Abstracts from Charleston HFpEF Conference

Abstracts from Charleston HFpEF Conference: The Latest Knowledge on Heart Failure with Preserved Ejection Fraction 28–30 July 2023 https://doi.org/10.15420/usc.2023.17.s1

www.USCjournal.com

ABSTRACT

Charleston HFpEF Conference

Looking Beyond the Usual Suspects: A Rare Case of Stiff Left Atrial Syndrome after Radiotherapy for Breast Cancer Sukriti Banthiya,1 Medhat Chowdhury,2 Harshil Patel,2 and Souheil Saba2 1. Department of Internal Medicine, Ascension Providence Hospital, Southfield, MI; 2. Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, MI

Citation: US Cardiology Review 2023;17(Suppl 1):A1.

Correspondence: Sukriti Banthiya, sukriti.banthiya@gmail.com Open Access: Abstract reproduced from Banthiya et al. 20231 under a Creative Commons CC BY-NC-ND 4.0 License.

Background: The most widely known risk factors for stiff left atrial syndrome are catheter ablations and maze procedures for atrial fibrillation. Here, we describe a rare case of a stiff left atrial syndrome years after radiotherapy for breast cancer.

prior atriotomy, or open heart surgery; hence radiotherapy was suspected as the unique predisposing factor.

Results: In our patient who presented with worsening, effort dyspnea giant V waves on PCWP tracing out of proportion to left ventricular diastolic end pressure and significant mitral regurgitation were indicative of stiff left atrial syndrome after radiotherapy for breast cancer.

Methods: A 68-year-old female with permanent atrial fibrillation and a history of radiotherapy for right breast cancer presented with worsening isolated dyspnea on exertion. Transthoracic echocardiogram showed severely dilated right and left atrium. A right heart catheterization was performed that demonstrated moderate pulmonary artery hypertension (29mmHg), and pulmonary capillary wedge pressure (52mmHg) with giant V waves apparent on the tracing (Fig 1A). A transesophageal echocardiogram showed no significant mitral regurgitation and the presence of systolic blunting of the pulmonary vein flow consistent with stiff left atrial syndrome (Fig 1B). There was no history of atrial ablation,

Conclusion: Stiff left atrial syndrome is uncommonly associated with radiotherapy and may be an under-recognized etiology of dyspnea in this patient population.

1.

Banthiya S, Chowdhury MR, Patel H, Saba S. Looking beyond the usual suspects: a rare case of stiff left atrial syndrome after radiotherapy for breast cancer. J Am Coll Cardiol 2023;81(Suppl 8):1083. https://doi.org/10.1016/S0735-1097(23)01527-9.

Figure 1

A: Pulmonary capillary wedge tracing from right heart catheterization showing giant V waves; B: TEE Doppler profile in the pulmonary vein showing systolic blunting of the pulmonary vein flow.

© The Author(s) 2023. Published by Radcliffe Group Ltd. www.USCjournal.com

2

Abstracts from the Charleston HFpEF Conference

Impact of Left Ventricular Ejection Fraction on the Correlation between Congestion Biomarkers and Blood Volume Measurements in Heart Failure Veraprapas Kittipibul, MD1,2 and Marat Fudim, MD, MHS1,2 1. Department of Medicine, Duke University School of Medicine, Durham, NC; 2. Duke Clinical Research Institute, Durham, NC

Citation: US Cardiology Review 2023;17(Suppl 1):A2 Correspondence: Veraprapas Kittipibul, veraprapas.kittipibul@duke.edu Open Access: This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.

Introduction: Assessment of congestion in heart failure (HF) is challenging.

Different biomarkers of congestion have been used in clinical practice, but their correlations with blood volume analysis (BVA) measurements are not well characterized. Furthermore, whether the association differs across left ventricular ejection fraction (LVEF) subgroups is not known.

Results: Overall, 43 patients (61 years, 35% female, 37% black, 47% HF with preserved ejection fraction [HFpEF]) were included. There was no difference in age, sex, comorbidities, or biomarker levels between LVEF subgroups. CA125 was correlated with TBV%deviation (r=0.508) and PV%deviation (r=0.447; Table 1). NT-proBNP was only correlated with PV%deviation (r=0.355). Serum sodium was not correlated with any BVA measurements. The correlation between CA125 and BVA measurements was only observed in HF with reduced ejection fraction (TBV: r=0.607, PV: r=0.508). In contrast, there was a correlation between NT-proBNP and BVA measurements only in HFpEF (TBV: r = 0.567, PV: r = 0.649).

Methods: We enrolled patients with HF who underwent BVA and had same-day measurements of N-terminal pro B-type natriuretic peptide (NTproBNP), carbohydrate antigen 125 (CA125), and serum sodium. BVA was performed using the I131-albumin indicator dilution technique. Absolute values and percent deviation from ideal values of total blood volume (TBV) and plasma volume (PV) were reported. The correlation between each biomarker and TBV/PV%deviation was determined using Pearson’s correlation. Patients were categorized into two groups using an LVEF cutoff of 50%. The same analysis was repeated by LVEF subgroups.

