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Background: Cardiac magnetic resonance imaging (CMR) remains underutilized as an exercise imaging modality, mostly because of the limited availability of MR-compatible exercise equipment. This study prospectively evaluates the clinical feasibility of a newly developed MR-conditional pedal ergometer for exercise CMR Methods: Ten healthy volunteers (mean age 44 ± 16 years) and 11 patients (mean age 60 ± 9 years) with known or suspected coronary artery disease (CAD) underwent rest and post-exercise cinematic 3T CMR. Visual analysis of wall motion abnormalities (WMA) was rated by 2 experienced radiologists, and volumes and ejection fractions (EF) were determined. Image quality was assessed by a 4-point Likert scale for visibility of endocardial borders. Results: Median subjective image quality of real-time Cine at rest was 1 (IQR 1–2) and 2 (IQR 2–2.5) for post-exercise real-time Cine (p = 0.001). Exercise induced a significant increase in heart rate (62 [62–73] to 111 [104–143] bpm, p < 0.0001). Stroke volume and cardiac index increased from resting to post-exercise conditions (85 ± 21 to 101 ± 19 mL and 2.9 ± 0.7 to 6.6 ± 1.9 L/min/m 2 , respectively; both p < 0.0001), driven by a reduction in end-systolic volume (55 ± 20 to 42 ± 21 mL, p < 0.0001). Patients (2/11) with inducible regional WMA at high-resolution post-exercise cine imaging revealed significant coronary artery stenosis in subsequently performed invasive coronary angiography. Conclusion: Exercise-CMR using our newly developed 3T MR-conditional pedal ergometer is clinically feasible. Imaging of both cardiac response and myocardial ischemia, triggered by dynamic stress, is rapidly conducted while the patient is near their peak heart rate.

Pacing-induced cardiomyopathy (PICM) consists of heart failure (HF) associated with a drop in the left ventricular ejection fraction (LVEF) in the setting of high-burden right ventricular pacing, with presentation that may range from subclinical to severe. Time to manifestation can go from weeks to years after device implantation. Treatment typically consists in an upgrade to a cardiac resynchronisation therapy (CRT) or His bundle pacing (HisP). Several risk factors for PICM have been described and should be considered before pacemaker (PM) implantation, as thorough patient selection for de novo CRT or HisP, may preclude its manifestation. We present the case of an 82-year-old patient presenting with acute congestive HF and new severely reduced LVEF, 30 days following dual chamber PM implantation for high-grade atrioventricular block. Treatment with HF medication and upgrade to a CRT permitted rapid resolution of the symptoms and normalisation of the LVEF at 1-month follow-up.

Background: Many patients in the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) had a significant improvement (> 10%) in the left ventricular ejection fraction (LVEF) during the course of the study, but the factors and outcomes associated with such improvement are uncertain. Methods: We examined factors and rates of mortality, cause-specific mortality, and implantable cardioverter defibrillator (ICD) shocks associated with improvement in LVEF by analyzing patients in the SCD-HeFT who were randomized to placebo or an ICD and who had an LVEF checked during follow-up. Results: During a median follow-up of 3.99 years, of 837 patients who had at least two follow-up LVEF measurements, 276 (33%) patients had > 10% improvement in LVEF and 561 (67%) patients had no significant change in LVEF. Factors significantly associated with LVEF improvement included female sex, white race, history of hypertension, a QRS duration < 120 ms, and beta-blocker use. Improvement in LVEF was associated with a significant improvement in survival. There was no significant association between improvement in LVEF and cause-specific death, but there was a significant association between improvement in LVEF and reduced risk of receiving appropriate ICD shocks. Conclusions: About a third of patients in this analysis, who were randomized to placebo or an ICD in SCD-HeFT, had a significant improvement in LVEF during follow-up; improvement in LVEF was associated with improved survival but not with cause-specific death, and with decreased likelihood of receiving appropriate ICD shocks.

OBJECTIVES Neonatal rodents and piglets naturally regenerate the injured heart after myocardial infarction. We hypothesized that neonatal rabbits also exhibit natural heart regeneration after myocardial infarction. METHODS New Zealand white rabbit kits underwent sham surgery or left coronary ligation on postnatal day 1 (n = 94), postnatal day 4 (n = 11), or postnatal day 7 (n = 52). Hearts were explanted 1 day postsurgery to confirm ischemic injury, at 1 week postsurgery to assess cardiomyocyte proliferation, and at 3 weeks postsurgery to assess left ventricular ejection fraction and scar size. Data are presented as mean ± standard deviation. RESULTS Size of ischemic injury as a percentage of left ventricular area was similar after myocardial infarction on postnatal day 1 versus on postnatal day 7 (42.3% ± 5.4% vs 42.3% ± 4.7%, P = .9984). Echocardiography confirmed severely reduced ejection fraction at 1 day after postnatal day 1 myocardial infarction (33.7% ± 5.3% vs 65.2% ± 5.5% for postnatal day 1 sham, P = .0001), but no difference at 3 weeks after postnatal day 1 myocardial infarction (56.0% ± 4.0% vs 58.0% ± 3.3% for postnatal day 1 sham, P = .2198). Ejection fraction failed to recover after postnatal day 4 myocardial infarction (49.2% ± 1.8% vs 58.5% ± 5.8% for postnatal day 4 sham, P = .0109) and postnatal day 7 myocardial infarction (39.0% ± 7.8% vs 60.2% ± 5.0% for postnatal day 7 sham, P

Aortic regurgitation (AR) is a common valvular heart disease, but the optimal timing of surgical intervention remains controversial. In the natural history of chronic severe AR, sudden death is rare, and the annual mortality rate is comparatively low. Considering the hemodynamic features of combined volume and pressure overload and long-term compensation in patients with chronic AR, symptoms related to AR do not frequently occur. Therefore, the progression of left ventricular (LV) dysfunction is a key factor in determining the timing of surgical intervention in patients with severe chronic AR. In addition to symptoms, an ejection fraction 45 mm are appropriate cutoff values for surgical intervention in Japanese patients, whereas LV end-diastolic diameter is not a good indicator. An LVESD index of 25 mm/m2is controversial, because adjusting for body size may cause overcorrection in Japanese patients who have a small body size compared with Westerners. Accumulation of data from the Japanese population is indispensable for establishing guidelines on optimal management of patients with chronic AR.

Background Concerns regarding long-term durability of surgical repair for functional mitral regurgitation are based on short-term data, with few comparisons of ischemic (IMR) versus non-ischemic (NIFMR) etiology. Methods 788 consecutive patients receiving mitral repair for functional mitral regurgitation were evaluated from a prospectively maintained database. Patients with other surgical procedures were included. Propensity score matching was used to compare outcomes in IMR versus NIFMR. Results Unmatched IMR patients tended to be older men with greater comorbidities. 198 matched pairs of IMR versus NIFMR patients had similar demographics with relatively preserved ejection fraction 40±13% and end-systolic diameter 4.3±1.1cm. Concomitant coronary revascularization occurred in 70% of matched IMR patients. All patients received an annuloplasty ring, usually 24-26 mm. Heart failure class improved from 2.8 preop to 1.5 at 5 years (P =2+) mitral regurgitation (27±4% v 26±4%, P=0.4), severe regurgitation (10±3% v 8±2%, P=0.5), and mitral reoperation (3±1% v 3±1%, P=0.4) were not different between IMR v NIFMR. Recurrent moderate regurgitation was associated with heart failure readmission but not with mortality. Conclusions In propensity-matched patients, IMR versus NIFMR had worse survival but similar repair durability, with moderate regurgitation in 27% at 10 years and rare severe regurgitation or mitral reoperation. In selected patients with relatively preserved function, mitral repair for IMR or NIFMR can improve symptoms with durable mild regurgitation in most patients out to 10 years.

Objective Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG). Currently, there is no reliable way to determine preoperatively which patients will develop POAF following CABG. The aim of this study was to determine whether preoperative left atrial (LA) strain analysis might identify patients destined to develop POAF following CABG. Methods From 2016 to 2018, 211 patients who had a preoperative left ventricular ejection fraction >50% and adequate preoperative, predischarge, and follow-up echo images for interpretation underwent isolated CABG surgery. Postoperatively, patients had continuous rhythm monitoring until hospital discharge. Retrospective speckle-tracking analysis of preoperative echocardiograms was performed to calculate preoperative left ventricular global longitudinal strain and LA compliance and contraction strains in 92 matched patients. Multivariate logistic regression and Cox proportional hazards models were used to determine the predictors of POAF after CABG. Results POAF occurred in 50 patients (24%). They were older, had longer intensive care unit and hospital stays, and a slightly greater 30-day mortality (P = .07). Preoperative LA volume index was larger in the patients with POAF but still “normal” as defined by current guidelines. However, preoperative LA compliance and contraction strains were significantly lower in patients who developed POAF after CABG. Conclusions Decreased preoperative LA strain measurements, especially LA-fractional area change, LA-emptying fraction, and LA-reservoir strain, taken jointly, are more specific and sensitive than other preoperative parameters in identifying patients who will develop POAF following CABG. The ability to identify patients preoperatively who are destined to develop POAF following CABG provides a basis for limiting POAF prophylactic therapy to only those patients undergoing CABG who are most likely to benefit from it rather than to all patients undergoing CABG.

