Le système nerveux autonome cardiaque est devenu une cible dans les thérapies ablatives de la fibrillation auriculaire. Nous avons étudié les voies de communication et la fonction des plexus ganglionnaires (PG) de l'oreillette gauche (PGOG) afin de clarifier la validité physiopathologique des méthodes de détection et des thérapies impliquant ces groupes de neuronnes. Méthodes: Vingt-deux chiens ont subi une double thoracotomie et ont été instrumentés avec des plaques auriculaires épidcardiques de multiélectrodes. Une stimulation électrique (2 mA, 15 Hz) des PGOG a été réalisée à l'état basal et successivement après: 1) une décentralisation vagale, 2) l'ablation par radiofréquence des plexus péri-aortiques et de la veine cave supérieure (Ao/VCS) et 3) l'ablation du PG de l'oreillette droite (PGOD). Ces procédures de dénervation ont été réalisées suivant une séquence antérograde (n = 17) ou rétrograde (n = 5). Résultats: Chez 17 des 22 animaux, la stimulation des PGOG a induit une bradycardie sinusale (149 ± 34 bpm vs 136 ± 28 bpm, p < 0.002) et des changements de repolarization (ΔREPOL) auriculaires isointégrales. Dans le groupe des ablations antérogrades, les réponses aux stimulations vagales ont été supprimées suite à la décentralisation vagale chez un seul animal, par l'ablation des plexus Ao/VCS dans 4 cas et par l'ablation du PGOG dans 5 autres animaux. Des changements ont persisté tout au long chez 2 chiens. La valeur de surface des ΔREPOL a diminué avec les dénervations séquentielles, passant de 365 ± 252 mm2 en basale à 53 ± 106 mm2 après l'ablation du PGOD (p < 0.03). Dans le groupe de dénervation rétrograde, les changements de repolarisation et chronotropiques ont été supprimés suite à l'ablation du PGOD chez deux chiens et suite à l'ablation Ao/VCS chez trois. La valeur de surface du ΔREPOL a aussi diminué après l'ablation du PGOD (269±144mm2 vs 124±158mm2, p<0.05). Conclusion: Les PGOD sont identifiables en préablation par la réponse bradycardique à la stimulation directe dans la plupart des cas. Le PGOD semble former la principale, mais non la seule, voie de communication avec le nœud sinusal. Ces résultats pourraient avoir des implications dans le traitement de la FA par méthodes ablatives. / The cardiac autonomic nervous system has recently become the target of ablative therapy in the treatment of atrial fibrillation. We investigated the pathways and function of the left atrial ganglionated plexus (LAGP) to clarify the pathophysiologic validity of therapies involving this cluster of neurons. Methods: Twenty-two bilaterally thoracotomized canines were instrumented with atrial epicardial plaques. LAGP stimulation was performed in the basal state and successively following 1) vagal decentralization, 2) radiofrequency ablation of the peri-aortic/superior vena caval (Ao/SVC) plexi, and 3) of the right atrial ganglionated plexus (RAGP). Denervation was carried out in either the aforementioned order (n=17, antegrade) or reversed (n=5, retrograde). Results: In 17 of 22 animals, LAGP stimulation induced a sinus bradycardia (149±34bpm to 136±28bpm, p<0.002) and atrial isointegral repolarization changes (REPOL∆). In the antegrade group, response was suppressed by vagal decentralization (n=1), Ao/SVC plexi ablation (n=4), and RAGP ablation (n=5). Changes persisted throughout in 2 canines. Surface area of REPOL∆ diminished with successive denervation, from 365±252 at baseline to 53±106mm2 following RAGP ablation (p<0.03). With retrograde denervation, chronotropic and repolarisation changes were suppressed following RAGP ablation in two canines, and following Ao/SVC ablation in three. Surface area of REPOL∆ diminished following RAGP ablation as well (269±144mm2 vs 124±158mm2, p<0.05). Conclusion: The LAGP can be identified intraoperatively by the bradycardic response to direct stimulation in most cases. The RAGP appears to be the primary, but not the only, gateway to the sinus node. These results could have important clinical implications relating to ablative treatment of atrial fibrillation.

