G. Javorsky

Arg389Gly-[beta]1-adrenergic receptors determine improvement in left ventricular systolic function in nonischemic cardiomyopathy patients with heart failure after chronic treatment with carvedilol

Objective Administration of the &bgr;-adrenergic receptor blocker carvedilol to patients with chronic heart failure leads to clinically significant benefits, including improvement in left ventricular systolic function in some, but not all, patients. We sought to determine the basis of the variable effect obtained with carvedilol in patients with heart failure. Carvedilol blocks both &bgr;1-adrenergic and &bgr;2-adrenergic receptors, and both receptors exist as polymorphisms. We aimed to determine whether these polymorphisms contribute to variability in response to carvedilol in patients with chronic heart failure. Methods We retrospectively and prospectively investigated 135 patients with nonischemic cardiomyopathy and chronic stable heart failure (New York Heart Association class II, III) treated with carvedilol. Baseline echocardiography was obtained before introduction of carvedilol and repeated after stabilization of a maximally tolerated dose of carvedilol (50–100u2009mg/day) for at least 1 year. Polymerase chain reaction and restriction fragment length polymorphism analysis were used to genotype &bgr;1-adrenergic and &bgr;2-adrenergic receptor polymorphisms. Results When grouped according to receptor polymorphisms patients were well matched for severity of heart failure, comorbidity and treatment. No significant difference was observed in baseline left ventricular ejection fraction (LVEF) between groups (P>0.05). After 1.5 years of treatment with carvedilol patients with Arg389Arg-&bgr;1-adrenergic receptors had a significantly greater improvement in LVEF compared with Gly389 carriers (Arg389Arg 18.8%; Arg389Gly 9.4%; Gly389Gly 6.0%; P<0.001) whereas there were no differences attributable to other &bgr;1-adrenergic and &bgr;2-adrenergic receptor polymorphisms (P>0.05). Conclusion In patients with nonischemic dilated cardiomyopathy, carvedilol leads to a significantly greater improvement in LVEF in patients with the Arg389Arg-&bgr;1 adrenergic receptor phenotype.

Comparison of fluoroscopic versus real-time three-dimensional transthoracic echocardiographic guidance of endomyocardial biopsies

AIMSnFluoroscopic-guided right ventricular (RV) endomyocardial biopsy (EMBx) is the conventional method for obtaining myocardial samples to assess for rejection following heart transplantation. This study was designed to assess the feasibility and accuracy of guiding RV sheath and bioptome tip position using real-time three-dimensional echocardiography (RT3DE).nnnMETHODS AND RESULTSnForty EMBx procedures were performed in 21 patients. Five procedures were in a native heart and 35 were performed following cardiac transplantation. A RV long sheath was positioned toward the mid to distal interventricular septum using fluoroscopy. RT3DE was used to correlate sheath tip position with fluoroscopic position. Bioptome tip visualization and position against the endocardium was assessed using RT3DE. Sheath tip location was repositioned in 18 cases (46%) following assessment using RT3DE, due to alignment toward the apex (9) and mid (5) or distal RV (4) free wall. The bioptome tip could be clearly visualized using RT3DE in 83% of passes. In 35% of passes, the bioptome tip was repositioned using RT3DE guidance to improve the sampling site.nnnCONCLUSIONnRT3DE-guided EMBx was feasible in the majority of patients and resulted in sheath repositioning in 46% of patients and bioptome tip reorientation in 35% of cases.

Improving medication titration in heart failure by embedding a structured medication titration plan