To determine the potential impact of referral bias on short- and long-term outcomes following septal myectomy for hypertrophic cardiomyopathy.We reviewed 2303 adult patients who underwent transaortic septal myectomy for obstructive hypertrophic cardiomyopathy from January 1993 to April 2016. Patients were divided into 3 groups according to their permanent address: local (state) residents (n = 324), regional (surrounding 5 states) patients (n = 515), and national (outside 5 states) patients (n = 1464).Patient groups were similar for age, sex, preoperative New York Heart Association class, and left ventricular ejection fraction. Local patients had increased prevalence of diabetes mellitus (13%, 11%, 8%; P = .006), coronary artery disease (25%, 21%, 19%; P = .031), severe chronic lung disease (2.3%, 1.9%, 0.4%; P .001), and atrial fibrillation (24%, 18%, 19%; P = .045) when compared with regional and national patients. Echocardiographic features did not differ between the 3 groups, including prevalence of moderate or greater mitral regurgitation (59%, 61%, 56%; P = .161). Local and regional patients were more likely to undergo concomitant procedures than national patients (P .001). Mitral valve surgery was performed in 9.6% of the patients, more commonly in local and regional patients (12%, 12%, 8%; P = .018). There were 11 operative deaths (0.5%), and early mortality was similar among the groups. Geographic origin did not impact overall late survival.Compared with distant referrals, local patients who undergo septal myectomy at our institution have more comorbid conditions, and require more concomitant surgical procedures. Despite these differences, referral patterns did not impact early or late outcomes following transaortic septal myectomy.

Takotsubo syndrome is an acute and often reversible condition, with initial presentation mimicking acute coronary syndrome. Typically, patients present with left ventricular regional wall motion abnormalities, without a corresponding coronary artery obstruction on angiography. Coexistence of a coronary artery disease is possible and may render the distinction between the two entities particularly challenging. We report the case of a 94-year-old woman with chest pain after an emotional upset and acute myocardial injury. Transthoracic echocardiogram (TTE) revealed a severely reduced left ventricular ejection fraction (LVEF) with apical ballooning. Coronary angiogram showed significant stenosis of the distal left main coronary artery and of the mid-left anterior descending artery, as well as a 30%–50% stenosis of the mid-distal right coronary artery. Revascularisation was deferred and antiplatelet as well as heart failure therapy begun. A repeat TTE 6 days later revealed a quasi-normalised LVEF. Ultimately, percutaneous coronary revascularisation of the left main and left anterior descending artery was performed, with favourable outcome at 6-month follow-up.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are now seen as an integral part of therapy in type 2 diabetes to control not only blood glucose but to improve cardiovascular and kidney outcomes. Diabetic ketoacidosis (DKA) is an uncommon but serious complication of type 2 diabetes, which has a high case fatality rate. The absolute risk of DKA in large, prospective randomized clinical trials in people with type 2 diabetes using SGLT2 inhibitors has been low, although the relative risk is higher in those assigned to SGLT2 inhibitors compared with placebo. In those without diabetes but prescribed SGLT2 inhibitors for heart failure or chronic kidney disease, the risk of DKA is similar to placebo. Over the course of the COVID-19 pandemic, cases of DKA have also been reported in cases of COVID-19 hospitalizations. Consensus guidelines have recommended that SGLT2 inhibitors should be avoided in cases of serious illness and suggest they are not recommended for routine in-hospital use. However, recent data suggest potential beneficial effects of SGLT2 inhibitors in the setting of acute illness with COVID-19 with no increase in adverse events and low rates of DKA, which were non-severe. Given the low rates of DKA in cardiovascular outcome trials and in hospitalized patients with type 2 diabetes, the potential for SGLT2 inhibitors not being re-initiated following discharge and their cardiovascular and kidney benefits, we believe the practice of routine 'sick day' guidance should be re-examined based on current evidence with a call for further research in this area. Furthermore, high-quality trials of initiation of SGLT2 inhibitors in people admitted to hospital with cardiovascular disease or kidney disease, and trials of continuation of SGLT2 inhibitors in people, with careful monitoring of DKA should be conducted. These should be further supplemented with large observational studies.

Background: Pathological Q waves are correlated with infarct size, and Q-wave regression is associated with left ventricular ejection fraction improvement. There are limited data regarding the association of Q-wave regression and clinical outcomes. Our main objective was to assess the association of pathological Q wave evolution after re-perfusion with clinical outcomes after anterior STEMI.Methods: Standard 12-lead electrocardiograms (ECGs) were recorded in 780 anterior STEMI patients treated with primary percutaneous coronary intervention (PCI) from the CIRCUS trial. ECGs were recorded before and 90 min following PCI, as well as at hospitalization discharge and 12 months of follow-up. The number of classic ECG criteria Q waves was scored for each ECG. Patients were classified in the Q wave regression group if they had re-gression of at least one Q wave between the post-PCI, the discharge and/or one year ECGs. Patients were classified in the Q wave persistent group if they had the same number or greater between the post-PCI, the discharge and/ or 1 and one year ECGs. All-cause death and heart failure events were assessed for all patients at one year.Results: There were 323(43%) patients with persistent Q waves (PQ group), 378(49%) patients with Q wave re-gression (RQ group) and 60(8%) patients with non-Q wave MI (NQ group). Infarct size as measured by the peak creatine kinase was significantly greater in the PQ group compared to the RQ and NQ groups (4633 +/- 2784 IU/l vs. 3814 +/- 2595 IU/l vs. 1733 +/- 1583 IU/l respectively, p b 0.0001). At one year, there were 22 deaths (7%) in the PQ-group, 15 (4%) in the RQ-group and none in the NQ-group (p = 0.04). There was a 4-fold increase in the risk of death or heart failure in the PQ compared to the NQ group (HR 4.7 [1.1; 19.3]; p = 0.03), but there was no significant difference between NQ and RQ groups (HR 3.3 [0.8; 13.8]; p = 0.09).Conclusion: Ina population of anterior STEMI patients, persistent Q waves defined according to the classic ECG criteria after reperfusion was associated with a 4-fold increase in the risk of heart failure or death compared to non-Q-wave MI, while Q-wave regression was associated with significantly lower risk of events.(c) 2019 Elsevier Inc. All rights reserved.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a class of anti-diabetic agents that block the reabsorption of glucose in the proximal convoluted tubule of the nephron, thereby contributing to glycosuria and lowering blood glucose levels. SGLT2 inhibitors have been associated with improved cardiovascular outcomes in patients with diabetes, including a reduced risk of cardiovascular death and hospitalizations for heart failure. Recently, DAPA-HF and EMPEROR REDUCED trials showed the beneficial cardiovascular effect of SGLT2 inhibitors in patients with heart failure with consistently reduced ejection fraction (HFrEF) regardless of the presence of diabetes. Moreover, some exploratory studies suggested that these drugs improve Left Ventricular (LV) systolic function and oppose LV adverse remodeling in patients with HFrEF. However, the exact mechanisms that mediated for this benefit are not fully understood. Beyond glycemic control, enhanced natriuresis, increased erythropoiesis, improved endothelial function, changes in myocardial metabolism, anti-inflammatory and anti-oxidative properties may all play an active role in SGLT2 inhibitors' cardiovascular benefits. A deep understanding of the pathophysiological interplay is key to define which HF phenotype could benefit more from SGLT2 inhibitors. Current clinical evidence on the comparison of different HF etiologies is limited to posthoc subgroup analysis of DAPA-HF and EMPEROR-REDUCED, which showed similar outcomes in patients with or without ischemic HF. On the other hand, in earlier studies of patients suffering from diabetes, rates of classic ischemic endpoints, such as myocardial infarction, stroke or coronary revascularization, did not differ between patients treated with SGLT2 inhibitors or placebo. The aim of this review is to discuss whether SGLT2 inhibitors may improve prognosis in patients with ischemic HF, not only in terms of reducing re-hospitalizations and improving left ventricular function but also by limiting coronary artery disease progression and ischemic burden.

The reduction in exercise capacity after mitral valve repair (MVr) for severe degenerative mitral regurgitation is an unsolved issue. This study aimed to evaluate hemodynamics after MVr using a partial semirigid band during exercise stress echocardiography and to identify predictive factors for achieving better exercise capacity after MVr.We retrospectively analyzed 48 patients using exercise stress echocardiography within 5 years of having undergone MVr using a partial semirigid band between 2013 and 2019. Values of maximal workload were converted into numbers of metabolic equivalents (METs) achieved for each patient. Age and sex expected METs (eMETs) were obtained, and percent eMETs (%eMETs [achieved METs / eMETs × 100]) were calculated. Multivariable linear regression analysis was used to identify the determinants of %eMETs.Only one third of patients achieved eMETs. Significant determinants of %eMETs were age at exercise stress echocardiography (β coefficient 0.64; 95% confidence interval, 0.31 to 0.96; P.001), female sex (β coefficient 16.9; 95% confidence interval, 8.58 to 25.17; P.001), and larger indexed device size (device size/body surface area; β coefficient 4.10; 95% confidence interval, 1.74 to 6.46; P = .001). Receiver-operating characteristic curve analysis revealed that a cutoff value of 19.5 mm/mPatients with larger indexed device size achieved greater exercise capacity after MVr using a partial semirigid band. Preoperative evaluation to decide whether we can use an annuloplasty device larger than 19.5 mm/m

Background: The current recommendations of the American College of Cardiology/ American Heart Association and a previous Bayesian analysis clearly show a mortality benefit with the use of β- blockers in chronic HF, especially for bisoprolol, carvedilol, and sustained-release metoprolol succinate. Objective: The main objective was to report the evidence on the use of the afore-mentioned β-blockers in subjects with heart failure and to characterize the stages of heart failure in response to the four different β-blockers. Furthermore, it shed light on the patient’s satisfaction and improved quality of life using the afore-mentioned β-blockers in subjects with heart failure. Method: The current perspective presented the clinical outcomes, including hospitalization, morbidity, mortality, patient’s satisfaction, and quality of life, of four beta (β)-blockers, namely bisoprolol, carvedilol, metoprolol succinate, and nebivolol in different stages of heart failure. Results : The use of these three agents should be recommended for all stable subjects with current or previous symptoms of heart failure and heart failure with reduced ejection fraction unless there is any contraindication. The fore-mentioned β-blockers (bisoprolol, carvedilol, and metoprolol succinate) can be initiated early, even in stable and symptom-free (at rest) subjects with heart failure. β-blockers in heart failure should be commenced at small doses and then titrated upward as tolerated to achieve the desired clinical effects on heart rate and symptom control. Conclusion: Cardiologists should weigh the benefit-risk in subjects with heart failure and other coexisting cardiovascular problems such as atrial fibrillation and diabetes.