De déterminer si une stratégie de contrôle du rythme améliore la qualité de vie et / ou la capacité fonctionnelle par rapport à une stratégie de contrôle de la fréquence cardiaque chez les patients atteints de fibrillation auriculaire et d'insuffisance cardiaque congestive. Méthode: Pour évaluer la qualité de vie, le questionnaire SF-36 a été administré à l'inclusion et à 4 mois chez 749 patients de l’étude AF-CHF. Les paramètres de capacité fonctionnelle évalués ont été la classe fonctionnelle NYHA (1376 patients) et la distance de marche de six minutes (1099 patients). Résultats: Le type du traitement assigné n'a pas eu un impact significatif sur la qualité de vie ou la capacité fonctionnelle. Conclusion: La qualité de vie et la capacité fonctionnelle sont similaires chez les patients randomisés au contrôle du rythme par rapport au contrôle de la fréquence. Les hommes non-obèses avec moins de comorbidités semblent plus susceptibles de s'améliorer. / To determine if a rhythm control strategy improves quality of life and/or functional capacity compared to a rate control strategy in patients with atrial fibrillation and congestive heart failure. Methods: To assess QoL, the Medical Outcomes Short Form-36 (SF-36) was administered to 749 patients included in the AF-CHF study at baseline and at 4 months. Functional capacity was assessed by NYHA class determined at baseline, 3 weeks, 4 months, and at 4-month intervals thereafter in 1376 patients and by 6 minutes walk test conducted at baseline, 3 weeks, 4 months, 1 year, and annually thereafter in 1099 patients. Results: The type of the assigned treatment had no significant impact on quality of life scores nor on functional capacity. Conclusion: Quality of life and functional capacity improved to a similar extent in patients randomised to rhythm versus rate-control strategies. Non-obese male patients with less comorbidities seem more likely to improve.

Les maladies cardio-vasculaires sont la première cause de mortalité dans le monde. L’hypertrophie cardiaque est un processus de remodelage provoqué par une surcharge de travail du muscle cardiaque afin de mieux répondre à la demande de l’organisme. Bien que bénéfique à court terme, une hypertrophie trop accentuée conduira à long terme, à une insuffisance cardiaque. L’hypertrophie est associée à un remodelage électrique qui conduit généralement à un allongement du potentiel d’action, une des causes des arythmies ventriculaires et de la mort subite. Généralement, le mécanisme causal est la fibrillation ventriculaire, un trouble du rythme irréversible dont les mécanismes sont complexes et méconnus. Si les conséquences fonctionnelles in vitro des mutations génétiques ou du remodelage ionique sont relativement simples à étudier ou à prévoir, leur rôle dans les mécanismes des troubles du rythme in vivo sont plus difficiles à appréhender. Parmi les nombreux modèles animaux développés pour la recherche sur les troubles du rythme, la souris est de plus en plus utilisée en raison de notre capacité à muter, invalider ou sur-exprimer les gènes d'intérêt chez ces animaux. L'objectif de mon travail de thèse était de mieux comprendre le rôle des canaux ioniques en physiopathologie cardiaque, en particulier dans la survenue des troubles du rythme in vivo. Ces travaux ont permis d'améliorer notre connaissance du rôle des anomalies génétiques impliquant des canaux ioniques et du remodelage ionique dans la physiopathologie des troubles du rythme et pourrait ainsi ouvrir de nouvelles perspectives thérapeutiques dans le traitement anti-remodelage cardiaque et la prévention de la mort subite. / Cardiovascular disease is the leading cause of death in the world each year. If no action is taken to improve cardiovascular health and current trends continue, WHO estimates that 25% more healthy life years will be lost to cardiovascular disease globally by 2020. Cardiac hypertrophy is the consequence of an excessive workload of the heart muscle leading to cardiac remodeling process. As the workload increases, the ventricular walls grow thicker, lose elasticity and eventually may fail to pump with as much force as a healthy heart. Furthermore, hypertrophied myocardium is not physiologically normal and may confer a predisposition to potentially fatal arrhythmias. Generally, the causal mechanism is ventricular fibrillation, a cardiac rhythm disorder which is irreversible but the pathophysiological mechanisms are complex and poorly understood. The functional consequences of mutations or ionic remodeling are relatively simple to study in vitro, but their role in the pathophysiology of arrhythmias in vivo is more difficult to grasp. Among the different