicine; 2 Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine Introduction: Identifying hospitalized patients at a high risk for worse clinical outcomes following acute decompensated heart failure (ADHF) is important. However, limited data regarding prognostic impact of sleep-disordered breathing (SDB) and its treatment by positive airway pressure (PAP) on clinical outcomes in patients hospitalized following ADHF are available. Methods: After the initial improvement of ADHF, overnight polysomnography was performed on consecutive hospitalized patients whose left ventricular ejection fraction <45% between 2012 and 2014. SDB was defined as an apnea-hypopnea index >15. Patients with SDB were subdivided as those with or without PAP treatment. The risk for clinical events including all-cause death and/or rehospitalization were assessed by stepwise multivariable Cox proportional model. Results: Overall, 114 patients including 76 with SDB (28 with PAP treatment) and 38 without SDB were enrolled. At a median follow-up of 6.8 months, 44 patients had clinical events (39%). In the multivariable analysis, SDB was associated with increased risk of clinical events (hazard ratio [HR], 3.41; P = .005). Among SDB patients, stepwise multivariable analysis showed that PAP treatment was associated with reduced risk of clinical events (HR 0.37; P = .027). Conclusion: In patients hospitalized following ADHF, presence of SDB was associated with worse clinical outcomes, which may be reversible by PAP therapy. Thus, in patients hospitalized following ADHF, SDB should be evaluated and if present, considered for SDB treatment.
O43-1 Real World Data of Adaptive Servo Ventilation Therapy for Patients with Heart Failure with Reduced Ejection Fraction Keita Goto1, Noriaki Takama2, Masahiko Kurabayashi2; 1Isesaki Municipal Hospital, Isesaki, Gunma, Japan; 2Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan Our aim in this study is to estimate whether ASV therapy is effective and safe for patients with HFrEF compared with standard medical therapy (SMT) in real world using three-year follow-up data. All patients with HFrEF (n = 186) were treated with SMT. The patients were divided into two groups by adding ASV therapy (n = 57) or SMT only (n = 129). We observed three-year follow-up to estimate fatal cardiovascular events based on comparisons with SMT. No significant difference (P = .19) was observed between two groups with respect to fatal cardiovascular events rate (Fig. 1). In spite of treating severe HFrEF, our study showed that ASV therapy was effective for HFrEF
O44-2 Incremental Value of Early Diastolic Flow to Global Longitudinal Strain Ratio for the Prediction of Exercise Intolerance in Heart Failure Takayuki Hidaka1, Kenji Masada2, Mirai Kinoshita1, Hiroto Utsuomiya1, Yu Harada1, Hitoshi Susawa1, Yasuki Kihara1; 1The Department of Cardiovascular Medicine, Hiroshima University Hospital, Hiroshima, Japan; 2Department of Cardiovascular Medicine, Hiroshima Prefecture Hospital Background: Abnormal elevation of left ventricular filling pressure during exercise is a cause of exercise intolerance (EI). The early diastolic inflow (E) to global longitudinal strain (GLS) ratio (E/GLS) is proposed as good predictor of LVFP. Objective: To evaluate utility of E/GLS for the prediction of EI in heart failure. Methods: Subjects consisted of 67 patients of heart failure with preserved ejection fraction (PEF) and 23 patients of heart failure with reduced ejection fraction (REF). Echocardiographic images were obtained at rest and GLS was calculated using Echopac software (GE Vingmed Ultrasaound). Cardiopulmonary exercise test was performed using bicycle ergometer. The diagnostic utility of E/GLS to predict EI, in which peak oxygen consumption was less than 55% of predicted maximal oxygen consumption, was evaluated. Results: In PEF, the addition of E/GLS to age and E/e’ significantly improved diagnostic ability. C statics (95%CI) changed from 0.59 (0.36 to 0.83) to 0.83 (0.70 to 0.65), P value was .044. It also significantly improved classification of risk (net reclassification improvement [95%CI], 0.779 [0.136 to 1.442], P = .018). In REF, those findings above mentioned were not confirmed. Conclusion: In patients of PEF, E/GLS was useful to predict EI.