Background This study aimed to clarify the incidence and determinants of postoperative adverse events in patients with ischemic cardiomyopathy who achieved long-term durable mitral valve repair. Methods Between 1999 and 2015, 166 patients with chronic ischemic mitral regurgitation (MR) and left ventricular (LV) ejection fraction ≤40% underwent restrictive mitral annuloplasty. During follow-up (65±34 months), echocardiographic assessments were performed 809 times (mean, 4.9±2.4 times) and 20 patients who had developed postoperative recurrent MR (≥moderate) were excluded. Finally, 146 patients (68±9 years) whose MR was well controlled over time were included. Results A total of 61 mortalities and/or 27 readmissions for heart failure were observed in 76 patients (52%). Among hospital survivors, age (adjusted hazard ratio: 1.05; P=0.001), and estimated glomerular filtration rate (adjusted hazard ratio: 0.61; P=0.001) were identified as independent predictors of long-term mortality and/or readmission for heart failure. The degree of LV function recovery after surgery was comparable between patients with and without adverse events. However, the former group showed greater values for systolic pulmonary artery pressure, tricuspid regurgitation severity, inferior vena cava dimension, and plasma brain natriuretic peptide level throughout the follow-up period (group effect p Conclusions Approximately 50% of patients died or were hospitalized for heart failure even in the absence of recurrent mitral regurgitation during the 5-year follow-up, indicating that durable mitral repair does not always lead to favorable clinical outcomes. The adverse events might be related to volume overload secondary to impaired renal function and less favorable pulmonary hemodynamics.

This study investigated a 2-stage arterial switch operation (ASO) to treat transposition of the great arteries (TGA) with intact ventricular septum (TGA-IVS) in late referral patients.We retrospectively analyzed patients with TGA-IVS or TGA with restricted ventricular septal defects who had undergone 2-stage ASO at our institution from February 2007 to August 2018. Included were 41 patients: 21 (51.2%) who had undergone long-term 2-stage ASO and 20 (48.8%) who had undergone rapid 2-stage ASO.The long-term 2-stage group was older at ASO (3.5 vs 25 months; P.001). Results were more satisfactory in the long-term group than in the rapid group for intensive care unit time (P = .004), mechanical ventilation time (P = .004), and length of stay (P = .007). No in-hospital death occurred in the long-term group, and the postoperative course was more manageable in the long-term group than in the rapid group. However, the risk of significant neoaortic regurgitation was lower in the rapid group, which also had a better left ventricular ejection fraction.The long-term group achieved better early-term outcomes than the rapid group. However, a high risk of neoaortic regurgitation and myocardial dysfunction was also noted.

Objective The severity of mitral regurgitation (MR) dynamically changes during a stress test. Isometric handgrip is a readily-available stress test in daily practice; however, little is known regarding the response to isometric handgrip in MR patients during right heart catheterization. We aimed to evaluate this issue from our case-series study. Methods We retrospectively investigated consecutive MR patients using the isometric handgrip stress test during right heart catheterization at our institution between October 2019 and April 2021. After resting measurements were obtained, sustained maximum-effort hand dynamometer grasping was maintained for about 2-3 minutes. We investigated the differences in right heart catheterization data between at rest and during handgrip, and evaluated the individual response to the isometric handgrip stress test. Results We investigated a total of 15 patients (mean age: 75±6 years, moderate/severe MR: 7/8, primary/secondary MR: 8/7, mean left ventricular ejection fraction: 56±16%, exertional dyspnea: 10). During the handgrip test, the pulmonary capillary wedge pressure (PCWP) significantly increased [9 (8, 13) mmHg at rest to 20 (15, 27) mmHg during handgrip; p0.001]. PCWP changes varied among individuals (range 2-22 mmHg) and were not correlated with patients' backgrounds including age, the natriuretic peptide levels, left ventricular ejection fraction, left atrial diameter or E/e' (all p0.05). Patients with PCWP ≥25 mmHg during handgrip had a higher prevalence of exertional dyspnea than those without [6 (100%) vs. 4 (44%); p=0.04]. Conclusion We observed dynamic and varied hemodynamic changes during isometric handgrip in MR patients, suggesting that further research is needed to evaluate the clinical value of this maneuver.

Background: Paradoxical low-flow, low-gradient (PLF-LG) aortic stenosis (AS) is associated with poor prognosis in patients undergoing transcatheter aortic valve implantation (TAVI). This study aimed to verify the conventional criteria of PLF-LG AS (left ventricular ejection fraction [LVEF] > 50%, mean aortic valve pressure gradient [AVPG] < 40 mm Hg and stroke volume index [SVI] < 35 ml/m2 by measuring Doppler method) compatible for predicting prognosis in patients undergoing TAVI., Materials and methods: A total of 128 consecutive patients who underwent TAVI for AS with LVEF > 50% were enrolled. The primary endpoint was the hospital readmission due to heart failure (HRHF) and the secondary endpoint was all-cause mortality after hospital discharge. The patients were classified by both the conventional criteria of PLF-LG AS and the proposal criteria of PLF-LG AS if mean aortic valve pressure gradient (AVPG) < 40 mmHg and SVI by measuring Simpson's method < cut off value based on the ROC curve for predicting HRHF., Results: According to the conventional criteria, only 6 patients were diagnosed with PLF-LG AS. However, according to the proposal criteria, 16 patients were diagnosed with PLF-LG AS. Fourteen patients developed HRHF during the follow-up period after TAVI. Based on the ROC curves, SVI by measuring Simpson's method (cut off value = 25 ml/m2) had higher sensitivity and specificity for predicting HRHF (AUC = 0.74, p = 0.0013) than SVI by measuring Doppler method (AUC = 0.63, p = 0.045). The multivariate analysis revealed that PLF-LG AS defined by the proposal criteria (HR: 5.25; 95% CI: 1.60–17.16; p = 0.0073) but not by the conventional criteria was independently associated with HRHF. PLF-LG AS defined by the conventional criteria and the proposal criteria were not associated with all-cause mortality in the univariate analysis., Conclusions: Our results demonstrated that new criteria of PLF-LG AS defined as SVI < 25 ml/m2 measured by Simpson's method could predict HRHF in patients with severe AS who underwent TAVI.

Background Normal flow low gradient severe aortic stenosis (NFLG-AS) with preserved ejection fraction is the most prevalent form of low gradient severe aortic stenosis. Despite the increased prevalence, the clinical outcomes and management strategy of NFLG-AS remain controversial. Therefore, our study aimed to evaluate transcatheter aortic valve implantation (TAVI) outcomes of patients with NFLG-AS compared with normal flow high gradient severe aortic stenosis (NFHG-AS). Methods We performed a retrospective analysis of 394 patients who underwent TAVI between January 2011 to September 2020. Among 394 patients, 232 patients had NFLG-AS, and 162 patients had NFHG-AS. The primary outcomes included all-cause mortality and cardiovascular mortality. In addition, multiple secondary outcomes were evaluated, including stroke, myocardial infarction, duration of hospital stay, new-onset atrial fibrillation, temporary or permanent pacemaker requirement, major bleeding, blood transfusion, vascular complications, acute kidney injury, hemodialysis requirement, symptom improvement, and repeat hospitalizations due to any cardiac disease. Results The cumulative six months incidence of all-cause mortality and cardiovascular mortality were similar between and NFLG-AS and NFHG-AS (4.32% vs. 5.17%, P = 0.71 and 2.47% vs. 2.59%, P = 0.94 respectively). There was no difference in the rates of stroke, myocardial infarction, duration of hospital stay, new-onset atrial fibrillation, temporary or permanent pacemaker requirement, major bleeding, blood transfusion, vascular complications, acute kidney injury, hemodialysis requirement, and symptom improvement between the two groups. However, patients with NFLG-AS compared to NFHG-AS had more frequent cardiac-related repeat hospitalizations (19.14% vs. 11.64%, P = 0.04%). Conclusion There was no significant difference in all-cause mortality and cardiovascular mortality between NFLG-AS and NGHG-AS six months post-TAVI. However, patients undergoing TAVI with NFLG-AS had significantly higher rates of cardiac-related repeat hospitalizations.

