Prognostic impact of remote dielectric sensing value following TAVR.

Remote dielectric sensing (ReDS) system non-invasively quantifies pulmonary congestion. Re-admission following trans-catheter aortic valve replacement (TAVR) remains an unsolved matter. Residual pulmonary congestion is a strong risk factor of worse clinical outcomes in patients with heart failure. ReDS system may have a prognostic impact in patients undergoing TAVR. Patients who received TAVR and ReDS measurements during index hospitalization between 2021 and 2022 were included. The prognostic impact of ReDS value on the composite endpoint of death or re-admission following index discharge was investigated. Totally, 42 patients (median 84 years, 14 men) were included. Median ReDS value at index discharge was 27% (24%, 30%) and 10 patients had ReDS values > 30%. During a median of 316 (282, 354) days following index discharge, a higher ReDS value at baseline was independently associated with the incidence of composite endpoint with an adjusted hazard ratio of 1.32 (95% confidence interval between 1.10 and 1.58) with a calculated cutoff of 30%, which significantly stratified the cumulative incidence of the composite endpoint (78% in the high ReDS group [N = 10] and 36% in the normal ReDS group [N = 32], p = 0.002). ReDS technology may be a promising tool to predict future clinical outcomes following TAVR by quantifying residual pulmonary congestion. The clinical implication of ReDS-guided aggressive intervention following TAVR remains the next concern.

Feasibility and Efficacy of Exercise Training Concomitant with Re-Assessment of Medical Therapy in Patients with Heart Failure Receiving Intravenous Inotropes.

Exercise training in addition to re-assessment of medical treatments is recommended for patients with advanced heart failure. However, the feasibility and efficacy of exercise training in patients with heart failure receiving intravenous inotropes remains uncertain.Clinical data were analyzed from consecutive patients with stabilized hemodynamics receiving intravenous inotropes for more than 1 week and undergoing cardiac rehabilitation at our institute between February 2020 and May 2022. All patients received re-assessment of guideline-directed medical therapy and non-pharmacological treatment, in addition to the exercise therapy. The intensity of exercise training was determined based on the results of cardiopulmonary exercise testing.A total of 10 patients receiving intravenous inotropes (median age 60 years, left ventricular ejection fraction 23%) were included. All patients received low-dose dobutamine and 4 patients received concomitant milrinone. Exercise training was continued for 112 days on median without any critical complications. Intravenous inotropes were continued for 41 days on median and weaned off in all patients. Plasma B-type natriuretic peptide decreased slightly from 291 (129, 526) to 177 (54, 278) pg/mL (P = 0.070) and peak oxygen consumption increased from 10.0 (8.3, 15.3) to 15.2 (10.9, 17.2) mL/kg/minute (P = 0.142) during the 6-month observational period following the initiation of exercise intervention.Exercise training might be feasible and effective in patients with advanced heart failure receiving low-dose intravenous inotrope support concomitant with re-assessment of medical treatment.

Association Between Remote Dielectric Sensing and Body Mass Index.

Remote dielectric sensing (ReDS) is a non-invasive, electromagnetic energy-based technology to quantify pulmonary congestion. However, the accuracy of ReDS values in patients with a variety of physiques has not been fully validated.Prospective successive measurements of ReDS values and body mass index (BMI) were performed on admission in consecutive hospitalized patients with cardiovascular diseases. Patients were stratified into 4 groups according to the WHO classification: underweight (BMI < 18.5), normal weight (18.5 ≤ BMI < 24.9), pre-obese (25.0 ≤ BMI < 29.9), and obese (30.0 ≤ BMI). The indexed ReDS value was defined as a ReDS value divided by the modified congestion score index (the severity of pulmonary congestion on chest X-ray). The indexed ReDS values were compared among the 4 stratified groups.A total of 436 patients (76 [69, 82] years old and 254 men) were included. The median indexed ReDS values were 21.3 (19.1, 23.8), 25.7 (21.0, 29.5), 25.7 (20.3, 31.0), and 28.0 (21.1, 34.0) in underweight, normal weight, pre-obese, and obese patients, respectively, highlighting the underweight group had the lowest values (P < 0.001).ReDS values may be underestimated and specific caution should be paid in its interpretation in underweight patients.

Combination Treatment of Balloon Pulmonary Angioplasty and Direct Oral Anticoagulant in a Patient with Chronic Thromboembolic Pulmonary Hypertension Complicated by Protein S Deficiency.