O44-3 Utility and Feasibility of Right Ventricular Strain of a Line Segment in Patients Referred for Left Ventricular Assist Device Shingo Tsujinaga1, Hiroyuki Iwano1, Daisuke Murai1, Taichi Hayashi1, Miwa Sarashina1, Takayuki Kawata2, Masao Daimon2, Toshinari Onishi3, Yasushi Sakata3, Satoshi Yamada1; 1Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University; 2Department of Cardiovascular Medicine, The University of Tokyo Hospital; 3Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Background: Right ventricular (RV) longitudinal strain (LS) is reported to correlate with RV stroke work index (RVSWI) which is a predictor of RV failure after LVAD implantation. However, RVLS occasionally cannot be analyzed in dilated hearts. Purpose: To test the utility and feasibility of a novel parameter, RV strain of a line segment (RVSLS), in patients undergoing LVAD. Methods: Twenty-two heart failure patients underwent right heart catheterization and speckle-tracking echocardiography before and after LAVD implantation. RVSWI was obtained by catheterization. RVLS of free wall (RVLSfw) and that of whole RV (RVLSglobal) were measured in RV-focused four-chamber view. From the same image, RVSLS between the apex and anterior tricuspid annulus (RVSLSfw) and that between the apex and midpoint of tricuspid annulus (RVSLSmid) were measured. Results: Among the 99 data sets, similar correlations to RVSWI were observed in RVLSfw (R = −0.55), RVLSglobal (R = −0.47), RVSLSfw (R = −0.44), and RVSLSmid (R = −0.40) (P < .05 for all). RVLSfw (0.82), RVLSglobal (0.82), RVSLSfw (0.72), and RVLSmid (0.75) had similar areas under the receiver operating characteristic curves to predict depressed RVSWI. RVLSfw and RVSLSfw could be successfully analyzed in 62 (63%) and 83 (84%) out of the 99 analyses, respectively (P < .0001). Conclusions: RVSLS correlated with RVSWI as RVLS did in patients undergoing LVAD. Furthermore, RVSLS had a higher feasibility than RVLS.
treatment, and fatal cardiovascular events in ASV therapy did not show higher rate in real world compared with SMT.
O42-6 Rapid Reductions in Mitral Regurgitation Fraction by CPAP and ASV in Heart Failure Patients with Reduced Ejection Fraction Takao Kato1, Takatoshi Kasai1,2, Shoichiro Yatsu1, Hiroki Matsumoto1,2, Azusa Murata1, Shoko Suda1, Masaru Hiki1, Hiroyuki Daida1; 1Department of Cardiovascular Medicine, Juntendo University; 2Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine Background: Rapid reductions in functional mitral regurgitation (MR) by continuous positive airway pressure (CPAP) and adaptive-servo ventilation (ASV) in heart failure patients with reduced ejection fraction (HFrEF) remain unclear. Methods: Twenty HFrEF patients (14 men) with functional MR underwent echocardiography during 10minute CPAP (4 and 8 cmH2O) and ASV. MR fraction was defined as the ratio of MR to the left atrial area. The forward stroke volume (SV) index was calculated from the time-velocity integral, cross-sectional area of the aortic annulus. Results: MR fraction significantly reduced due to CPAP of 8 cmH2O (0.30 ± 0.12) and ASV (0.29 ± 0.12), compared with the baseline phase (0.37 ± 0.12) and CPAP of 4 cmH2O (0.34 ± 0.12) (P < .001). The forward SV index did not change in any of the sessions (P = .888). However, in men, the forward SV index increased as the applied airway pressure increased, whereas in women, it did not (P = .006). Additionally, patients with a high left ventricular end-systolic volume index and those with a low forward SV index at baseline showed increases in the forward SV index, as the applied airway pressure increased (P = .034 and .017, respectively). Conclusion: In HFrEF patients with functional MR, positive airway pressure can alleviate functional MR without changing forward SV. However, in men with dilated LV and those with low baseline SV, MR alleviation was accompanied by an increase in forward SV.
O42-7 Prognostic Impact of Sleep-disordered Breathing and Its Treatment on Clinical Outcomes in Patients Hospitalized Following Acute Decompensated Heart Failure Hiroki Matsumoto1,2, Takatoshi Kasai1,2, Shoko Suda1,2, Shoichiro Yatsu1, Azusa Murata1, Jun Shitara1, Megumi Shimizu1, Takao Kato1, Masaru Hiki1, Hiroyuki Daida1; 1 Department of Cardiology, Juntendo University Graduate School of Medicine; 2 Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine Introduction: Identifying hospitalized patients at a high risk for worse clinical outcomes following acute decompensated heart failure (ADHF) is important. However, limited data regarding prognostic impact of sleep-disordered breathing (SDB) and its treatment by positive airway pressure (PAP) on clinical outcomes in patients hospitalized following ADHF are available. Methods: After the initial improvement of ADHF, overnight polysomnography was performed on consecutive hospitalized patients whose left ventricular ejection fraction <45% between 2012 and 2014. SDB was defined as an apnea-hypopnea index >15. Patients with SDB were subdivided as those with or without PAP treatment. The risk for clinical events including all-cause death and/or rehospitalization were assessed by stepwise multivariable Cox proportional model. Results: Overall, 114 patients including 76 with SDB (28 with PAP treatment) and 38 without SDB were enrolled. At a median follow-up of 6.8 months, 44 patients had clinical events (39%). In the multivariable analysis, SDB was associated with increased risk of clinical events (hazard ratio [HR], 3.41; P = .005). Among SDB patients, stepwise multivariable analysis showed that PAP treatment was associated with reduced risk of clinical events (HR 0.37; P = .027). Conclusion: In patients hospitalized following ADHF, presence of SDB was associated with worse clinical outcomes, which may be reversible by PAP therapy. Thus, in patients hospitalized following ADHF, SDB should be evaluated and if present, considered for SDB treatment.