Adenosine triphosphate potassium sensitive channels provide endogenous myocardial protection via coupling of cell membrane potential to myocardial metabolism. Adenosine triphosphate potassium sensitive channel openers, such as diazoxide, mimic ischemic preconditioning, prevent cardiomyocyte swelling, preserve myocyte contractility after stress, and provide diastolic protection. We hypothesize that diazoxide combined with hyperkalemic cardioplegia provides superior myocardial protection compared with cardioplegia alone during prolonged global ischemia in a large animal model.Twelve pigs were randomized to global ischemia for 2 hours with a single dose of cold blood (4:1) hyperkalemic cardioplegia alone (n = 6) or with diazoxide (500 μmol/L) (n = 6) and reperfused for 1 hour. Cardiac output, myocardial oxygen consumption, left ventricular developed pressure, left ventricular ejection fraction, diastolic function, myocardial troponin, myoglobin, markers of apoptosis, and left ventricular infarct size were compared.Four pigs in the cardioplegia alone group could not be weaned from cardiopulmonary bypass. There were no differences in myoglobin, troponin, or apoptosis between groups. Diazoxide preserved cardiac output versus control (74.5 vs 18.4 mL/kg/min, P = .01). Linear mixed regression modeling demonstrated that the addition of diazoxide to cardioplegia preserved left ventricular developed pressure by 36% (95% confidence interval, 9.9-61.5; P .01), dP/dt max by 41% (95% confidence interval, 14.5-67.5; P .01), and dP/dt min by 33% (95% confidence interval, 8.9-57.5; P = .01). It was also associated with higher (but not significant) myocardial oxygen consumption (3.7 vs 1.4 mL ODiazoxide preserves systolic and diastolic ventricular function in a large animal model of prolonged global myocardial ischemia. Diazoxide as an adjunct to hyperkalemic cardioplegia may allow safer prolonged ischemic times during increasingly complicated cardiac procedures.

Background In patients with heart failure with reduced ejection fraction (HFrEF) and hypertension, systolic blood pressure is recommended to be maintained below 130 mmHg, although this has not been shown to be associated with improved outcomes. We examined the association of anti-hypertensive drug initiation and outcomes in patients with HFrEF. Methods In the Medicare-linked OPTIMIZE-HF, 7966 patients with HFrEF (ejection fraction ≤40%) without renal failure were not receiving anti-hypertensive drugs before hospitalization, of whom 692 received discharge prescriptions for those drugs (thiazides and calcium channel blockers). We assembled a propensity score-matched cohort of 687 pairs of patients initiated and not initiated on anti-hypertensive drugs, balanced on 38 baseline characteristics. Hazard ratios (HR) and 95% confidence intervals (CI) for outcomes associated with anti-hypertensive drug initiation were estimated in matched cohort. Results Matched patients (n=1374) had a mean age of 74 years, 41% were women, 17% were African American, 66% were discharged on renin-angiotensin system inhibitors and beta blockers, and 10% on aldosterone antagonists. During 6 (median 2.5) years of follow-up, 70% of the patients died and 53% had heart failure readmission. Anti-hypertensive drug initiation was not significantly associated with all-cause mortality (HR, 0.95; 95% CI, 0.83–1.07) or heart failure readmission (HR, 0.93; 95% CI, 0.80–1.07). Similar associations were observed during 30 days and 12 months of follow-up. Conclusions Among hospitalized older patients with HFrEF receiving contemporary treatments for heart failure, initiation of an anti-hypertensive drug was not associated with a lower risk of all-cause mortality or hospital readmission.

INTRODUCTION The obesity paradox, where obesity is associated with improved survival, has been described in patients undergoing haemodialysis and in those with heart failure. It was also demonstrated in patients undergoing valve replacement for aortic stenosis (AS). We explored this phenomenon in medically managed severe AS. METHODS 154 patients with medically managed severe AS (aortic valve area index [AVAi] < 0.6 cm2/m2; mean pressure gradient > 40 mmHg and peak velocity > 400 cm/s) and preserved left ventricular ejection fraction (> 50%) were categorised into the obese (body mass index [BMI] Asian cut-off ≥ 27.5 kg/m2) and non-obese groups. Their clinical and echocardiographic profiles were compared. RESULTS 24 (15.6%) patients were obese. Obese patients were similar to non-obese patients in age (68.5 ± 11.6 years vs. 68.9 ± 13.1 years) but had higher prevalence of cardiovascular risk factors. Left atrial diameter (43.7 ± 6.7 mm vs. 38.5 ± 10.2 mm) was larger in obese patients, while left ventricular outflow tract diameter (19.5 ± 1.7 mm vs. 20.4 ± 2.1 mm) was smaller. Despite lower AVAi in obese patients (0.36 ± 0.10 cm2/m2 vs. 0.43 ± 0.11 cm2/m2), there was lower mortality (37.5% vs. 41.0%, log-rank 4.06, p = 0.045) on follow-up (8.0 ± 5.7 years). After adjusting for age and AVAi, higher BMI ≥ 27.5 kg/m2 remained protective for mortality (hazard ratio 0.38, 95% confidence interval 0.15 to 0.98, p = 0.046). CONCLUSION We demonstrated that obesity was associated with improved survival in severe AS despite lower AVAi and increased prevalence of cardiovascular risk factors.

OBJECTIVES The goal of this study was to investigate the long-term outcome of aortic valve replacement (AVR) for severe aortic insufficiency with a focus on pre- and postoperative left ventricular (LV) function to explore predictive factors that influence the recovery of LV function and clinical outcome. METHODS A total of 478 patients who underwent AVR for pure severe aortic insufficiency were grouped according to the preoperative echocardiographical LV ejection fraction (EF): low (LO) EF 50% (n = 285). RESULTS Actuarial survival at 10 years post-AVR was 64% with a LO EF, 92% with a moderate EF and 93% with a normal EF (P = 0.016), whereas 10-year rates of freedom from major adverse cerebral and cardiovascular events were 47%, 79% and 84%, respectively (P 365 pg/mL (P = 0.0022) and echocardiographic LV mass index) >193 g/m2 (P = 0.0018). CONCLUSIONS Long-term outcome post-AVR for severe aortic insufficiency was largely influenced by preoperative LV function. Predictive factors of failure to recover ventricular function post-AVR included EF 365 pg/mL or LV mass index >193 g/m2.

To assess the incidence and risk factors for heart failure in patients with psoriatic disease and to describe their electrocardiographic and echocardiographic findings.A cohort analysis was conducted involving patients with psoriatic disease followed prospectively from 1978 to 2018. Participants were assessed according to a standard protocol every 6 to 12 months. The primary outcome was the time to first event of heart failure, further classified into ischemic and nonischemic heart failure (secondary outcomes). The association between cardiovascular risk factors, measures of disease activity, and heart failure events was assessed using Cox proportional hazards regression. Electrocardiographic and echocardiographic findings associated with heart failure events were described.A total of 1,994 patients with psoriatic disease were analyzed, with 64 incident heart failure events (38 ischemic, 26 nonischemic). The incidence rate of first heart failure event was 2.85 per 1,000 patient-years. In all events, the most common electrocardiographic findings were atrial fibrillation (22%) and bundle branch blocks (29%). Echocardiogram revealed 37% reduced ejection fraction and 63% preserved ejection fraction. In multivariable analysis, independent risk factors for all heart failure events were ischemic heart disease, adjusted mean tender joint count, adjusted mean swollen joint count, adjusted mean erythrocyte sedimentation rate, adjusted mean C-reactive protein level, and physical function (by Health Assessment Questionnaire) (all P 0.05). Minimal disease activity state was protective for all heart failure (P 0.05).Increased risk of heart failure is associated with a combination of known cardiovascular risk factors and measures of disease activity, particularly in nonischemic heart failure. The effect of inflammation on heart failure may be partially independent of atherosclerotic disease.

Introduction and objectives Microvascular obstruction (MVO) is negatively associated with cardiac structure and worse prognosis after ST-segment elevation myocardial infarction (STEMI). Epithelial cell adhesion molecule (EpCAM), involved in epithelium adhesion, is an understudied area in the MVO setting. We aimed to determine whether EpCAM is associated with the appearance of cardiac magnetic resonance (CMR)-derived MVO and long-term systolic function in reperfused STEMI. Methods We prospectively included 106 patients with a first STEMI treated with percutaneous coronary intervention, quantifying serum levels of EpCAM 24 hours postreperfusion. All patients underwent CMR imaging 1 week and 6 months post-STEMI. The independent correlation of EpCAM with MVO, systolic volume indices, and left ventricular ejection fraction was evaluated. Results The mean age of the sample was 59 ± 13 years and 76% were male. Patients were dichotomized according to median EpCAM (4.48 pg/mL). At 1-week CMR, lower EpCAM was related to extensive MVO (P = .021) and larger infarct size (P = .019). At presentation, EpCAM values were significantly associated with the presence of MVO in univariate (OR, 0.58; 95%CI, 0.38-0.88; P = .011) and multivariate logistic regression models (OR, 0.55; 95%CI, 0.35-0.87; P = .010). Although MVO tends to resolve at chronic phases, decreased EpCAM was associated with worse systolic function: reduced left ventricular ejection fraction (P = .009) and higher left ventricular end-systolic volume (P = .043). Conclusions EpCAM is associated with the occurrence of CMR-derived MVO at acute phases and long-term adverse ventricular remodeling post-STEMI.