animal models developed in cardiac arrhythmias research, the mouse is increasingly used because of our ability to mutate, knock-out or over-express genes of interest. The objective of my thesis was to study the role of ion channels in physiology as well as cardiac pathophysiology, particularly in the involvement of the occurrence of cardiac arrhythmias in vivo. This thesis will improve our understanding of the role of genetic abnormalities involving ionic remodeling in the pathogenesis of the heart and may also open new therapeutic perspectives in the treatment of cardiac remodeling as well as sudden cardiac death. / Thèse en cotutelle avec Université de Nantes - Pays de La Loire - France (2005-2010)

Introdução: Amplo debate tem associado a incorporação de novas tecnologias para a saúde com os custos crescentes dos sistemas de saúde. Face à dúvidas \"se as novas tecnologias são parte do problema, parte da solução ou as duas coisas\" relativamente à saúde da população e do sistema de saúde, este estudo de caso analisa a incorporação de três inovações no Instituto do Coração, InCor-HC/FMUSP, visando elaborar quais fatores influenciaram a decisão de adoção e exemplificar as metodologias de avaliação de novo medicamento, de procedimento diagnóstico e intervenção cirúrgica. A avaliação das tecnologias para a saúde, ATS, pode auxiliar a constituir algumas propostas de respostas. Metodologia: estudo qualitativo empírico em caso retrospectivo de incorporação de três inovações para assistência de alta complexidade em cardiologia. As metodologias utilizadas consistiram em entrevistas aos tomadores de decisão, revisões sistemáticas da literatura relevante, descritiva ou meta-analítica, e análise de impacto econômico hospitalar. Resultados: O padrão do InCor para a incorporação das inovações funciona como um sistema social criativo, sob uma estratégia prática pluralista, ou seja, utilizam as pesquisas, aprovadas pela Comissão de Ética e Pesquisa do InCor e do HC, que se sucederam e que sucedem em incrementos, verificando e ajustando as informações segundo os resultados obtidos para desenhar novas pesquisas. Os atores construíram conhecimentos e negociaram protocolos de pesquisa, promoveram a capacitação de super-especialistas técnicos, transferindo práticas internacionais e gerando conhecimentos adaptados à realidade do Brasil. A avaliação do medicamento tacrolimus demonstra que se poderia resgatar uma média de 75% das rejeições refratárias às terapias convencionais, proporcionando um custo hospitalar de R$ R$ 102,99 por dia de sobrevida nos 8 adultos e R$ 137,53 nas 13 crianças observadas, comparativamente à R$ 229,00 e R$ 260,00, com ciclosporina, respectivamente. Assim, se evitaria 37% da mortalidade associada à episódios de rejeição nos pacientes com transplante cardíaco e, mesmo no único óbito, o custo hospitalar por dia de sobrevida foi de metade que o custo dos períodos observados nos 32 pacientes sob ciclosporina que foram a óbito. O diagnóstico por angiotomocoronariografia em pacientes com angina atípica e risco moderado permitiria orientar o manejo de até dois terços destes casos evitandose coronariografias invasivas. Isto permitiria aumentar a resolutividade do Departamento de Hemodinâmica de 25% para mais 20% dos casos assim estudados, com economias para o InCor, aumento do acesso e resolutividade, podendo evitar até 2.000 mortes, e com o acréscimo estimado de <10% do valor destas 14% mais angioplastias e 6% mais revascularizações cirúrgicas para o SUS. A ablação cirúrgica tem o potencial de curar >10% das fibrilações atriais refratárias a medicamentos em pacientes com indicação de cirurgia aberta para correção de problemas cardíacos estruturais, evitando morbidade e mortalidade em até 1.000 pacientes por ano, se houver suposição que esta seja utilizada apenas com as cirurgias valvares no âmbito do SUS. Conclusões e discussão: As novas tecnologias estudadas proporcionam benefícios à saúde, mas ainda possuem variados graus de incerteza sobre aspectos de segurança e sobre seu potencial de impacto econômico para os programas assistenciais para o InCor e para o SUS. O InCor e os demais hospitais universitários possuem alta capacidade técnica instalada, onde a estruturação de pesquisas facilita e permite a incorporação de inovações de alta complexidade, sem contudo haver planejamento econômico para os programas de assistência à saúde. O isolamento destes atores, em relação às instâncias gestoras do SUS, permite construções sob visões parciais e imediatistas, permite desenvolvimento de interesses externos e diversos, e, por outro lado, pressiona de maneira desordenada a organização e o sistema de saúde. A integração da