Dominik Schlosshan

The benefits of valsartan in the treatment of heart failure: results from Val-HeFT

Angiotensin II receptor blockers (ARBs) are the most recent class of anti‐hypertensive drug to enter clinical use for chronic heart failure (CHF). In the landmark Valsartan Heart Failure Trial (Val‐HeFT), valsartan reduced the risk of the combined endpoint of all‐cause mortality and morbidity by 13.2% over a 2‐year follow‐up. Although it significantly improved a pre‐specified primary endpoint, it did not improve the endpoint of all‐cause mortality. Valsartan administered to patients not receiving angiotensin‐converting enzyme inhibitors (ACEI) at baseline reduced the endpoint of all‐cause mortality by 33% and the combined endpoint of mortality and morbidity by 44%, compared with placebo. Based on these findings, valsartan became the first ARB to be approved by the US Food and Drug Administration for the treatment of New York Heart Association class II–IV HF in patients who are intolerant of ACEIs. This review provides a summary of the key Val‐HeFT results and their implications in the treatment of CHF patients.

Prognostic indicators in patients presenting with acute cardiogenic pulmonary edema treated with CPAP: it's not the acid that matters, it's back to basics.

Several prognostic markers have been identified for patients admitted with acute cardiogenic pulmonary edema. Most of the markers are based on clinical risk scores. Unlike hypercapnic respiratory failure, acidosis is not an adverse predictor in these patients. Hemodynamic variables that assess pathophysiological mechanisms may be more helpful to guide appropriate management.

Trans-catheter aortic valve implantation without contrast using the Lotus mechanically-expanded heart valve

Trans-catheter aortic valve implantation (TAVI) has become an established treatment for inoperable and high-surgical risk patients with severe, symptomatic aortic stenosis (AS). Post-procedural acute kidney injury (AKI) is a frequent complication following TAVI and is associated with increased mortality. Patients with pre-existing chronic renal impairment are at particularly high risk. The etiology of post-TAVI AKI is multi-factorial, but the principal procedural issues are contrast-induced nephropathy, and renal hypoperfusion secondary to intra-procedural hypotension. We report a case of a TAVI in an 80-year-old patient with severe AS and significant chronic kidney disease (CKD), which was carried out without the use of contrast and with minimal procedural hypotension. Pre-procedural imaging was carried out using 3D trans-esophageal echocardiography (TEE) rather than computed tomography (CT) to avoid contrast administration. The Lotus valve (Boston Scientific, Marlborough, MA, USA) was chosen due to a number of design features which minimize both the need for contrast injection and procedural hypotension during valve positioning and deployment. The procedure was carried out successfully and produced an excellent result with no decline in renal function. We believe that the approach of using TEE and the mechanically-expanded Lotus valve illustrates an important therapeutic approach in patients with severe CKD. <Learning objective: Post-procedural acute kidney injury (AKI) is a frequent complication following trans-catheter aortic valve implantation (TAVI), and is associated with increased mortality. The principal procedural issues are contrast-induced nephropathy and intra-procedural hypotension. Our case report demonstrates how TAVI can be performed with zero contrast and minimization of procedural hypotension, facilitated by the use of trans-esophageal echocardiography and the mechanically-expanded Lotus valve. This approach should only be used in exceptional circumstances, but can be particularly relevant for patients with pre-existing chronic renal impairment, who are at increased risk of post-TAVI AKI.>.

Severe aortic stenosis, critical coronary artery disease, and transfusion-dependent angiodysplasia – A management conundrum

The combination of severe aortic stenosis, bleeding due to Heydes syndrome and critical coronary artery disease presents a management challenge. We report the case of an 86-year-old who underwent percutaneous coronary intervention to the right coronary artery, simultaneous balloon aortic valvuloplasty to treat aortic stenosis and address bleeding from Heydes syndrome, and subsequent staged transcatheter aortic valve implantation. <Learning objective: The combination of severe aortic stenosis (AS), bleeding due to Heydes syndrome and critical coronary artery disease presents a management challenge. This case demonstrated the efficacy of balloon aortic valvuloplasty in resolving gastrointestinal bleeding, with intravascular ultrasound-guided percutaneous coronary intervention with a bare metal stent and single anti-platelet therapy safely and effectively addressing critical coronary stenosis, allowing definitive treatment of AS by transcatheter aortic valve implantation to be performed as a staged procedure.>.