Background: Beta-blockers improve clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). Less is known about their role in older nursing home residents with HFrEF. Methods: From the combined OPTIMIZE-HF and Alabama Heart Failure Project datasets, we assembled a propensity score-matched balanced cohort of 6494 hospitalized patients ≥65 years with HFrEF (ejection fraction ≤40%). In our primary approach, hazard ratios (HR) and 95% confidence intervals (CI) for outcomes associated with discharge prescriptions for beta-blockers were estimated, examining for heterogeneity by admission from nursing homes. In our sensitivity approach, we examined these associations in a separately assembled propensity score-matched cohort of 122 patients admitted from nursing homes. Results: In the matched primary cohort of 6494 patients, HRs (95% CIs) for 12-month all-cause mortality and heart failure readmission were 0.80 (0.74–0.87) and 0.94 (0.86–1.02), respectively. Respective HRs (95% CIs) in the nursing home and non-nursing home subgroups were 0.77 (0.51–1.16) and 0.81 (0.74–0.87) for all-cause mortality (interaction p, 0.653) and 1.06 (0.53–2.12) and 0.89 (0.82–0.96) for heart failure readmission (interaction p, 0.753). In the matched sensitivity cohort of 122 patients admitted from nursing homes, HRs (95% CIs) for 12-month all-cause mortality and heart failure readmission were 0.86 (0.55–1.35) and 1.07 (0.52–2.22), respectively. Similar associations were observed for 30-day outcomes. Conclusions: Beta-blocker use was associated with a lower risk of all-cause mortality but not of heart failure readmission in older patients with HFrEF, which were similar for patients admitted and not admitted from nursing homes.

BACKGROUND Sacubitril/valsartan (LCZ696) has progressed to be one of the most promising medication since its approval for chronic heart failure with reduced ejection fraction. Recent data have suggested a superior blood pressure control with LCZ696. STUDY QUESTION What is the antihypertensive efficacy and safety profile of sacubitril/valsartan? DATA SOURCES Randomized controlled trials (RCTs) comparing the efficacy and safety of LCZ696 against a placebo or angiotensin receptor blocker (ARB). RCTs were identified from a comprehensive search in PubMed, Embase, Cochrane library, and clinicaltrials.gov. STUDY DESIGN We used a change in systolic and diastolic blood pressures, both sitting as well as ambulatory, to calculate relevant effect sizes with their standard errors from the available change in mean and SD data. In addition, we also collected categorical data for the reported adverse effects from these trials. We performed a series of pairwise meta-analyses between LCZ696 versus an active comparator or a placebo. RESULTS Eleven RCTs with a total of 6028 participants had the relevant data available. Our meta-analysis showed that LCZ696 is an effective and a safe treatment for hypertension. It outperformed ARBs in every category, and the results are consistent across the different dosages of LCZ696. Compared with ARBs, 200 mg of LCZ696 reduced systolic blood pressure and diastolic blood pressure (DBP) by 4.62 mm Hg (95% confidence interval, 3.33-5.90, P < 0.001) and 2.13 mm Hg (95% confidence interval, 1.69-2.57, P < 0.001), respectively. Similarly, 400 mg of LCZ696 reduced systolic blood pressure and diastolic blood pressure by 5.50 mm Hg (2.94-8.07, P < 0.001) and 2.51 mm Hg (1.80-3.21, P < 0.001), respectively, in comparison with ARBs. The adverse effects with LCZ696 were not significantly higher compared with ARBs or placebo. CONCLUSIONS Sacubitril/valsartan is more effective for the management of hypertensive patients, compared with an ARB. Long-term prospective studies are required to identify whether this result translates into morbidity and mortality benefits.

BACKGROUND Current guidelines favor transcatheter aortic valve implantation (TAVI) over surgical aortic valve replacement in patients with porcelain aorta (PAo). The clinical relevance of PAo in patients undergoing TAVI is however incompletely understood. The purpose of this study is to evaluate clinical outcome of patients with PAo undergoing TAVI. METHODS Consecutive patients undergoing TAVI were enrolled in a prospective single-center registry. Presence of PAo was evaluated by ECG-gated multi-slice computed tomography prior to the intervention. The primary endpoint was disabling stroke. RESULTS Among 2199 patients (mean age, 82.0������������6.3 years; 1135 females [51.6%]) undergoing TAVI between August 2007 and December 2019, 114 patients (5.2%) met VARC-2 criteria for PAo. Compared to individuals without PAo, patients with PAo were younger (79.4������������7.4 years vs. 82.1������������6.2 years; p�����

Aim: To assess relations between Valsalva- and phenylephrine test-derived measures and outcome in reduced ejection fraction heart failure (HFrEF) patients receiving comprehensive neurohormonal blockade pharmacotherapy. Methods: Data from 56 HFrEF patients (LVEF: 32±6%; mean±SD) subjected to Valsalva and phenylephrine tests were analyzed retrospectively. Baroreflex-related (Valsalva-ratio [cBRSVR] and BP-RRI slope from phase IV [cBRSIV_SLOPE]) and non-baroreflex-related measures (systolic BP rise in phase IV [ΔSBPPHASE_IV], and pulse-amplitude-ratio [PAR]) were calculated from Valsalva. Short-term outcome (HF-related hospitalization, ICD shock or all-cause death within 24-months from examination) and long-term outcome (ICD shock or all-cause death within 60-months) were analyzed. Results: The endpoint occurred in 16 and 18 patients, for short- and long-term outcome, respectively. Low ΔSBPPHASE_IV identified patients at risk in long-term perspective, as evidenced by low- vs. high ΔSBPPHASE_IV comparison (square-wave response patients assigned to low ΔSBPPHASE_IV group, P=0.002), and Cox model (HR: 0.91, CI: 0.86-0.96, P Conclusions: Non-baroreflex-related measures obtained from Valsalva: ΔSBPPHASE_IV and PAR, might carry prognostic value in HFrEF patients receiving neurohormonal blockade pharmacotherapy.

Background: Heart failure (HF) with preserved ejection fraction (HFpEF) and monoclonal gammopathy of uncertain significance (MGUS) are two entities that share pathophysiological mechanisms. The aim herein, was to assess the prevalence of MGUS in patients with HFpEF and no left ventricular (LV) hypertrophy, as well as its association with a pre-specified clinical endpoint at 12 months. Methods: The present study prospectively enrolled 69 patients admitted with HF, with ejection fraction ≥ 50%, and LV wall thickness < 12 mm. All patients were screened for MGUS. Clinical events were determined over a 12 month follow-up. The pre-specified composite clinical endpoint was readmission for HF or death. Results: The prevalence of MGUS in this population was 13%. There were no differences in the incidence of the composite clinical endpoint between patients with and without MGUS. Multivariate analysis showed that treatment with angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) was associated with fewer clinical events (HR: 0.153, 95% CI: 0.037–0.622, p = 0.009) and indicated a trend to lower risk of readmission for HF and death. Beta-blockers were associated with lower rates of the composite clinical endpoint (HR: 0.192, 95% CI: 0.05–0.736, p = = 0.016), readmission for HF (HR: 0.272, 95% CI: 0.087–0.851, p = 0.025) and indicated a trend to lower mortality. Moreover, potassium serum levels > 5 mEq/L were associated with higher rates of the composite endpoint (HR: 6.074, 95% CI: 1.6–22.65, p = 0.007). Conclusions: The prevalence of MGUS in patients with HFpEF without hypertrophy was 3-fold that of the general population. There was no significant correlation between clinical outcomes and the presence of MGUS. Beta-blockers and ACEIs/ARBs reduced the composite of mortality and readmissions for HF in HFpEF patients. Hyperpotassemia was related to worse prognosis, This work was supported by grants from Instituto de Salut Carlos III (PI19/00655), financed jointly with European Regional Development Funds (ERDF)

Danon disease (DD) is a rare X-linked dominant cardioskeletal myopathy caused by mutations in the lysosome-associated membrane protein-2 (LAMP-2) gene that is usually lethal without cardiac transplantation. The purpose of this study was to characterize post-transplant outcomes in a large cohort of patients with DD who underwent cardiac transplantation.The clinical phenotype and outcome data of patients with DD who underwent cardiac transplantation (n = 38; 19 males and 19 females) were obtained from 8 centers. Study outcomes included graft survival, defined as death or retransplantation, and episodes of acute cellular and antibody-mediated rejection and cardiac allograft vasculopathy at 1 year.Median follow-up time after transplantation for the entire cohort was 4.4 years (IQR: 1.5-12.8 years). The median age at transplant for the cohort was 20.2 years (15.8-27.9 years), with no difference in age between sexes. Median pretransplant left-ventricular ejection fraction for the entire cohort was 30% (range 11%-84%). Males had higher pretransplant aspartate aminotransferase, alanine aminotransferase and creatine phosphokinase levels than females (P0.001). There were 2 deaths in the entire cohort and 2 retransplants. There was no difference in actuarial graft survival between males and females (P = 0.8965); the estimated graft survival was 87.1% (95%CI: 63.6%-95.9%) at 5 years. One episode (2.7%) of antibody-mediated rejection, grade 2, and 7 episodes (19%) of acute cellular rejection, grade 2 or 3, were reported in patients who survived to discharge (6 females and 1 male; P = 0.172).Heart transplantation outcomes are acceptable in DD with high probabilities of 5-year graft survival for males and females suggesting that cardiac transplantation is an effective treatment option for DD patients.

Pulmonary hypertension (PH) is a common complication of end-stage heart failure (ESHF) and associated with increased mortality. The definition of PH has recently been changed from a mean pulmonary arterial pressure (PAPm) ≥25 mmHg to a PAPm20 mmHg. Since this change, there are no data evaluating group 2 PH subgroups on outcomes. The purpose of this study was to determine the impact of updated group 2 PH subgroups on outcomes, as well as to evaluate the clinical, echocardiographic, and haemodynamic characteristics of subgroups, and determine predictors of PH in patients with ESHF.A total of 416 patients with ESHF with left ventricular ejection fraction (LVEF) ≤25% were divided into three groups. Pulmonary hypertension was defined as PAPm20 mmHg. Primary outcome was defined as left ventricular assist device (LVAD) implantation, urgent heart transplantation (HT), or death. Secondary outcome was defined as LVAD implantation and HT.Over a median follow-up of 503.5 days, combined pre- and postcapillary PH (Cpc-PH) displayed greater risk of primary outcome than those with isolated postcapillary (Ipc-PH) (hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.29-1.91; p0.001) and those with no PH (HR, 2.47; 95% CI, 1.68-3.63; p0.001). Patients with Ipc-PH demonstrated greater risk than those with no PH (HR, 1.57; 95% CI, 1.57-1.90; p0.001). Likelihood ratios of updated PH criteria and old PH criteria (PAPm ≥25 mmHg) in identifying primary outcome were 75.6 (RPulmonary hypertension increases the risk of LVAD, urgent HT, or death, and Cpc-PH further increases risk in patients with ESHF. Compared to the previous definition, a new PH definition better discriminates death, going to urgent HT, or LVAD implantation for PH subgroups.