capacidade profissional, instalada nos hospitais universitários, dentro do circuito de planejamento de médio e longo prazo para o SUS, avaliando as tecnologias inovadoras comparativamente às estabelecidas para a saúde, com base na epidemiologia local observada, pode permitir uma atualização planejada e contínua dos serviços de saúde, construída sobre bases sólidas de conhecimento científico adaptado à nossa realidade e com o responsável equilíbrio orçamentário. / Introduction: There is an ongoing international debate associating the increasing health care costs with adoption of new health technologies. To aid to ascertain whether new health technologies are part of the problem, part of the solution or both in relation to the health of the population and of the health care system, this case study analyses retrospectively three recent decisions to adopt innovations at the Heart Institute, InCor-HC/FMUSP. In order to provide examples of the application of methods for health technologies assessment, the InCor Board of Directors indicated one innovative drug, a new diagnostic procedure and a recent surgery. Methods: Qualitative, retrospective field evaluation of the three decisions for the highest complexity of care in cardiology. Decision-makers survey, systematic reviews (descriptive or meta-analytic) and hospital economic impact analysis were the methodologies applied to this case. Results: A pattern of new technologies incorporation through incremental research, a strategic and pluralist practice emerged within a creative social system. Approved by the InCor and HC Research Ethics Boards and based on previous research results, successive investigations verified and adjusted the informations and generated additional research. Thus, the decision-makers do build knowledge, negotiate research protocols, promote very technical specialists formation and transfer international practice, inter- and up-grading it to the Brazilian reality. Evaluation of these three innovative technologies results are: - The drug tacrolimus may rescue and resolve an average of 75% of the episodes of rejection refractory to conventional medications. The average hospital cost observed (since conversion from CSA, censored at March the 30th, 2006) was of US$45 or R$102.99 per day of survival in 8 adults and of US$61 or R$137.53 for the 13 children (<18 years of age), compared with R$ 229.00 and R$ 260.00, respectively, in those who remained under cyclosporine treatment. Thus, it could prevent 37% rejection related mortality and bring some economy (even in the single child death observed, the hospital cost per day until death was the half of the cost observed for the 32 cyclosporine treated). - The tomoangiocoronariography diagnosis for patients presenting atypical angina and moderate to low risk of stenosis may orient and modify up to 66% clinical decisions preventing requirement of an invasive procedure. This would increase 20% to the Haemodynamic Department 25% resolutivity, may prevent up to 2000 deaths with an estimated additional 10% of the costs of 14% more angioplasties and 6% increase in surgical coronary bypasses for the health care system. - Surgical ablation has the potential to cure more than 10% of medications refractory atrial fibrillation in patients undergoing open heart surgery for structural corrections. Supposing it is restricted only to the group of patients undergoing valve surgery in the health care system, it could prevent morbidity and mortality for up to 1000 patients. Conclusions and discussion: The new technologies evaluated bring benefits to the health of the patients. Safety concerns and economic impact for the InCor and for the health care system assistance programs require further investigation. InCor and the other university hospitals have enhanced technical capacity installed. The structured research facilitates and allows incorporation of highly complex innovations without planning future programs for care. The isolation of these decision makers from the health care system decision planners allows partial views and immediacies. Such a distance facilitates development of external and diverse interests. These facts, consequently, pressures on the organization and the health care system. The integration of the university hospitals installed professional capacities, within an average and long term health care system plans, making evaluations of the innovative health technologies in comparison with the established ones based on local epidemiology, may permit a planned and continuous actualization of the health services on solid scientific basis adapted to the Brazilian reality and with a responsible financial balance.