Conclusion: Correlation between congestion biomarkers and BVA measurements exists but differs between LVEF subgroups. Further studies are warranted to explore the underlying mechanisms of these observations.

Table 1: Correlation Between Congestion Biomarkers and Blood Volume Measurements Based on Left Ventricular Ejection Fraction Phenotypes TBV %deviation Total (n=43) r

PV %deviation

HFrEF (n = 23)

HFpEF (n = 20)

Total (n=43)

HFrEF (n = 23)

HFpEF (n = 20)

p-value

r

p-value

r

p-value

r

p-value

r

p-value

r

p-value

NT-proBNP 0.298

0.052

0.192

0.381

0.567

0.009

0.355

0.020

0.203

0.353

0.649

0.002

CA125

0.508

<0.001

0.607

0.002

−0.017

0.943

0.447

0.003

0.508

0.013

0.141

0.554

Serum Na

0.105

0.502

0.146

0.505

0.108

0.650

0.099

0.529

0.216

0.321

−0.219

0.927

CA125 = carbohydrate antigen 125; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; Na = sodium; NT-proBNP = N-terminal pro B-type natriuretic peptide; PV = plasma volume; TBV = total blood volume.

US CARDIOLOGY REVIEW www.USCjournal.com

3

Abstracts from the Charleston HFpEF Conference

A Case of Pericardial Disease Masquerading as Heart Failure with Preserved Ejection Fraction Cara Pietrolungo, MS, DO, Nasser Monzer, MD, Karla Asturias, MD, and Stuart Prenner, MD Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA

Citation: US Cardiology Review 2023;17(Suppl 1):A3.

Correspondence: Cara Pietrolungo, cara.pietrolungo@pennmedicine.upenn.edu Open Access: This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.

Introduction: Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome that is defined by the presence of signs and symptoms of heart failure in the setting of preserved left ventricular systolic function.

There is a differential for HFpEF syndromes, and recognition of HFpEF mimics is essential. We present a case of idiopathic pericardial disease mimicking HFpEF.

testing is required to establish the diagnosis and rule out HFPEF mimics.

More recently, the H2FPEF risk calculator has proven a useful tool to determine the pretest probability of HFpEF and guide subsequent cardiac testing.

Our patient had a low H2FPEF score of 1, suggesting a low likelihood of traditional HFpEF. However, given clinical concern, additional cardiac testing was obtained to better determine his hemodynamics invasively. In this case, the patient underwent simultaneous right- and left heart catheterization, which revealed constrictive physiology. Pericardial enhancement and thickening was also seen on cardiac MRI, leading to a diagnosis of pericardial constriction, in this case idiopathic.

Case: A 64-year-old man without past medical history was referred to our heart failure program for chronic dyspnea. Six months prior, coronary calcium CT obtained for risk stratification revealed incidental pericardial thickening on the background of chronic pericardial calcifications. Vital signs were within normal limits. Physical examination was notable for elevated jugular venous pressure (7 mm) and a positive Kussmaul’s sign.

Electrocardiogram showed normal sinus rhythm, right axis deviation, possible right ventricular hypertrophy, and abnormal QRS-T angle. An initial echocardiogram showed inferior and inferoseptal apical hypokinesis, septal bounce, normal left atrial size, a lateral E’ 10, and septal E’ 9, E/E’ ratio of 6. Labs were notable for elevated total bilirubin (1.6 mg/dL). Cardiac catheterization showed findings consistent with constrictive physiology including positive Kussmaul (Figure 1) and square root (Figure 2) signs, elevated biventricular filling pressures, and ventricular interdependence following volume loading (Figure 3).

The pericardium exerts significant modulatory effects on ventricular hemodynamics, which results in impaired diastolic filling and ventricular pressure equalization despite preserved ventricular function on echocardiography. This physiology may clinically present as HFpEF but is treated differently; it is a potentially curable form of heart failure.

Therefore, the evaluation of HFpEF should include probability testing and – if clinical suspicion remains – more advanced imaging and hemodynamic tests.

Conclusion: HFpEF should be considered as a cause of unexplained dyspnea particularly in the presence of typical risk factors. Consideration of HFpEF mimics is essential in all cases of HFpEF, but particularly when patient comorbidities do not reflect those of typical HFpEF.

Discussion: There are various cardiac and noncardiac pathologies that mimic HFpEF. In general, the differential diagnosis for HFpEF is broad, and a high index of suspicion coupled with appropriate diagnostic

US CARDIOLOGY REVIEW www.USCjournal.com

4

Abstracts from the Charleston HFpEF Conference Figure 1: Right Atrial Pressure Tracing

Figure 3: Simultaneous Right Ventricular and Left Ventricular Pressure Tracings

Figure 2: Right Ventricular Pressure Tracing

US CARDIOLOGY REVIEW www.USCjournal.com

5

Abstracts from the Charleston HFpEF Conference

End-expiratory Versus Averaged Pulmonary Artery Wedge Pressure Measurements for the Diagnosis of Exercise-induced HFpEF Oliver Mithoefer,1 Jacob Read,1 Carson Keck,2 John Elliott Epps,3 Sheng Fu,2 Jagpreet Grewal,2 Michael Rofael,2 Mathew Gregoski,4 Brian Houston,2 and Ryan Tedford2 1. Department of Medicine, Medical University of South Carolina, Charleston, SC; 2. Division of Cardiology, Medical University of South Carolina, Charleston, SC; 3. Wofford College, Spartanburg, SC; 4. Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC

Citation: US Cardiology Review 2023;17(Suppl 1):A4.