Introduction: Chronic thromboembolic pulmonary hypertension (CTEPH) is a phenotype of pulmonary hypertension due to chronic and multiple organized thrombus. The therapeutic strategy for patients with CTEPH and comorbid protein S deficiency remains unknown due to its rarity. Case: We encountered a 49-year-old male patient with CTEPH and concomitant mild protein S deficiency (type III). We could successfully perform balloon pulmonary angioplasty without any major complications, including thromboembolism and bleeding, followed by standard-dose oral anticoagulation therapy instead of warfarin. Conclusion: A currently established standard therapeutic strategy for CTEPH, including pulmonary angioplasty, may be safe and effective even in patients with concomitant inherent coagulation abnormalities.

Decoupling Between Pulmonary Artery Diastolic and Wedge Pressure Following Transcatheter Aortic Valve Replacement.

BACKGROUND: Coexistent pulmonary hypertension with severe aortic stenosis confers a greater risk of mortality for patients undergoing transcatheter aortic valve replacement (TAVR). In this patient population, the impact of significant decoupling between pulmonary artery diastolic and pulmonary capillary wedge, as it relates to clinical risk, remained uncertain.Methods and Results:Patients with severe aortic stenosis who underwent TAVR and completed pre-procedural and post-procedural invasive hemodynamic assessments with right heart catheterization were retrospectively assessed. The impact of post-TAVR decoupling, defined as a pressure difference ≥3 mmHg, on 2-year all-cause mortality or risk of heart failure admission was analyzed. Among 77 included patients (median age 86 years, 23 men), 16 had post-TAVR decoupling. The existence of post-TAVR decoupling was associated with a higher cumulative incidence of the primary endpoint (44% vs. 7%, P=0.001), with an adjusted hazard ratio of 5.87 (95% confidence interval 1.58-21.9, P=0.008). CONCLUSIONS: A greater risk of worse outcomes in those with post-TAVR decoupling was observed. A therapeutic strategy for post-TAVR decoupling and its clinical implication need to be created and investigated in the future.

Impact of the whole activated clotting time during Impella support on short-term prognosis.

Impella (Abiomed, Danvers, MA, USA) is a percutaneous trans-catheter left ventricular assist device. Anticoagulant therapy targeting whole activated clotting time (ACT) between 160 and 180 s is recommended to prevent pump thrombosis during support. However, we sometimes experience fatal bleeding despite achieving the target ACT range. Consecutive patients who received Impella support in our institute between March 2018 and October 2020 were included in this retrospective study. The association between the averaged ACT levels during the Impella support and 30-day mortality was investigated. A total of 36 patients (71 years old, 61% males) were included. Most of the patients were managed within the recommended therapeutic range of ACT, and the average ACT level was 162 s. The higher ACT group (> 168 s) had older age, smaller body mass index, and higher serum creatinine compared with the lower ACT group (p < 0.05 for all). A higher ACT level was an independent risk factor of 30-day mortality with an adjusted hazard ratio of 1.085 (95% confidence interval 1.037-1.154) with a cut-off level of 168 s. There were only two thromboembolic events. Patients managed with higher ACT levels had a higher risk of 30-day mortality during Impella support. A low-dose heparin purge solution might be recommended in patients with high-risk for bleeding events.

Responders to Sodium-Glucose Cotransporter 2 Inhibitors in Improving Left Ventricular Function.

Sodium-glucose cotransporter 2 inhibitor (SGLT2i)-incorporated medical therapy is associated with cardiac function improvement in patients with heart failure. However, the factors associated with such an improvement remain unknown.This study included patients with heart failure and type 2 diabetes mellitus who received SGLT2i-incorporated medical therapy in our institute. Transthoracic echocardiography was performed at baseline and 3-18 months later. The factors associated with cardiac function improvement were investigated.A total of 47 patients (median age, 69 years old; 35 men) were included in this study. SGLT2i was administered for median 284 days (range: 86-730 days). The left ventricular ejection fraction increased from 39.0% to 54.0% (P < 0.001), and the E/e' ratio decreased from 14.0 to 10.4 (P = 0.002). Younger age, higher serum albumin level, and lower serum sodium level were independently associated with an improvement in systolic function, defined as an increase in the ejection fraction of ≥ 35% among patients with systolic heart failure (P = 0.018). Male sex and impaired renal function tended to be associated with an improvement in diastolic function, defined as a decrease in the E/e' ratio of ≥ 20% among the overall cohort.Several factors were associated with improvements in systolic and diastolic functions during the SGLT2i-incorporated medical therapy.