A ablação cirúrgica por radiofreqüência (RF) é uma nova técnica para tratar a fibrilação atrial (FA) permanente. O objetivo deste estudo é avaliar a eficácia da ablação cirúrgica por RF da FA permanente em pacientes com valvopatia mitral reumática (VMR). Entre Fevereiro de 2002 e Abril de 2003, 70 pacientes com FA permanente e VMR foram submetidos à operação da valva mitral associada à ablação por RF da FA (Grupo A); ou à operação da valva mitral isolada (Grupo B). No seguimento pós-operatório foram avaliados: a reversão para o ritmo sinusal (RS) e a contratilidade atrial. Após 12 meses de seguimento, os índices de reversão para o RS e de restabelecimento da contratilidade atrial foram significativamente superiores no Grupo A. A ablação cirúrgica por RF é eficaz para o tratamento da FA permanente em pacientes com VMR / Radiofrequency ablation is a new surgical technique to treat permanent atrial fibrillation. The aim of this study was to evaluate the effectiveness of the (RF) ablation for the treatment of permanent AF in patients with rheumatic mitral valve (MV) disease. Between February 2002 and April 2003, 70 patients with permanent AF and rheumatic MV disease were assigned to undergo a MV surgery associated with RF ablation (Group A), or MV surgery alone (Group B). After 12 months of follow-up, the cumulative rates of sinus rhythm conversion and atrial transport function restoration were higher in Group A.The RF ablation is effective for treating permanent AF associated with rheumatic MV disease

Contexte: La maladie de Fabry (MF) se caractérise par l'accumulation de sphingolipides dans de multiples organes dont l'oreillette gauche (OG). La littérature existante ne permet pas d'établir si les fonctions réservoir, conduit et pompe de l'OG étudiées par échocardiographie de suivi des marqueurs acoustiques (speckle-tracking echocardiography, STE) sont affectées dans la MF et si la thérapie de remplacement enzymatique (TRE) permet d'améliorer la fonction de l'OG. Méthodes: Dans cette étude de cohorte rétrospective, la déformation, le taux de déformation et les volumes phasiques de l'OG ont été étudiés chez 50 patients atteints de la MF et comparés à 50 contrôles sains. Résultats: Les trois fonctions phasiques de l'OG étaient altérées. La déformation positive maximale (fonction réservoir) était de 38,9 ± 14,9 % vs. 46,5 ± 10,9 % (p=0,004) et la déformation télédiastolique (fonction pompe) était de 12,6 ± 5,9 % vs. 15,6 ± 5,3 % (p=0,010). Chez 15 patients ayant débuté la TRE pendant l'étude, la majorité des paramètres de fonction de l'OG se sont améliorés après un suivi d'un an (déformation positive maximale de 32,0 ± 13,5 % à 38,0 ± 13,5 %; p=0,006) alors qu'il y a eu une tendance vers une détérioration des paramètres chez 15 patients n'ayant jamais reçu de traitement (déformation positive maximale de 47,3 ± 10,8 % à 41,3 ± 9,3 %; p=0,058). Neuf patients atteints de la MF (21%) ont développé une fibrillation auriculaire ou un accident vasculaire cérébral pendant un suivi de quatre ans. La déformation positive maximale et la déformation protodiastolique étaient plus fortement associés aux événements cliniques que les paramètres cliniques et les paramètres échocardiographiques standards. Conclusions: Les fonctions réservoir, conduit et pompe de l'OG par STE étaient affectées dans la MF. La TRE a permis d'améliorer la fonction de l'OG. Les paramètres de déformation de l'OG étaient associés à la survenue de fibrillation auriculaire et d'accidents