Correspondence: Oliver Mithoefer, Mithoefe@musc.edu Open Access: This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.

Introduction: Exercise right heart catheterization (RHC) is useful in the evaluation of unexplained dyspnea, particularly in diagnosing exerciseinduced heart failure with preserved ejection fraction (HFpEF). Two diagnostic criteria are commonly utilized for supine exercise: pulmonary artery wedge pressure (PAWP) at peak exercise ≥25 mmHg, and multipoint slope of the PAWP/cardiac output (CO) ratio ≥2 mmHg*min/L. Given marked intrathoracic pressures swings that can occur during exercise, an additional major controversy exists regarding how to assess pressures regarding the respiratory cycle (end-expiratory versus averaged measures). We hypothesized that the PAWP/CO slope diagnostic criteria would be less impacted by differences in respiratory variation assessment than peak pressure criteria.

cycle (PAWPave) were also collected. Related-Sample Cochran’s Q Test and Dunn post-hoc pairwise comparison with Bonferroni correction were used to determine differences in reclassification based on respiratory variation assessment.

Methods: A single-center retrospective review of patients who underwent supine exercise RHC for unexplained dyspnea from July 2018 to August 2022 was performed. End-expiratory PAWP (PAWPexp) were manually assessed, and computer generated PAWP averaged over the respiratory

Conclusion: Diagnostic criteria for exercise-induced HFpEF lead to significant differences in the number of patients ultimately diagnosed with HFpEF. However, the PAWP/CO slope methodology reduces the diagnostic variation introduced by respiratory cycle assessment differences.

Results: Seventy-seven patients were identified and had an average H2FpEF score of 3.58 ± 2.07. Using peak PAWPexp criteria, 42 patients (54.5%) met the criteria for HFpEF, whereas only 21 patients (27.3%) met the criteria by peak PAWPave, a net reclassification of 21 patients (p<0.001). When using the PAWPexp/CO slope >2 for diagnosis, 58 (75.3%) of the patients met the criteria, with reclassification of only 10 patients (48 patients, 62.3%) when using PAWPave/CO (p=0.960).

US CARDIOLOGY REVIEW www.USCjournal.com

6

Abstracts from the Charleston HFpEF Conference

Transseptal Access After Interatrial Shunt Devices: Try Everything Once and Great Things Twice Molly Silkowski, DO, and Nicholas Amoroso, MD Medical University of South Carolina, Charleston, SC

Citation: US Cardiology Review 2023;17(Suppl 1):A5.

Correspondence: Molly Silkowski, silkowsk@musc.edu Open Access: This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.

Introduction: Heart failure with preserved ejection fraction (HFpEF) and AF are both common cardiovascular conditions and frequently coexist.

Recent approaches to unload the left atrium with interatrial shunt devices (IASD) are on the rise while, over the past 20 years, endovascular left atrial appendage closure (LAAC) requiring transvenous left atrial access through interatrial septum has grown increasingly popular for the prevention of thromboembolism related to AF. People may be frequently indicated for both LAAC and IASD therapies. Whether the presence of IASD impacts technical access to LAAC devices requiring transseptal approach is unknown.

with an existing IASD. One patient had a Corvia atrial device (Corvia Medical) with peri-device transseptal puncture for LAAC and the other had a V-wave Ventura device (V-Wave Medical) with LAAC transseptal approach through the IASD aperture; both received WATCHMAN FLX devices (Boston Scientific). Hemodynamics for both patients remained stable throughout the procedure and no major complications occurred.

On follow up transesophageal echocardiography (TEE), one patient had evidence of iatrogenic atrial septal defect (ASD) from the WATCHMAN transseptal puncture along with a patent IASD exhibiting left-to-right flow.

The other showed patent IASD with bidirectional flow and no additional ASD present. Treatment success was achieved on routine 45-day follow up TEE.

Methods: In our single center, we retrospectively reviewed 481 patients from August 2018 to May 2023 who underwent LAAC and 40 patients who underwent IASD, and identified which patients had an existing IASD at time of LAAC. Rates of LAAC technical success, 45-day LAAC treatment success, procedural complications, and implant method were assessed.

Conclusion: Our cases demonstrate favorable safety and outcomes with a transseptal approach for WATCHMAN FLX deployment in the presence of Corvia or V-wave IASDs. Our results show promise that treating HFpEF and AF with both IASD and LAAC is possible, although uncommon todate.

Results: We identified two patients who underwent endovascular LAAC

US CARDIOLOGY REVIEW www.USCjournal.com

7