BACKGROUNDnTo improve up-titration of medications to target dose in heart failure patients by improving communication from hospital to primary care.nnnMETHODSnThis quality improvement project was undertaken within three heart failure disease management (HFDM) services in Queensland, Australia. A structured medication plan was collaboratively designed and implemented in an iterative manner, using methods including awareness raising and education, audit and feedback, integration into existing work practice, and incentive payments. Evaluation was undertaken using sequential audits, and included process measures (use of the titration plan, assignment of responsibility) and outcome measures (proportion of patients achieving target dose) in HFDM service patients with reduced left ventricular ejection fraction.nnnRESULTSnComparison of the three patient cohorts (pre-intervention cohort A n=96, intervention cohort B n=95, intervention cohort C n=89) showed increase use of the titration plan, a shift to greater primary care responsibility for titration, and an increase in the proportion of patients achieving target doses of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) (A 37% vs B 48% vs C 55%, p=0.051) and beta-blockers (A 38% vs B 33% vs C 51%, p=0.045). Combining all three cohorts, patients not on target doses when discharged from hospital were more likely to achieve target doses of ACEI/ARB (p<0.0001) and beta blockers (p<0.0001) within six months if they received a medication titration plan.nnnCONCLUSIONSnA medication titration plan was successfully implemented in three HFDM services and improved transitional communication and achievement of target doses of evidence-based therapies within six months of hospital discharge.

Orthotopic Cardiac Transplantation for Chagas Cardiomyopathy in Australia

A 54-year-old male of Central-American descent with a diagnosis of idiopathic dilated-cardiomyopathy was referred to a tertiary referral center for cardiac transplantation assessment. He had no other medical co-morbidities and had been living in Australia for 26 years. At initial presentation three years prior, the left ventricular ejection fraction was 15%. Conventional cardiomyopathy screening was negative. Cardiac MRI showed partial to full thickness scarring of both the lateral and apical left ventricular walls. Coronary angiography revealed minor coronary artery disease only.

Point-of-care INR compared to laboratory INR in patients supported with a continuous flow left ventricular assist device

Fig. 1. Correlation between INR as measured by CoaguChek® XS and the laboratory. Continuous-flow left ventricular assist devices (CF-LVAD) are utilised in patients with end-stage heart failure (ESHF) as a bridge to cardiac transplantation or in some countries, as destination therapy [1]. Thrombotic and bleeding events are the most frequent and serious complications in patients with CF-LVAD [2]. As such, warfarinisation and a daily reported international normalised ratio (INR) value between 2.0 and 3.0 are required to reduce the thrombotic risk [3]. The CoaguChek® XS (Roche Diagnostics, Indiana, North America) has been approved for use as a form of anticoagulation monitoring. However there is limited data in its use formonitoring anticoagulation in patients with a CF-LVAD [4]. We analysed 230 INR values, as measured by CoaguChek® XS and the laboratory (Stagos STA-R Evolution, Leicester, United Kingdom), from 15 patients with CF-LVAD for ESHF as a bridge to transplant at The Prince Charles Hospital (Brisbane, Australia) between December 2013 and August 2015. Blood samples for each of the testing methods were taken on the same day and within a 4-hour window of each other. Mean age of 40 ± 14 years. 10 (67%) were male and target INR was 2–3 for all patients. 4 (27%) were on amiodarone, mean creatinine was 89±53 μmol/L,meanhaematocrit 0.32 (+/−0.05) and nopatients had hepatic synthetic or thyroid dysfunction. There was amoderate correlation between laboratory and CoaguChek® XS INR values with a correlation coefficient of 0.86 (r2= 0.75, p b 0.001) shown in Fig. 1. Mean INR was significantly different between the laboratory and CoaguChek® XS

Excessive Daytime Sleepiness and Sleep Disordered Breathing in Stable Heart Failure Patients

considered preventable. Readmission monitoring is a key performance indicator for Heart Failure Management Programmes (HF-MPs). Aim: To investigate the underlying causes, contributing factors and incidence of unplanned hospital readmissions for HF patients. Methods:A sixmonth prospective studywas performed at the PrincessAlexandraHospital, a tertiary referral facility. A convenience sample of 50 adult patientsmanaged by theHF-MPwas recruited.Health literacywas assessed.All unplanned admissions were investigated with admission interview andworksheet. At six months hospital readmissions were verified by patients, patient medical records and electronic databases. Results: Participants mean age was 70 (±11.6), 38 (76%) were male, 11 (22%) had inadequate health literacy. Of the 45 (90%) patients with systolic HF, 35 (78%) had an ejection fraction (EF)≤ 30%. There were 46 unplanned readmissions during six month follow-up, 28 were HF related and involved 17 patients (HF readmissions 34%). Six of these patients had >1 readmission and six (12%) patients died. Of the patients readmitted for HF, 82% had systolic HF with EF≤ 30%, and an average length of stay of seven (±5.7) days. Thirty days readmission rate was 12%. Eighty-six percent of patients readmitted with HF were on optimal medical therapy including beta blocker, ACE inhibitor/Angiotensin II receptor antagonist and mineralocorticoid receptor antagonist. All patients received self-care education and early follow-up from multi-disciplinary HF clinicians. Conclusion:Unplanned HF readmissions in this cohort of patients with severe systolic HF are common despite optimal medical therapy and intensive HF-MPs. http://dx.doi.org/10.1016/j.hlc.2013.05.182