vasculaires cérébraux. / Background: Fabry disease (FD) is characterized by the accumulation of sphingolipids in multiple organs including the left atrium (LA). It is uncertain if the LA reservoir, conduit and contractile functions evaluated by speckle-tracking echocardiography are affected in Fabry cardiomyopathy and whether enzyme replacement therapy can improve LA function. Methods: In this retrospective cohort study, LA strain, strain rates and phasic LA volumes were studied in 50 FD patients and compared to 50 healthy controls. Results: All three LA phasic functions were altered. The peak positive strain (reservoir function) was 38.9 ± 14.9 % vs. 46.5 ± 10.9 % (p=0.004) and the late diastolic strain (contractile function) was 12.6 ± 5.9 % vs. 15.6 ± 5.3 % (p=0.010). In 15 patients who started enzyme replacement therapy during the study, most of the LA parameters improved at one-year follow-up (peak positive strain from 32.0 ± 13.5 % to 38.0 ± 13.5 %; p=0.006) whereas there was a trend towards deterioration in 15 patients who never received treatment (peak positive strain from 47.3 ± 10.8 % to 41.3 ± 9.3 %; p=0.058). Nine FD patients (21%) experienced new-onset atrial fibrillation or stroke during four-year follow-up. By univariate analysis, peak positive strain and early diastolic strain demonstrated significant associations with clinical events, surpassing conventional echocardiographic parameters and clinical characteristics. Conclusions: Left atrial reservoir, conduit and contractile functions by speckle-tracking echocardiography were all affected in FD. Enzyme replacement therapy improved LA function. Left atrial strain parameters were associated with atrial fibrillation and stroke.

Atrial fibrillation (AF), the most common cardiac arrhythmia in persons over age 65, is associated with an increased stroke risk necessitating the need for long-term oral anticoagulation for risk reduction. With the introduction of direct thrombin and factor Xa inhibitors in the US since 2010, these novel oral anticoagulants (NOACs) are increasingly being prescribed, replacing the use of warfarin, a vitamin K antagonist. AF catheter ablation (CA), an elective procedure requiring femoral vascular access is a treatment for drug refractory and persistent AF. Bedrest, limb immobilization, and limited head of bed elevation are nursing measures utilized following femoral venous, and sometimes arterial, sheath removal and hemostasis. Limited research is available on the appropriate duration of bedrest to minimize bleeding complications associated with AF ablation in patients who use NOACs. The purpose of this quality improvement project was to compare and evaluate the effect of bedrest duration on post-procedure bleeding outcomes, urinary complaints, and back pain among patients taking NOACs while undergoing AFCA. Thirty patients undergoing elective AFCA on NOACs were orally consented to participate in the study and placed on shortened (8 hours) or prolonged (>8 hours) bedrest following vascular hemostasis. Outcome measurements included bleeding after ambulation, back pain, and urinary complaints. Fifteen patients (50%) were on shortened bedrest and 15 (50%) were on prolonged bedrest. No statistically significant difference in bleeding, urinary complaints, or back pain were found. Since there is no clear advantage to prolonged bedrest for patients on NOACS after an AFCA procedure, clinicians should consider this when deciding on bedrest duration for their patients.