31 Pulmonary hypertension in severe aortic stenosis: prevalence and reversibility with transcatheter aortic valve implant

Introduction We explored the impact of transcatheter aortic valve implantation (TAVI) on pulmonary hypertension (PH) by assessing the prevalence and reversibility of PH in an unselected TAVI cohort. We also identified factors that may predict PH and regression of PH after TAVI. Methods Retrospective analysis of a local TAVI database. 308 consecutive patients underwent TAVI between 2008–13. Pulmonary artery systolic pressure (PASP) was estimated from the velocity of tricuspid regurgitation jet using Bernouille principle; PH was diagnosed if PASP was ≥50mmHg. Simple correlation (Spearman’s rank rS) and regression analyses were used to determine predictors of PH and the change (and 95% confidence interval) in PASP (ΔPASP) after TAVI. Wilcoxon signed-rank Z-test was used to analyse ordinal data. Results 71 (23%) patients had PH, in this group mean PASP before TAVI was 62 ± 6.5mmHg. PASP reduced in 56%, the mean ΔPASP was -12.8mmHg (95% C. I. -9.5 to -16.1, P < 0.001). PASP was weakly positively associated with the severity of MR (rS=0.276, p = 0.03); ΔPASP was associated only with baseline PASP (rS=0.3, p = 0.02) and change in LV end diastolic pressure (rS=0.4, p < 0.003). There were small improvements in severity of MR (Z=-3.5, p < 0.01) and a trend to improved LV function (Z=-1.9, p = 0.06) however regression analysis identified only change in LV end diastolic pressure to predict ΔPASP (p < 0.05). Conclusion PH is common and usually reversible post TAVI. MR is a significant predictor of PH, the only predictor of regression of PH is reduction in LV end-diastolic function at implantation.

36 Direct Measurement of Cardiac Compensation in Valvular Heart Disease

Purpose The natural history of valvular heart disease (VHD) suggests that the heart initially adapts to compensate for valve lesions and thereby maintain physiological function. When these compensatory mechanisms become exhausted, cardiac decompensation commences. We tested the hypothesis that all VHD patients with normal exercise capacity are in the compensatory phase with no symptoms and normal cardiac reserve. Methods Unselected consecutive male patients with VHD performed cardiopulmonary exercise (CPX) testing with non-invasive central haemodynamic measurements during symptom-limited treadmill exercise. Exercise capacity was represented by peak oxygen consumption (VO2max) and cardiac pumping capability by peak exercise cardiac power output (CPOmax). Data are given as mean±SD. Results Of the entire VHD patient cohort (n = 215), 81.4% (n = 175) had VO2max which were within or above the reference range of healthy male sedentary controls (n = 101). This is shown in Figure 1A where individual patient VO2max is expressed as a percentage of the average VO2max of age- and sex-matched controls. These 175 patients with normal VO2max had a mean age of 63.1 ± 14.0 years, and consisted of 98 (56%) who were asymptomatic (NYHA class I) and 77 (44%) who were discordantly symptomatic in NYHA II+ (.001). As shown in Figure 1B, 117 patients (66.9%) had CPOmax within the normal range, of whom 80 (45.7%) were asymptomatic, but 37 (21.1%) were in NYHA II+ despite having normal VO2max and CPOmax (.001). Conversely, 58 (33.1%) had CPOmax below the normal range, and yet 18 (10.3%) of these were discordantly still in NYHA I (P < 0.001). These patients were classified asymptomatic by their responsible clinicians but our results revealed they had early, objective evidence of cardiac decompensation. Abstract 36 Figure 1 (a) Peak O2 consumption (VO2max) and (b) peak cardiac power output (CPOmax) expressed as a percentage of the average VO2max of age- and sex-matched controls Conclusions This investigation demonstrates that it is now possible to directly and objectively measure whether patients are in the compensated or decompensated phases of VHD. There were discrepancies between subjective symptomatic statuses and objectively measured cardiac and physical functional statuses. The possibility to determine whether patients are in the compensatory phase or not, might help in the management of difficult VHD cases. Abstract 36 Figure 2 Valve disease patients with normal exercise capacity (VO 2max ) and their compositions with respect to NHYA classification and low or normal peak cardiac power output (CPOmax)