Validation of Inter-Rater and Intra-Rater Reliability of Remote Dielectric Sensing Measurement.

Remote dielectric sensing (ReDS) is a recently introduced non-invasive electromagnetic-based device used to quantify lung fluid levels. Nevertheless, its inter-rater and intra-rater reliability remain uncertain. In 10 healthy volunteers, ReDS values were measured three times successively by the officially trained expert examiner to validate intra-rater reliability. Similar measures were performed by a total of three examiners to validate inter-rater reliability. Intra-class correlation (ICC) was applied to validate each reliability. Ten healthy volunteers [median 34 (32, 40) years old, 10 men, body mass index 23.0 (21.2, 23.9) ] were included. Median ReDS value was 28% (25%, 31%). For the intra-rater reliability, ICC (1, 1) and ICC (1, 3) were 0.966 and 0.988, respectively (P < 0.001). For the inter-rater reliability, ICC (2, 1) and ICC (2, 3) were 0.683 and 0.866, respectively (P < 0.001). Given almost perfect intra-rater reliability, an examiner does not need to repeat ReDS measurement. Given substantial inter-rater reliability, ReDS measurements had better be measured by multiple examiners if possible.

Trans-Apical Transcatheter Aortic Valve Replacement in a Dialysis Patient with Systolic Heart Failure.

Mortality and morbidity remain high following transcatheter aortic valve replacement (TAVR) in dialysis patients or those with low left ventricular ejection fraction. Therapeutic strategy for those with these comorbidities remains unestablished. We had a dialysis patient with peripheral artery disease and low left ventricular ejection fraction, who received successfully scheduled trans-apical TAVR following sufficient reverse remodeling by 3-month optimal medical therapy. Our strategy should be validated in a larger robust cohort.

Renoprotective effects of sodium glucose cotransporter 2 inhibitors in type 2 diabetes patients with decompensated heart failure.

BACKGROUND: Sodium-glucose cotransporter 2 inhibitor (SGLT2i) reduces the risk of the composite renal endpoint and weakens the progressive decline in renal function in patients with chronic heart failure (HF). However, a detailed mechanism of SGLT2i on renal function and outcome remains uninvestigated. METHODS: We prospectively included 40 type 2 diabetic mellitus (T2DM) patients (median 68 years old, 29 male) who were hospitalized for decompensated HF and received SGLT2i during the index hospitalization. Of them, 24 patients had increases in estimated glomerular filtration rate (eGFR) at 12-month follow-up and 16 had decreases in eGFR. We investigated the baseline factors associating with the improvement in renal function. RESULTS: Lower plasma B-type natriuretic peptide (BNP) level and the use of renin-angiotensin system inhibitor (RASI) were independently associated with increases in eGFR during the follow-up period (p < 0.05 for both). Patients with both low plasma BNP levels and uses of RASI achieved significant increases in eGFR irrespective of the baseline HbA1c levels. CONCLUSIONS: Lower plasma BNP level and the use of RASI at baseline were the key factors contributing to the renoprotective effects of SGLT2i among patients with decompensated HF and T2DM.

The implication of optimal heart rate in patients with systolic dysfunction following TAVR.

Heart rate reduction therapy using ivabradine has demonstrated its prognostic implication in patients with heart failure with reduced ejection fraction. However, the target heart rate with optimal clinical outcomes, particularly for those with systolic dysfunction following a transcatheter aortic valve replacement (TAVR), remains unknown. Consecutive patients with left ventricular ejection fraction (LVEF) < 50% and sinus rhythm following TAVR received transthoracic echocardiography at index discharge. The ideal heart rate was calculated using a formula: 93 - 0.13 × (deceleration time [ms]). Those whose actual heart rates at discharge were within 10 bpm of the calculated ideal heart rate were assigned to the optimal heart rate group, and their prognosis was compared with those without. Twenty-four patients (83 [78, 85] years old, LVEF 41% [35%, 44%], 16 males) were included. The median difference between actual heart rate and ideal heart rate was 12 (0, 16) bpm and 11 patients were assigned to the optimal heart rate group. One year later, the optimal heart rate group achieved more improvement in LVEF (24% [15%, 28%] vs. 7% [7%, 12%], p = .003) and had lower heart failure readmission rates (0.059 vs. 0.116 events/year; p = .49). In conclusion, an optimal heart rate might be associated with cardiac reverse remodeling and prevention of heart failure recurrences in patients with systolic dysfunction following TAVR. The implication of deceleration time-guided heart rate optimization therapy for such cohorts remains the next concern.