Dilated cardiomyopathy (DCM) is a frequent cause of cardiac disability, congestive heart failure (CHF), and arrhythmic death in dogs. The etiology of DCM is usually idiopathic/genetic, but some causes of a DCM phenotype are reversible. The disease is classified into preclinical (occult) and clinical (overt) stages; the latter stems from heart failure with reduced ejection fraction. DCM is further characterized by clinical, electrocardiographic, circulating biomarker, and imaging abnormalities. The diagnosis of clinical DCM with CHF is straightforward; however, identification of the preclinical stage can be challenging. Echocardiography is central to the diagnosis of both stages and characterized by left ventricular (LV) systolic dysfunction with progressive chamber dilation and variable enlargements of the left atrium and right-sided chambers. Left ventricular dilation is defined by increased LV end-diastolic volumes, areas, and internal dimensions normalized to body size or indexed to the aorta. Systolic dysfunction is characterized by decreased LV ejection fraction, increased end-systolic volume, and reduced shortening across minor and longitudinal LV axes. Dyssynchrony can confound the interpretation of linear indices of systolic function. A comprehensive echocardiogram in DCM includes two-dimensional and M-mode studies, spectral and tissue Doppler imaging, and potentially three-dimensional echocardiography and myocardial strain imaging. Echocardiographic findings should be interpreted within the context of identifiable risks and comorbidities, physical diagnosis, complementary diagnostic testing, and limitations of current reference intervals. Ambiguous examinations should be repeated. Specific echocardiographic criteria for the diagnosis of DCM are proposed to encourage discussion and additional outcome and breed-specific echocardiographic studies of canine DCM.

Objectives The authors sought to elucidate the prognostic value of cardiac sympathetic nerve dysfunction as evaluated using iodine-123-labeled metaiodobenzylguanidine (123I-MIBG) single-ph...

Background Out-of-pocket (OOP) drug costs for Medicare Fee-for-Service (FFS) beneficiaries with heart failure with reduced ejection fraction (HFrEF) are not well characterized. This study evaluated Part D OOP spending by Medicare beneficiaries with chronic HFrEF, stratified by those with and without a worsening HF event (WHFE). Methods Medicare FFS 100% Part D claims were used to identify HFrEF patients with 12 months of continuous Part D enrollment in 2018. HFrEF was defined as 1 inpatient or 2 outpatient claims of systolic HF or 1 systolic HF plus 1 HF outpatient claim. WHFE was defined as having a HF hospitalization or intravenous diuretic use within 12 months of HFrEF index date. OOP costs by Medicare Part D coverage phase for all covered drugs were calculated for HFrEF patients, and those with and without WHFE. Results Of 305,373 Medicare patients with HFrEF, 26% had a WHFE. Total mean (SD) OOP drug costs among all HFrEF patients was $1,166 (1,205)/year. Patients with WHFE and patients without WHFE had respectively a mean (SD) annual OOP costs of $1,302 (1,273) and $1,117 (1,176). Over 39% of HFrEF patients entered the "donut hole" (44% and 37% of patients with WHFE and without WHFE, respectively), while 11% of HFrEF patients entered the catastrophic phase (13% and 10% of patients with and without WHFE, respectively). Conclusion More than 1 in 10 patients with heart failure entered the catastrophic phase within Medicare-Fee-For-Service, whereas in 2018 only 10% of costs were attributable to heart failure medication and 90% to comorbidities.

Background Ventricular interdependence may account for altered ventricular mechanics in congenital heart disease. The present study aimed to identify differences in load-dependent right ventricular (RV)–left ventricular (LV) interactions in porcine models of pulmonary stenosis (PS) and pulmonary insufficiency (PI) by invasive admittance-derived hemodynamics in conjunction with noninvasive cardiovascular magnetic resonance (CMR). Methods Seventeen pigs were used in the study (7 with PS, 7 with PI, and 3 controls). Progressive PS was created by tightening a Teflon tape around the pulmonary artery, and PI was created by excising 2 leaflets of the pulmonary valve. Admittance catheterization data were obtained for the RV and LV at 10 to 12 weeks after model creation, with the animal ventilated under temporary diaphragm paralysis. CMR was performed in all animals immediately prior to pressure–volume catheterization. Results In the PS group, RV contractility was increased, manifested by increased end-systolic elastance (mean difference, 1.29 mm Hg/mL; 95% confidence interval [CI], 0.57-2.00 mm Hg/mL). However, in the PI group, no significant changes were observed in RV systolic function despite significant changes in RV diastolic function. In the PS group, LV end-systolic volume was significantly lower compared with controls (mean difference, 25.1 mL; 95% CI, -40.5 to -90.7 mL), whereas in the PI group, the LV showed diastolic dysfunction, demonstrated by an elevated isovolumic relaxation constant and ventricular stiffness (mean difference, 0.03 mL−1; 95% CI, -0.02 to 0.09 mL−1). Conclusions The LV exhibits systolic dysfunction and noncompliance with PI. PS is associated with preserved LV systolic function and evidence of some LV diastolic dysfunction. Interventricular interactions influence LV filling and likely account for differential effects of RV pressure and volume overload on LV function.

Background: Subclinical left ventricular diastolic dysfunction (LVDD) is an emerging consequence of increased insulin resistance, and dyslipidemia is one of the few correctable risk factors of LVDD. This study evaluated the role of mean and visit-to-visit variability of lipid measurements in risk of LVDD in a healthy population.Methods: This was a 3.7-year (interquartile range, 2.1 to 4.9) longitudinal cohort study including 2,817 adults (median age 55 years) with left ventricular ejection fraction >50% who underwent an annual or biannual health screening between January 2008 and July 2016. The mean, standard deviation (SD), coefficient of variation (CV), variability independent of the mean (VIM), and average real variability of total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), apolipoprotein B (apoB), non-HDL-C, and triglycerides were obtained from three to six measurements during the 5 years preceding the first echocardiogram.Results: Among the 2,817 patients, 560 (19.9%) developed LVDD. The mean of no component of lipid measurements was associated with risk of LVDD. CV (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.10 to 1.67), SD (HR, 1.27; 95% CI, 1.03 to 1.57), and VIM (HR, 1.26; 95% CI, 1.03 to 1.55) of LDL-C and all the variability parameters of apoB were significantly associated with development of LVDD. The association between CV-LDL and risk of LVDD did not have significant interaction with sex, increasing/decreasing trend at baseline, or use of stain and/or lipid-modifying agents.Conclusion: The variability of LDL-C and apoB, rather than their mean, was associated with risk for LVDD.

Background COVID-19 infection is known to cause a wide array of clinical chronic sequelae, but little is known regarding the long-term cardiac complications. We aim to report echocardiographic follow-up findings and describe the changes in left (LV) and right ventricular (RV) function that occur following acute infection. Methods Patients enrolled in the World Alliance Societies of Echocardiography-COVID study with acute COVID-19 infection were asked to return for a follow-up transthoracic echocardiogram. Overall, 198 returned at a mean of 129 days of follow-up, of which 153 had paired baseline and follow-up images that were analyzable, including LV volumes, ejection fraction (LVEF), and longitudinal strain (LVLS). Right-sided echocardiographic parameters included RV global longitudinal strain, RV free wall strain, and RV basal diameter. Paired echocardiographic parameters at baseline and follow-up were compared for the entire cohort and for subgroups based on the baseline LV and RV function. Results For the entire cohort, echocardiographic markers of LV and RV function at follow-up were not significantly different from baseline (all P > .05). Patients with hyperdynamic LVEF at baseline (>70%), had a significant reduction of LVEF at follow-up (74.3% ± 3.1% vs 64.4% ± 8.1%, P < .001), while patients with reduced LVEF at baseline (−20%) at baseline had significant improvement at follow-up (−15.2% ± 3.4% vs −17.4% ± 4.9%, P = .004). Patients with abnormal RV basal diameter (>4.5 cm) at baseline had significant improvement at follow-up (4.9 ± 0.7 cm vs 4.6 ± 0.6 cm, P = .019). Conclusions Overall, there were no significant changes over time in the LV and RV function of patients recovering from COVID-19 infection. However, differences were observed according to baseline LV and RV function, which may reflect recovery from the acute myocardial injury occurring in the acutely ill. Left ventricular and RV function tends to improve in those with impaired baseline function, while it tends to decrease in those with hyperdynamic LV or normal RV function.