Heart rate changes mediate the embryotoxic effect of antiarrhythmic drugs in the chick embryo A significant increase in cardiovascular medication use during pregnancy has occurred in recent years but only limited evidence on its safety profile is available. We hypothesized that drug-induced bradycardia is the leading mechanism of developmental toxicity. We tested metoprolol, carvedilol, or ivabradine for embryotoxicity and their acute effect on chick embryonic model. We used video microscopy and ultrasound biomicroscopy. Significant dose-dependent mortality was achieved in embryos injected with carvedilol and ivabradine. In ED4 embryos, metoprolol, carvedilol and ivabradine reduced the heart rate by 33%, 27%, and 55%, respectively, compared to controls (6%). In ED8 embryos this effect was more pronounced with a heart rate reduction by 71%, 54%, 53%, respectively (controls 36%). Cardiac output decreased in all tested groups but only proved significant in the metoprolol group in ED8 embryos. The number of -adrenergic receptors showed a downward tendency during embryonic development but a negative chronotropic effect of tested drugs was increasingly pronounced with embryonic maturity. This effect was associated with reduced cardiac output in chick embryos, probably leading to premature death....

Heart rate changes mediate the embryotoxic effect of antiarrhythmic drugs in the chick embryo A significant increase in cardiovascular medication use during pregnancy has occurred in recent years but only limited evidence on its safety profile is available. We hypothesized that drug-induced bradycardia is the leading mechanism of developmental toxicity. We tested metoprolol, carvedilol, or ivabradine for embryotoxicity and their acute effect on chick embryonic model. We used video microscopy and ultrasound biomicroscopy. Significant dose-dependent mortality was achieved in embryos injected with carvedilol and ivabradine. In ED4 embryos, metoprolol, carvedilol and ivabradine reduced the heart rate by 33%, 27%, and 55%, respectively, compared to controls (6%). In ED8 embryos this effect was more pronounced with a heart rate reduction by 71%, 54%, 53%, respectively (controls 36%). Cardiac output decreased in all tested groups but only proved significant in the metoprolol group in ED8 embryos. The number of -adrenergic receptors showed a downward tendency during embryonic development but a negative chronotropic effect of tested drugs was increasingly pronounced with embryonic maturity. This effect was associated with reduced cardiac output in chick embryos, probably leading to premature death....

Limited data exists describing the long-term prognosis of patients with acute decompensated heart failure (ADHF) further stratified according to currently recommended ejection fraction (EF) findings. In addition, little is known about the magnitude of, and factors associated with, long-term prognosis for these patients. Based on previously validated and clinically relevant criteria, we defined HF-REF as patients with an EF value ≤40%, HF-PEF was defined as an EF value > 50%, and HF-BREF was defined as patients with an EF value during their index hospitalization between 41 and 49%. The hospital medical records of residents of the Worcester (MA) metropolitan area who were discharged after ADHF from all 11 medical centers in central Massachusetts during the 5 study years of 1995, 2000, 2002, 2004, and 2006 were reviewed. Follow-up was completed through 2011 for all patient cohorts. The average age of this population was 75 years, the majority was white, and 44% were men. Patients with HF-PEF experienced higher post discharge survival rates than patients with either HF-REF or HF-BREF at 1, 2, and 5-years after discharge. Advanced age and lower estimated glomerular filtration rate findings at the time of hospital admission were important predictors of 1-year death rates, irrespective of EF findings. Previously diagnosed chronic obstructive pulmonary disease, chronic kidney disease, and atrial fibrillation were associated with a poor prognosis in patients with PEF and REF whereas a history of diabetes was an important prognostic factor for patients with REF and BREF. In conclusion, although improvements in 1-year post-discharge survival were observed for patients in each of the 3 EF groups examined to varying degrees, the post- 7 discharge prognosis of all patients with ADHF remains guarded. In addition, we observed differences in several prognostic factors between patients with ADHF with varying EF findings, which have implications for more refined treatment and surveillance plans for these patients.