Risk Stratification of Percutaneous Edge-to-Edge Repair by MitraClip in Patients with Mitral Regurgitation.

Edge-to-edge repair using the MitraClip system is indicated in patients with severe mitral regurgitation (MR) who are at high risk for open-heart surgery due to comorbidity or reduced cardiac function. However, less is known about pre-procedural risk factors for mortality and morbidity following MitraClip implantation. Consecutive 25 patients with severe MR who underwent MitraClip therapy (mean age, 77 years old, 14 males) were included. Right heart catheterization and echocardiographic data before and after the procedure were collected and their prognostic impacts were investigated. Acute procedural success was 96%. At one week following MitraClip repair, left ventricular ejection fraction (LVEF) remained unchanged and left ventricular end-diastolic volume tended to be smaller. Cardiac index and mean pulmonary artery pressure (mPAP) were markedly improved following the procedure (P < 0.001 for both). In the multivariate analyses using baseline characteristics, both lower LVEF (hazard ratio 0.57, 95% confidence interval 0.30-0.89) and higher mPAP (hazard ratio 1.23, 95% confidence interval 1.06-1.56) were independently associated with post-procedural 1-year death or heart failure readmission (P < 0.05 for both). The lower LVEF and higher mPAP group had lower 1-year survival free from HF readmission compared with those without (16.7% versus 100%; P < 0.001). In conclusion, a combination of baseline mPAP and LVEF might be a useful tool in predicting post-MitraClip procedural clinical outcomes.

Relationship Between HbA1c Level and Effectiveness of SGLT2 Inhibitors in Decompensated Heart Failure Patients with Type 2 Diabetes Mellitus.

The DAPA-HF trial demonstrated that sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduced worsening heart failure (HF) events in chronic HF patients with or without type 2 diabetic mellitus (T2DM). However, it remains unclear whether the effectiveness of SGLT2i is also observed in patients with decompensated HF irrespective of HbA1c level. Eighty-one T2DM patients hospitalized due to decompensated HF were enrolled and divided into 2 groups according to their HbA1c levels (group H, HbA1c 6.9-13.0%, n = 41; group L, HbA1c < 6.9%, n = 40). After the initial management of HF, one of the SGLT2i (canagliflozin 100 mg/day or dapagliflozin 5 mg/day or empagliflozin 10 mg/day) was non-randomly administered, and clinical parameters associating with HF and T2DM were followed for 7 days. No symptomatic hypoglycemia was observed in any patient. In both groups, urine glucose excretion was increased significantly after the administration of SGLT2i. However, its amount was greater in group H than group L. Urine volume was increased significantly at day 1 in both groups. Urine volume returned to the baseline after one week in group L. In contrast, the increase in urine volume persisted at least for one week in group H. Of note, a decrease in B-type natriuretic peptide levels after the initiation of SGLT2i was observed in both groups similarly despite differences in urine output and excretion of urine glucose. In conclusion, SGLT2i can improve decompensated HF in patients with T2DM irrespective of the HbA1c level.

Efficacy of Continuing SGLT2 Inhibitors on Outcomes in Patients with Acute Decompensated Heart Failure.

Sodium-glucose cotransporter 2 inhibitor (SGLT2i) reduces mortality and morbidity in patients with chronic heart failure (HF). However, the clinical implication of SGLT2i therapy in patients with acute decompensated HF remains uncertain. We prospectively studied 86 type 2 diabetic mellitus (T2DM) patients (71.8 ± 12.1 years, 55 men) who were hospitalized for acute decompensated HF and received SGLT2i during the index hospitalization. Among the patients, 56 continued SGLT2i at discharge and 30 did not. The continued group experienced fewer HF re-hospitalizations than the discontinued group (24% versus 39%, P = 0.008) with a hazard ratio of 0.29 (95% confidence interval 0.10-0.85) adjusted for other significant potential confounders. In conclusion, long-term SGLT2i therapy might prevent unplanned HF re-hospitalization in patients with T2DM and acute decompensated HF.