Background Home Based Cardiac Rehabilitation (HBCR) has been considered a reasonable alternative to Center-based Cardiac Rehabilitation (CBCR) in patients with established cardiovascular disease, especially in the midst of COVID-19 pandemic. However, the long-term cardiovascular outcomes of patients referred to HBCR remains unknown. Objectives To compare outcomes of patients who were referred and attended HBCR vs patients referred but did not attend HBCR (Non-HBCR). Methods We performed a retrospective study of 269 patients referred to HBCR at Providence Veterans Affairs Medical Center (PVAMC). From November 2017 to March 2020, 427 patients were eligible and referred for Cardiac Rehabilitation (CR) at PVAMC. Of total patients, 158 patients were referred to CBCR and 269 patients to HBCR based on patient and/or clinician preference. The analysis of outcomes was focused on HBCR patients. We compared outcomes of patients who were referred and attended HBCR vs patients referred but did not attend HBCR (Non-HBCR) from 3 to 12 months of the referral date. HBCR consisted of face-to-face entry exam with exercise prescription, weekly phone calls for education and exercise monitoring, with adjustments where applicable, for 12-weeks and an exit exam. Primary outcome was composite of all-cause mortality and hospitalizations. Secondary outcomes were all-cause hospitalization, all-cause mortality and cardiovascular hospitalizations, separately. We used cox proportional methods to calculate hazard ratios (HR) and 95% CI. We adjusted for imbalanced characteristics at baseline: smoking, left ventricular ejection fraction and CABG status. Results A total of 269 patients (mean age: 72, 98% Male) were referred to HBCR, however, only 157 (58%) patients attended HBCR. The primary outcome occurred in 30 patients (19.1%) in the HBCR group and 30 patients (30%) in the Non-HBCR group (adjusted HR=0.56, CI 0.33-0.95, P=.03). All-cause mortality occurred in 6.4% of patients in the HBCR group and 13% patients in the Non-HBCR group 3 to 12 months after HBCR referral (adjusted HR=0.43, CI 0.18-1.0, P= .05). There was no difference in cardiovascular hospitalizations (HBCR: 5.7% vs Non-HBCR: 10%, adjusted HR 0.57, CI 0.22-1.4, P= .23) or all cause hospitalizations at 3 to 12 months between the groups (HBCR: 12.7% vs Non-HBCR: 21%, adjusted HR 0.53, CI 0.28-1.01, P= .05). Conclusion Completion of HBCR among referred patients was associated with a lower risk of the combined all-cause mortality and all-cause hospitalizations up to 12 months. Based on the outcomes, HBCR is a reasonable option that can improve access to CR for patients who are not candidates of or cannot attend CBCR. Randomized-controlled studies are needed to confirm these findings.

The decision to treat moderate ischemic mitral regurgitation (IMR) at the time of coronary artery bypass surgery (CABG) remains controversial. We previously conducted a prospective randomized trial that showed a benefit of adding restricted annuloplasty to bypass surgery (CABG-Ring group) in terms of IMR grade, New York Heart Association classification, and left ventricle reverse remodeling. Here, we present the long-term (10 years) follow-up data from this randomized trial.The original trial arms accounted for 54 patients in the CABG-alone and 48 in the CABG-Ring group; patients were re-contacted for follow-up to obtain relevant clinical and echocardiographic information.The mean follow-up was 160.4 ± 45.5 months. Survival probabilities in the CABG-alone and CABG-Ring groups were 96% vs 93% at 3 years, 85% vs 89% at 6 years, 79% vs 85% at 9 years, 77% vs 83% at 12 years, and 72% vs 80% at 15 years, respectively (P = .18) Freedom from at least moderate IMR or reintervention at last follow-up was also higher in the CABG-Ring group (P.001). Compared with the CABG-alone group, the CABG-Ring group had a higher degree of left ventricular reverse remodeling (54.7 ± 6.9 mm vs 51.6 ± 6 mm, respectively; P = .03), lower New York Heart Association class (P.001), and a lower rate of rehospitalization (P = .002).Long-term follow-up data from our randomized trial further support the utility of performing restricted annuloplasty at the time of CABG to prevent further progression of IMR, mitral reintervention, and left ventricle remodeling. Untreated IMR was associated with significantly higher New York Heart Association class and rehospitalization.

Objective Patients discharged from the hospital to a skilled nursing facility (SNF) are not typically part of a heart failure disease management program (HF-DMP). The objective of this study is to determine if an HF-DMP in SNF improves outcomes for patients with HF. Design Cluster-randomized controlled trial. Participants The trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care). Methods The HF-DMP included documentation of ejection fraction, symptoms, weights, diet, medication optimization, education, and 7-day visit post SNF discharge. The composite outcome was all-cause hospitalization, emergency department visits, or mortality at 60 days. Secondary outcomes included the composite endpoint at 30 days, change in the Kansas City Cardiomyopathy Questionnaire and the Self-care of HF Index at 60 days. Rehospitalization and mortality rates were calculated as an exploratory outcome. Results Mean age of the patients was 79 ± 10 years, 58% were women, and the mean ejection fraction was 51% ± 16%. At 30 and 60 days post SNF admission, the composite endpoint was not significant between DMP (29%) and usual care (32%) at 30 days and 60 days (43% vs 47%, respectively). The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P = .039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P = .016). Self-care of HF Index was not significant. The total number of events (composite endpoint) totaled 517 (231 in HF-DMP and 286 in usual care). Differences in the 60-day hospitalization rate [mean HF-DMP rate 0.43 (SE 0.03) vs usual care 0.54 (SE 0.05), P = .04] and mortality rate (HF-DMP 5.2% vs usual care 10.8%, P Conclusions and Implications The composite endpoint was high for patients with HF in SNF regardless of group. Rehospitalization and mortality rates were reduced by the HF-DMP. HF-DMPs in SNFs may be beneficial to the outcomes of patients with HF. SNFs should consider structured HF-DMPs for their patients.

BACKGROUND: We aimed to investigate the associations of glycemic markers (hemoglobin A(1C) [HbA(1C)], fasting plasma glucose [FPG] and glycemic status [normoglycemia, prediabetes and diabetes]) with incident heart failure (HF) and its subtypes, among Blacks. METHODS: We included 2,290 community-dwelling Blacks(64% women, mean age 58 years) without prevalent HF from the Jackson Heart Study who attended the second exam (2005–2008). The associations between glycemic markers and incident HF (and subtypes including HF with preserved ejection fraction [HFpEF] and reduced ejection fraction [HFrEF]) were evaluated using Cox proportional hazards regression models, adjusting for risk factors and coronary heart disease. RESULTS: There were 119 incident HF events (48 HFpEF, 58 HFrEF, and 13 unclassified HF events) over a median follow-up of 10.5 years. Higher levels of HbA(1C) (HR per SD increment, 1.30; 95% CI 1.12, 1.51) and FPG (HR per SD increment FPG: 1.32; 95% CI: 1.17, 1.48) were associated with a higher risk of incident HF. Compared to normal glycemia, diabetes status was associated with a higher risk of incident HF (HR: 1.24; 95%CI: 1.02, 2.05). HbA(1C) was significantly associated with higher risks of HFpEF (HR per SD increment: 1.41, 95% CI: 1.18, 1.69) and HFrEF (HR per SD increment: 1.32; 95% CI: 1.12, 1.56). FPG was significantly associated with higher risk of HFpEF (HR per SD increment: 1.35, 95% CI: 1.14, 1.62) but not HFrEF (HR per SD increment: 1.12; 95% CI: 0.53, 2.35). CONCLUSIONS: Among community-dwelling Blacks, higher levels of glycemic markers were associated with higher risk of HF subtypes. CLINICAL TRIALS. GOV IDENTIFIER: NCT00005485) of the Jackson Heart Study.

Purpose We investigated the impact of radial access on contrast-induced acute kidney injury (CI-AKI) in patients with coronary artery bypass graft (CABG) undergoing cardiac catheterization . Methods This retrospective monocenter study included 527 CABG patients undergoing cardiac catheterization via radial (58.1%, N = 306) or femoral access (41.9%, N = 221). Primary outcome measure was CI-AKI defined in accordance with the KDIGO criteria. Independent predictors for CI-AKI were assessed. 1-year mortality was assessed depending on the occurrence of CI-AKI. Results In total, 99 CABG patients (18.8%) developed CI-AKI within 48 h after cardiac catheterization. Compared to patients without CI-AKI, amount of contrast media used (203.1 ± 102.6 ml vs. 204.2 ± 98.2 ml; P = 0.892) as well as procedural times (87.9 ± 44.8 vs. 79.8 ± 37.0; P = 0.190) were similarly. Regarding vascular access , there was no significant difference in the incidence of CI-AKI between radial and femoral approach (19.0% vs. 18.6%; p = 0.907). However, poor left ventricular ejection fraction (odds ratio [OR] = 1.72, P = 0.026), chronic kidney disease (OR = 2.30, P = 0.001) and acute coronary syndrome (OR = 1.64, P = 0.043) were independent predictors for CI-AKI. The occurrence of CI-AKI was significantly associated with an increased 1-year mortality (hazard ratio [HR] = 2.52, P = 0.003). Conclusions With 18.8%, CI-AKI is a frequent complication in CABG patients undergoing cardiac catheterization. Radial access did not decrease the risk when compared to the femoral approach.