Heart Transplant Survival Rates in Patients Requiring a Ventricular Assist Device as a Bridge to Transplant

Conclusions: CRT generally reduces mortality and improves outcomes, AdaptivCRT® improves the costeffectiveness of this device class. http://dx.doi.org/10.1016/j.hlc.2013.05.184

Indolent cardiac angioma mimicking hypertrophic obstructive cardiomyopathy and causing right ventricular outflow tract obstruction

A 20-year-old female with a 12-year history of hypertrophic obstructive cardiomyopathy (HOCM) with progressive right ventricular outflow obstruction (RVOTO) and mild left ventricular outflow obstruction (LVOTO) was referred to our institution for consideration of septal myomectomy due to symptomatic outflow tract obstruction. The patient had New York Heart Association Class III dyspnoea, abdominal bloating, nausea, and vomiting with palpitations and presyncope on standing or walking up stairs. Examination revealed …

580 Evaluation of the Role of a Long Sheath for Endomyocardial Biopsy Following Heart Transplantation on the Incidence of Tricuspid Regurgitation

Purpose: In the first 12 months following heart transplantation it is standard practice to perform a schedule of endomyocardial biopsies (EMBx) to detect allograft rejection. The commonest cardiac complication of this procedure is tricuspid regurgitation (TR), which is thought to reflect damage to tricuspid valve leaflets or sub-valvular apparatus by the bioptome during its repeated passage across the tricuspid valve. At our institution, we have adopted the use a long sheath which sits directly in the right ventricle to guide the bioptome and avoid repeatedly crossing the tricuspid valve. We sought to assess the impact of this technique on the degree of tricuspid regurgitation. Methods and Materials: We performed a retrospective analysis of all the available echocardiograph reports at approximately 5 years follow up of all patients transplanted at our centre. There were two patient groups; the first group had EMBx without a long sheath (“standard technique”, prior to year 2000) and the second group had an EMBx with a long sheath. Patients were excluded from analysis if they did not survive to at least 4 years post transplant. Conventional echocardiographic parameters were used to grade TR severity from 0 to 4. Results: There were 109 patients in group one (no long sheath) and 55 patients in group two (long sheath utilsied). The mean severity of TR using a long sheath was significantly reduced (0.64, SD: 0.754) compared to the standard technique (1.33, SD: 1.03) (p 0.001). The incidence of trivial or less TR at 5 years post transplant was 34/55 (62%) for long sheath use vs 31/109 (28%) for standard technique (p 0.001). Incidence of grade 3 or 4 TR at 5 years post transplant was 1/55 (2%) for long sheath use vs 13/109 (12%) for the standard technique (p 0.005). Conclusions: Use of a long sheath for routine post heart transplant right ventricular endomyocardial biopsy reduces the severity and incidence of subsequent tricuspid regurgitation although the overall incidence is low whichever technique is employed.

Predicting Success of Prednisolone Weaning in Heart Transplant Recipients

the reduction significantly greater for placebo vs. irbesartan for PIIINP only, p= 0.185. Conclusions: Increased peripheral collagen turnover markers are associated with increased mortality and cardiovascular hospitalisation in a HFPEF population. These findings suggest that pathological fibrosis in the heartmay contribute to adverse clinical outcomes inHFPEFpatients. Therapies specifically targeting cardiac fibrosismay therefore be of clinical benefit in this setting. doi:10.1016/j.hlc.2010.06.849