How to Estimate the Optimal Heart Rate in Patients with Heart Failure with Preserved Ejection Fraction.

Ideal heart rate (HR), particularly for those with heart failure with preserved ejection fraction (HFpEF), remains unknown. We hypothesized that cardiac output would be maximum when the overlap between E-wave and A-wave at the trans-mitral flow is "zero" in the Doppler echocardiography. We retrospectively investigated the association among the overlap length between two waves, actual HR, and other echocardiographic parameters to construct a formula for estimating theoretically ideal HR among those with HFpEF. In total, 48 HFpEF patients were included (70-year-olds, 18 males). Given the results of multivariate linear regression analyses, the overlap length was estimated as follows: -1,050 + 8.4 × (HR [bpm]) + 0.6 × (deceleration time [millisecond]) + 1.7 × (A-width [millisecond]), which had a strong agreement with the actually measured overlap length (r = 0.86, P < 0.001). Theoretically ideal HR was calculated by substituting zero into the estimated overlap length as follows: 125 - 0.07 × (deceleration time [millisecond]) - 0.20 × (A-width [millisecond]). In the validation cohort including another 143 HFpEF patients, the estimated overlap using the formula again had a strong agreement with the actually measured overlap (r = 0.72, P < 0.001). In this study, we proposed a novel formula for calculating theoretically ideal HR, consisting of deceleration time and A-width, in the HFpEF cohort. Clinical implication to optimize the HR targeting the theoretically ideal HR should be investigated in prospective studies.

Improvement in Vascular Endothelial Function following Transcatheter Aortic Valve Implantation.

Background and objectives: Endothelial dysfunction is associated with exercise intolerance and adverse cardiovascular events. Transcatheter aortic valve implantation (TAVI) is applied to treat elderly patients with severe aortic stenosis, but less is known about the impact of TAVI on endothelial dysfunction, which can be assessed by measuring flow-mediated vasodilation (FMD). In this parameter, a low value indicates impaired endothelial function. Materials and Methods: Vascular endothelial function was evaluated by FMD of the brachial artery just before and one week after TAVI. Factors associated with the normalization of FMD and their prognostic impact were investigated. Results: Fifty-one patients who underwent TAVI procedure (median 86 years old, 12 men) were included. FMD improved significantly from baseline to one week following TAVI (from 5.3% [3.7%, 6.7%] to 6.3% [4.7%, 8.1%], p < 0.001). Among 33 patients with baseline low FMD (≤6.0%), FMD normalized up to >6.0% following TAVI in 15 patients. Baseline higher cardiac index was independently associated with normalization of FMD following TAVI (odds ratio 11.8, 95% confidence interval 1.12-124; p < 0.04). Conclusions: Endothelial dysfunction improved following TAVI in many patients with severe aortic stenosis. The implication of this finding is the next concern.

B-type Natriuretic Peptide Regulation in Patients with Severe Aortic Stenosis Following Transaortic Valvular Implantation.

Peri-procedural elevated B-type natriuretic peptide (BNP) is also associated with worse outcomes following transcatheter aortic valve implantation (TAVI). However, the mechanism of BNP regulation in patients with severe aortic stenosis (AS) remains unknown. Consecutive patients with severe AS who were referred for TAVI were enrolled in our prospective registry. BNP levels were correlated with other clinical variables. Ninety-six patients (84.7 ± 5.0 years old, 34% males) were investigated in this study. Plasma BNP averaged 353 ± 179 pg/mL. Log10 BNP had no significant correlation with severity of AS including aortic valve area and maximum flow velocity across the aortic valve (P > 0.05 for all), whereas a higher left ventricular end-diastolic dimension (LVDd) index was a significant factor associating with BNP >100 pg/mL with an odds ratio of 1.34 (95% confidence interval 1.06-1.52, P = 0.004) adjusted for several other echocardiographic parameters, with a cutoff of 30.8 mm/m2 (equivalent to LVDd 44 mm). In conclusion, among the patients with severe AS who undergo TAVI, even slight eccentric hypertrophy can cause a considerable increase in BNP level.

Transcatheter Aortic Valve Implantation Improves Cardiac Sympathetic Nerve Activity on 123I-Metaiodobenzylguanidine Myocardial Scintigraphy in Severe Aortic Valve Stenosis.