Aim Abnormal ankle-brachial index (ABI) is regarded as peripheral artery disease and can be used to predict cardiovascular (CV) outcomes. However, the usefulness of ABI for the prediction of CV outcome in patients with normal ABI is limited. Upstroke time per cardiac cycle (UTCC) is recently reported to be associated with mortality in patients with acute myocardial infarction and the elderly. Therefore, we aimed to evaluate UTCC, left ventricular ejection fraction (LVEF), brachial-ankle pulse wave velocity (baPWV), and ABI for the prediction of mortality in patients with normal ABI. Methods Patients arranged for echocardiographic examinations were enrolled, and 1076 patients with normal ABI were included. ABI, baPWV, and UTCC were measured by an ABI-form device. Results The median follow-up to mortality was 95 months. There were 88 CV and 244 all-cause deaths. After multivariate analysis, UTCC was associated with increased CV and all-cause mortality (P ≤ 0.004). Age, diabetes, heart failure, left ventricular hypertrophy, baPWV, and LVEF were also independent predictors of CV and all-cause mortality, but ABI was not. Furthermore, UTCC had a better additive predictive value than ABI, baPWV, and LVEF for CV mortality (P ≤ 0.012). It also had a better additive predictive value than ABI and LVEF for all-cause mortality (P ≤ 0.013). Conclusions UTCC is an independent predictor for CV and all-cause mortality in patients with normal ABI. It also has a better additive predictive value of CV and all-cause mortality than ABI and LVEF. Therefore, UTCC is a simple, novel, and useful parameter for identifying high-risk patients with normal ABI.

Heart failure with reduced ejection fraction (HFrEF) and chronic obstructive pulmonary disease (COPD) individually cause significant morbidity and mortality. Their coexistence is associated with even worse outcomes, partly due to suboptimal heart failure therapy, especially underutilisation of beta-blockers. Our aim was to investigate outcomes in HFrEF patients with and without COPD, and the effects of mineralocorticoid receptor antagonists (MRAs) on outcomes.\ud \ud Methods and results:\ud \ud We studied the effect of MRA therapy in a post-hoc pooled analysis of 4397 HFrEF patients in the RALES and EMPHASIS-HF trials. The primary endpoint was the composite of heart failure hospitalisation or cardiovascular death. A total of 625 (14.2%) of the 4397 patients had COPD. Patients with COPD were older, more often male, and smokers, but less frequently treated with a beta-blocker. In patients with COPD, event rates (per 100 person-years) for the primary endpoint and for all-cause mortality were 25.2 (95% confidence interval 22.1–28.7) and 17.2 (14.9–19.9), respectively, compared with 19.9 (18.8–21.1) and 12.8 (12.0–13.7) in participants without COPD. The risks of all-cause hospitalisation and sudden death were also higher in patients with COPD. The benefit of MRA, compared with placebo, was consistent in patients with or without COPD for all outcomes, e.g. hazard ratio for the primary outcome 0.66 (0.50–0.85) for COPD and 0.65 (0.58–0.73) for no COPD (interaction p = 0.93). MRA-induced hyperkalaemia was less frequent in patients with COPD.\ud \ud Conclusions:\ud \ud In RALES and EMPHASIS-HF, one-in-seven patients with HFrEF had coexisting COPD. HFrEF patients with COPD had worse outcomes than those without. The benefits of MRAs were consistent, regardless of COPD status.

Background Cardiac amyloidosis (CA) is an increasingly recognised condition in patients with aortic stenosis (AS). However, there is large variation in the reported prevalence figures, due to differences in populations and diagnostic methods. We aimed to investigate the prevalence, risk factors and outcomes of concomitant CA and AS. Methods We performed a systematic review and meta-analysis of the literature searched on Medline, EMBASE, Scopus and CENTRAL. We analysed the prevalence of CA in AS grouped according to diagnostic techniques, and the risk factors and outcomes of concomitant CA and AS was analysed in AS patients referred for surgical or transcatheter aortic valve replacement (AVR). Results A total of 21 studies were included, involving 4,243 patients. The pooled prevalence of CA in patients with AS was 14.4%, with substantial heterogeneity. The pooled prevalence of AS in CA was 8.7%, with substantial heterogeneity. Patients with both AS and CA had higher all-cause mortality than those with AS or CA alone. In AS patients requiring AVR, CA was associated with increasing age, male sex, higher NT-proBNP levels, increased interventricular septal end diastole thickness and lower left ventricular ejection fraction. Concomitant AS and CA was associated with increased all-cause mortality and pacemaker implantation post-procedure. Study limitations included the heterogeneity of results and the fair to good quality of studies published. Conclusion Overall, a substantial proportion of patients with AS may have CA, and they have poorer prognosis. A high degree of clinical suspicion is needed to identify “red flags” and perform appropriate diagnostic imaging.

Background Ventricular function, including left ventricular systolic dysfunction (LVSD), right ventricular systolic dysfunction (RVSD), and biventricular dysfunction (BVD), contribute to shock in cardiac intensive care unit (CICU) patients, but the prognostic utility remains unclear. Research Question Do patients with ventricular dysfunction have higher mortality at each Society for Cardiovascular Angiography and Intervention (SCAI) shock stage? Study Design and Methods We identified CICU patients admitted with available echocardiography data. LVSD was defined as left ventricular ejection fraction less than 40%, RVSD as moderate or greater systolic dysfunction by semi-quantitative measurement, and BVD as the presence of both. Multivariable logistic regression determined the relationship between ventricular dysfunction and adjusted in-hospital mortality as a function of SCAI stage. Results The study population included 3,158 patients with a mean age of 68.2 years (±14.6), of which 51.8% had acute coronary syndromes. LVSD was present in 22.3%, RVSD in 11.8%, and 16.4% had BVD. After adjustment for SCAI shock stage there was no difference in in-hospital mortality between patients with LVSD or RVSD and those without ventricular dysfunction (p >0.05), but BVD was independently associated with higher in-hospital mortality (adjusted HR 1.815, 95% CI 1.237-2.663, p = 0.0023). The addition of ventricular dysfunction to the SCAI staging criteria increased discrimination for hospital mortality (AUC 0.784 vs. 0.766, p Interpretation Among patients admitted to the CICU, only BVD was independently associated with higher hospital mortality. The addition of echocardiography assessment to the SCAI shock criteria may facilitate improved clinical risk stratification.

Objective The study objective was to evaluate the short- and long-term outcomes of patients with ischemic cardiomyopathy after surgical ventricular restoration and to identify risk factors related to poor results. Methods Between August 2002 and April 2016, 62 patients affected by ischemic cardiomyopathy underwent surgical left ventricular restoration at our unit. Patients' mean age at operation was 63 years (39-79 years). Mean ejection fraction was 29.6%. The Surgical Treatment for Ischemic Heart Failure trial criteria have been used as indications for surgery. Fifty-seven patients (91%) received surgical myocardial revascularization. Mitral valve repair was performed in 39 patients (63%). The surgical technique consisted of the classic Dor operation or a different approach reducing the equatorial diameter of the left ventricle and avoiding the use of a patch. The data were analyzed retrospectively for perioperative results and short- and long-term clinical outcomes. Results One patient died of noncardiac causes within 30 days (1.6%). All-cause death occurred in 36 patients (58%) during follow-up (0.6-14.7 years; median follow-up time, 7.02 years), of whom 15 died of cardiac causes. Age, need for preoperative intra-aortic balloon pump, reduction less than 35% of postoperative left ventricular end-diastolic and end-systolic volumes, type of surgical technique, and ejection fraction less than 25% were identified as risk factors for late cardiac mortality. Perioperative levosimendan administration and presence of preoperative moderate to severe mitral regurgitation influenced early and intermediate-term outcomes, but no statistical relevance on long-term results was demonstrated. Conclusions Patients with ischemic dilative cardiomyopathy have favorable short- and long-term outcomes after ventricular restoration. Age, preoperative ejection fraction less than 25%, inadequate left ventricular surgical reverse remodeling, and type of surgical technique negatively affect long-term survival.

Background Despite exercise being one of few strategies to improve outcomes for individuals with heart failure with preserved ejection fraction (HFpEF), exercise clinical trials in HFpEF are plagued by poor interventional adherence. Over the last 2 decades, our research team has developed, tested, and refined Heart failure Exercise And Resistance Training (HEART) Camp, a multicomponent behavioral intervention to promote adherence to exercise in HF. We evaluated the effects of this intervention designed to promote adherence to exercise in HF focusing on subgroups of participants with HFpEF and heart failure with reduced ejection fraction (HFrEF). Methods and Results This randomized controlled trial included 204 adults with stable, chronic HF. Of those enrolled, 59 had HFpEF and 145 had HFrEF. We tested adherence to exercise (defined as ≥120 minutes of moderate-intensity [40%–80% of heart rate reserve] exercise per week validated with a heart rate monitor) at 6, 12, and 18 months. We also tested intervention effects on symptoms (Patient-Reported Outcomes Measurement Information System-29 and dyspnea-fatigue index), HF-related health status (Kansas City Cardiomyopathy Questionnaire), and physical function (6-minute walk test). Participants with HFpEF (n = 59) were a mean of 64.6 ± 9.3 years old, 54% male, and 46% non-White with a mean ejection fraction of 55 ± 6%. Participants with HFpEF in the HEART Camp intervention group had significantly greater adherence compared with enhanced usual care at both 12 (43% vs 14%, phi = 0.32, medium effect) and 18 months (56% vs 0%, phi = 0.67, large effect). HEART Camp significantly improved walking distance on the 6-minute walk test (η2 = 0.13, large effect) and the Kansas City Cardiomyopathy Questionnaire overall (η2 = 0.09, medium effect), clinical summary (η2 = 0.16, large effect), and total symptom (η2 = 0.14, large effect) scores. In the HFrEF subgroup, only patient-reported anxiety improved significantly in the intervention group. Conclusions A multicomponent, behavioral intervention is associated with improvements in long-term adherence to exercise, physical function, and patient-reported outcomes in adults with HFpEF and anxiety in HFrEF. Our results provide a strong rationale for a large HFpEF clinical trial to validate these findings and examine interventional mechanisms and delivery modes that may further promote adherence and improve clinical outcomes in this population. Clinical Trial Registration : URL: https://clinicaltrials.gov/. Unique identifier: NCT01658670