O43-1 Real World Data of Adaptive Servo Ventilation Therapy for Patients with Heart Failure with Reduced Ejection Fraction Keita Goto1, Noriaki Takama2, Masahiko Kurabayashi2; 1Isesaki Municipal Hospital, Isesaki, Gunma, Japan; 2Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan Our aim in this study is to estimate whether ASV therapy is effective and safe for patients with HFrEF compared with standard medical therapy (SMT) in real world using three-year follow-up data. All patients with HFrEF (n = 186) were treated with SMT. The patients were divided into two groups by adding ASV therapy (n = 57) or SMT only (n = 129). We observed three-year follow-up to estimate fatal cardiovascular events based on comparisons with SMT. No significant difference (P = .19) was observed between two groups with respect to fatal cardiovascular events rate (Fig. 1). In spite of treating severe HFrEF, our study showed that ASV therapy was effective for HFrEF
O44-2 Incremental Value of Early Diastolic Flow to Global Longitudinal Strain Ratio for the Prediction of Exercise Intolerance in Heart Failure Takayuki Hidaka1, Kenji Masada2, Mirai Kinoshita1, Hiroto Utsuomiya1, Yu Harada1, Hitoshi Susawa1, Yasuki Kihara1; 1The Department of Cardiovascular Medicine, Hiroshima University Hospital, Hiroshima, Japan; 2Department of Cardiovascular Medicine, Hiroshima Prefecture Hospital Background: Abnormal elevation of left ventricular filling pressure during exercise is a cause of exercise intolerance (EI). The early diastolic inflow (E) to global longitudinal strain (GLS) ratio (E/GLS) is proposed as good predictor of LVFP. Objective: To evaluate utility of E/GLS for the prediction of EI in heart failure. Methods: Subjects consisted of 67 patients of heart failure with preserved ejection fraction (PEF) and 23 patients of heart failure with reduced ejection fraction (REF). Echocardiographic images were obtained at rest and GLS was calculated using Echopac software (GE Vingmed Ultrasaound). Cardiopulmonary exercise test was performed using bicycle ergometer. The diagnostic utility of E/GLS to predict EI, in which peak oxygen consumption was less than 55% of predicted maximal oxygen consumption, was evaluated. Results: In PEF, the addition of E/GLS to age and E/e’ significantly improved diagnostic ability. C statics (95%CI) changed from 0.59 (0.36 to 0.83) to 0.83 (0.70 to 0.65), P value was .044. It also significantly improved classification of risk (net reclassification improvement [95%CI], 0.779 [0.136 to 1.442], P = .018). In REF, those findings above mentioned were not confirmed. Conclusion: In patients of PEF, E/GLS was useful to predict EI.
O44-3 Utility and Feasibility of Right Ventricular Strain of a Line Segment in Patients Referred for Left Ventricular Assist Device Shingo Tsujinaga1, Hiroyuki Iwano1, Daisuke Murai1, Taichi Hayashi1, Miwa Sarashina1, Takayuki Kawata2, Masao Daimon2, Toshinari Onishi3, Yasushi Sakata3, Satoshi Yamada1; 1Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University; 2Department of Cardiovascular Medicine, The University of Tokyo Hospital; 3Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Background: Right ventricular (RV) longitudinal strain (LS) is reported to correlate with RV stroke work index (RVSWI) which is a predictor of RV failure after LVAD implantation. However, RVLS occasionally cannot be analyzed in dilated hearts. Purpose: To test the utility and feasibility of a novel parameter, RV strain of a line segment (RVSLS), in patients undergoing LVAD. Methods: Twenty-two heart failure patients underwent right heart catheterization and speckle-tracking echocardiography before and after LAVD implantation. RVSWI was obtained by catheterization. RVLS of free wall (RVLSfw) and that of whole RV (RVLSglobal) were measured in RV-focused four-chamber view. From the same image, RVSLS between the apex and anterior tricuspid annulus (RVSLSfw) and that between the apex and midpoint of tricuspid annulus (RVSLSmid) were measured. Results: Among the 99 data sets, similar correlations to RVSWI were observed in RVLSfw (R = −0.55), RVLSglobal (R = −0.47), RVSLSfw (R = −0.44), and RVSLSmid (R = −0.40) (P < .05 for all). RVLSfw (0.82), RVLSglobal (0.82), RVSLSfw (0.72), and RVLSmid (0.75) had similar areas under the receiver operating characteristic curves to predict depressed RVSWI. RVLSfw and RVSLSfw could be successfully analyzed in 62 (63%) and 83 (84%) out of the 99 analyses, respectively (P < .0001). Conclusions: RVSLS correlated with RVSWI as RVLS did in patients undergoing LVAD. Furthermore, RVSLS had a higher feasibility than RVLS.