BACKGROUND: There is a consensus that overactivation of the cardiac sympathetic nervous system (CSN) proportionately increases the severity of heart failure and is accompanied by worse prognosis. Because it is unknown whether patients with aortic valve stenosis (AS) have similar CSN activation, we investigated the effect of transcatheter aortic valve implantation (TAVI).Methods and Results:We enrolled 31 consecutive patients with AS treated by TAVI. 123I-metaiodobenzylguanidine (MIBG) myocardial scintigraphy was performed at baseline and at 2 weeks after TAVI. At baseline, the early heart-mediastinum ratio (H/M) was within normal limits (3.0±0.5), but the delayed H/M was low (2.6±0.6) and the washout rate (WR) was high (34±13%). WR negatively correlated with aortic valve area (r=-0.389, P<0.01) and cardiac output (r=-0.595, P<0.01) and positively correlated with norepinephrine (r=0.519, P<0.01) and log NT-proBNP level (r=0.613, P<0.01). After TAVI, there were significant decreases in the norepinephrine level (366±179 ng/mL vs. 276±125 ng/mL, P<0.01) and WR (34±13 vs. 26±11%, P<0.01). CONCLUSIONS: The WR of MIBG was a useful marker of CSN activity and severity of AS. Immediate improvement of CSN activity after TAVI implied that AS hemodynamics per se enhanced CSN.

Impact of right ventricular distensibility on congestive heart failure with preserved left ventricular ejection fraction in the elderly.

To elucidate involvement of age-related impairments of right ventricular (RV) distensibility in the elderly congestive heart failure (CHF), we examined the prevalence of less-distensible right ventricle in patients with preserved left ventricular ejection fraction (LVEF) over a wide range of ages. In 893 patients aged from 40 to 102 years, we simultaneously recorded electrocardiogram, phonocardiogram, and jugular venous pulse wave. Using signal-processing techniques, the prominent 'Y' descent of jugular pulse waveform was detected as a hemodynamic sign of a less-distensible right ventricle. Prevalence of less-distensible right ventricle and elevated RV systolic pressure increased along with aging from the 50s to the 90s in an exponential fashion from 3.3 and 12% up to 33 and 61%, respectively (p < 0.001 for each). This age-dependent deterioration of ventricular distensibility was not observed for the left ventricle. Higher age and higher RV systolic pressure were independently associated with less-distensible right ventricle (Odds ratio, 1.05 per 1 year, p = 0.003; and 1.03 per 1 mmHg, p = 0.026, respectively). The elderly CHF was associated with high prevalence of the less-distensible right ventricle and higher RV systolic pressure, both of which were independent risk factors for CHF (Odds ratio, 5.27, p = 0.001, and 1.08 per 1 mmHg, p < 0.001, respectively). In elderly patients with preserved LVEF, the combination of a less-distensible right ventricle and a high RV systolic pressure seems to be related to developing CHF. The less-distensible right ventricle and elevated RV systolic pressure are closely associated with CHF with preserved LVEF in the elderly patients.

Restrictive Lung Function Is Related to Sympathetic Hyperactivity in Patients With Heart Failure.

BACKGROUND: Sympathoexcitation and impaired lung function are common in patients with severe heart failure (HF). However, the association between impaired lung function and sympathoexcitation remains unknown. METHODS AND RESULTS: Muscle sympathetic nerve activity (MSNA) and clinical variables were determined in 83 HF patients with left ventricular ejection fraction (LVEF) <0.45. Restrictive and obstructive changes on spirometry were defined as reduced forced vital capacity (FVC) of <80% of predicted and a ratio of forced expiratory volume in the first second to FVC of <70%, respectively. Restrictive and obstructive changes were identified in 17 and 21 patients, respectively. MSNA was higher in patients with restrictive changes than in those without restrictive changes (84 vs 66 bursts per 100 beats; P < .01), but was similar in those with and without obstructive changes. Univariate analyses showed that FVC, estimated glomerular filtration rate (eGFR), specific activity scale, B-type natriuretic peptide level, LVEF, age, and use of aldosterone receptor blockers were significant predictors of MSNA burst incidence. Multivariate analysis revealed that FVC, LVEF, and eGFR were independent factors for increased burst incidence. Changes in FVC during follow-up negatively correlated with changes in burst rate (n = 11; P < .01). CONCLUSION: Restrictive lung function was associated with increased sympathetic nerve activity independently from HF severity.