93 Does Intervention of Severe Valve Lesions always Improve Cardiac Function

Introduction Severe valve lesions can result in cardiac decompensation. This study investigated the effects of surgical valvular intervention upon cardiac function assessed as peak cardiac power output (CPOmax) generation during exercise. We hypothesised that (i) cardiac function improves after valvular intervention, and (ii) those with subnormal pre-operative cardiac reserve indicative of cardiac decompensation would gain less physical and cardiac functional benefits than those with preserved pre-operative cardiac function. Methods We compared the cardiopulmonary exercise performance and non-invasive haemodynamics of 46 consecutive patients with severe valvular disease before and after valvular intervention with reference to 101 healthy male and 139 female controls without cardiovascular disease. Cardiac and physical functional reserves were measured with standard respiratory gas analyses and CO2 rebreathing to measure peak cardiac output and quantify peak cardiac power output (CPOmax) non-invasively during treadmill exercise. Data are given as mean±SD and statistical significance accepted at P < 0.05. Results The patient cohort showed no overall benefit from valvular intervention (pre-operative CPOmax 3.48 ± 1.27W, post-operative CPOmax 3.60 ± 0.96W, P = 0.42, n = 46). However, this comprised opposing effects upon two subgroups distinguished by a pre-operative CPOmax below (LoW subgroup) or within (HiW subgroup) the normal range defined by the control population. Thus, in the LoW subgroup CPOmax increased with valvular intervention from 2.63 ± 0.67 to 3.42 ± 0.98W (P = 0.000014; n = 26), NYHA class improved (from 2.29 ± 0.75 to 1.65 ± 0.75, P = 0.0004), peak oxygen consumption (VO2max) increased (from 1.38 ± 0.55 to 1.56 ± 0.59 l.min-1, P = 0.002), and peak flow- and cardiac pressure-generating capacities increased. In contrast, in the HiW subgroup, CPOmax decreased from 4.58 ± 0.96 to 3.84 ± 0.92W following intervention (P = 0.00026; n = 20). NYHA classification remained unchanged, VO2max decreased (from 2.29 ± 0.72 to 1.97 ± 0.75 l.min-1, P = 0.005) and peak cardiac flow- and pressure-generating capacities significantly decreased (all P < 0.05) after valve intervention. Conclusions This is the first investigation of the effects of surgical intervention upon non-invasively measured CPOmax during exercise in patients with severe valvular disease. It unexpectedly demonstrates that valvular interventions performed in routine clinical practice do not consistently improve cardiac function. Patients with subnormal pre-operative cardiac functional reserve benefited from intervention, with significantly improved cardiac and physical fitness. Patients with normal pre-operative cardiac functional reserve generally showed decreased cardiac and physical fitness. Abstract 93 Figure 1 Abstract 93 Table 1 Peak cardiopulmonary exercise haemodynamic and gaseous exchange data

97 Value of Cardiopulmonary Exercise and Non-invasive Haemodynamic assessment during Exercise in Patients with Asymptomatic Severe Aortic Stenosis

Background Timing of aortic valve replacement in patients with severe asymptomatic aortic stenosis (VD) is controversial. Exercise testing may uncover symptoms and early cardiac dysfunction. However there is little information on the value of cardiopulmonary exercise (CPX) testing combined with haemodynamic assessment during exercise in this patient group. We report preliminary results of CPX and haemodynamic data in this patient cohort. Methods 21 consecutive patients with severe VD underwent maximal CPX tests. Central haemodynamics including cardiac output were measured non-invasively at rest and during peak exercise. The results were compared to normal values from a cohort of healthy controls and depicted as % of predicted for normal healthy controls. Abstract 97 Figure 1 Abstract 97 Figure 2 Results The following preliminary observations were made and are depicted on the graphs: (1) All patients except one (5%) had peak oxygen consumption (VO2max) within the ranges for healthy controls. (2) Five patients (24%) had cardiac power output (CPOmax) below the range for healthy controls. (3) When plotted together relative to healthy controls the CPOmax of patients with severe VD were lagging below the VO2max, suggesting measurement of VO2max alone may not pick out the ones with early cardiac dysfunction. Conclusion Haemodynamic assessment during exercise using direct indicators of cardiac function may be more sensitive than conventional cardiopulmonary exercise parameters in detecting early cardiac dysfunction in patients with severe asymptomatic aortic stenosis.