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Background— Three-dimensional electroanatomic voltage mapping offers the potential to identify low-voltage areas that correspond to regions of right ventricular (RV) myocardial loss and fibrofatty replacement in patients with arrhythmogenic RV cardiomyopathy/dysplasia (ARVC/D). Methods and Results— Thirty-one consecutive patients (22 men and 9 women; mean age, 30.8±7 years) who fulfilled the criteria of the Task Force of the European Society of Cardiology and International Society and Federation of Cardiology (ESC/ISFC) for ARVC/D diagnosis after noninvasive clinical evaluation underwent further invasive study including RV electroanatomic voltage mapping and endomyocardial biopsy (EMB) to validate the diagnosis. Multiple RV endocardial, bipolar electrograms (175±23) were sampled during sinus rhythm. Twenty patients (group A; 65%) had an abnormal RV electroanatomic voltage mapping showing ≥1 area (mean 2.25±0.7) with low-voltage values (bipolar electrogram amplitude 1.5 mV). Low-voltage electrograms appeared fractionated with significantly prolonged duration and delayed activation. In 11 patients (group B; 35%), electroanatomic voltage mapping was normal, with preserved electrogram voltage (4.4±0.7 mV) and duration (37.2±0.9 ms) throughout the RV. Low-voltage areas in patients from group A corresponded to echocardiographic/angiographic RV wall motion abnormalities and were significantly associated with myocyte loss and fibrofatty replacement at EMB ( P P P P =0.02). Conclusions— Three-dimensional electroanatomic voltage mapping enhanced accuracy for diagnosing ARVC/D (1) by demonstrating low-voltage areas that were associated with fibrofatty myocardial replacement and (2) by identifying a subset of patients who fulfilled ESC/ISFC Task Force diagnostic criteria but showed a preserved electrogram voltage, an inflammatory cardiomyopathy mimicking ARVC/D, and a better arrhythmic outcome.

Background— Conduction disturbances are relatively common after transcatheter aortic valve implantation. Previous data demonstrated an adverse impact of persistent left bundle-branch block (LBBB) after surgical aortic valve replacement. It is unclear whether new-onset LBBB may also impact the prognosis of patients after transcatheter aortic valve implantation. Methods and Results— Among 1060 patients treated with a CoreValve Revalving System transcatheter aortic valve implantation between October 2007 and April 2011 in high-volume centers in Italy, we analyzed those without LBBB or pacemaker at admission (879 patients [82.9%]). We further excluded those who underwent permanent pacemaker implantation within 48 hours after the procedure (61 patients [7%]), for a final study population of 818 patients. Among them, 224 patients (group A; 27.4%) developed a persistent LBBB and the remaining 594 (group B; 72.6%) did not. Clinical characteristics were similar between groups. A low implantation was significantly more frequent in group A (15% versus 9.8%, P =0.02). No patients were censored before 1 year (median follow-up period 438 days, interquartile range 174–798 days). Survival analyses and inherent log-rank tests showed that LBBB was not associated with higher all-cause mortality, cardiac mortality, or hospitalization for heart failure at 30 days or 1 year. At 30 days, but not at 1 year, group A had a significantly higher rate of pacemaker implantation. Conclusions— In this registry of high-volume centers, persistent LBBB after CoreValve Revalving System transcatheter aortic valve implantation showed no effect on hard end points. On the other hand, LBBB was associated with a higher short-term rate of pacemaker implantation.

Background— There is a lack of information on the incidence and predictors of early mortality at 30 days and late mortality between 30 days and 1 year after transcatheter aortic valve implantation (TAVI) with the self-expanding CoreValve Revalving prosthesis. Methods and Results— A total of 663 consecutive patients (mean age 81.0±7.3 years) underwent TAVI with the third generation 18-Fr CoreValve device in 14 centers. Procedural success and intraprocedural mortality were 98% and 0.9%, respectively. The cumulative incidences of mortality were 5.4% at 30 days, 12.2% at 6 months, and 15.0% at 1 year. The incidence density of mortality was 12.3 per 100 person-year of observation. Clinical and hemodynamic benefits observed acutely after TAVI were sustained at 1 year. Paravalvular leakages were trace to mild in the majority of cases. Conversion to open heart surgery (odds ratio [OR] 38.68), cardiac tamponade (OR 10.97), major access site complications (OR 8.47), left ventricular ejection fraction Conclusions— Benefit of TAVI with the CoreValve Revalving System is maintained over time up to 1 year, with acceptable mortality rates at various time points. Although procedural complications are strongly associated with early mortality at 30 days, comorbidities and postprocedural paravalvular aortic regurgitation ≥2+ mainly impact late outcomes between 30 days and 1 year.

Abstract: Background. The mortality benefit of primary percutaneous coronary angioplasty (PPCI) over fibrinolysis is risk and time dependent. A PPCI-delay > 60 minute nullify the mortality advantage of PPCI. Registry data have shown that the acceptable PPCI-delay depends on the risk of the patient. We explored the relationship between the risk and PPCI-delay leading to equivalent 30-day mortality between PPCI and fibrinolysis by the results of published randomized trials comparing PPCI with fibrinolytic therapy using fibrin specific agents Methods We included 14 trials into final analysis. The DANAMI-2 study, which consisted of 2 substudies was treated as 2 separate trials. When the outcome is mortality, the control (lytic arm) mortality rate can be interpreted as a proxy for mortality risk. We calculated the PPCI-delay as the difference between mean or median door-to-balloon - door-to-needle time and PPCI survival benefit as 30-day mortality after fibrinolysis minus 30-day mortality after PPCI. Results. Multiple regression analysis showed that fibrinolysis mortality risk (regression coefficient 0.96, p shows the P PCI-delays that lead to equivalent 30-day mortality between PPCI and fibrinolysis according to different risk of the STEMI. Conclusions. The mortality risk of the STEMI patients may modify the acceptable amount of delays to choose a given reperfusion strategy. A longer delay could be justified to choose PPCI instead of fibrinolysis (fibrin specific agents) in high-risk STEMI patients.

A 39-year-old female patient was admitted to our department after referral from another hospital because of echocardiographic evidence of an aneurysmal mass close to the right atrium. The patient complained of frequent episodes of palpitations that had been occurring for the past 4 months. She had no history of cardiac disease or trauma. On admission, her blood pressure was normal and there was no evidence of jugular venous distension or hepatosplanchnic congestion. Supraventricular tachycardia was recorded by 12-lead ECG (Figure 1A). Plain chest x-ray showed a huge enlargement of the cardiac silhouette with normal pulmonary vascular markings (Figure 1B). Both transthoracic …

Background— We assessed coronary flow velocity pattern and coronary flow reserve (CFR) by contrast-enhanced transthoracic echocardiography (CE-TTE) as markers of major adverse cardiac events (MACE) related to cardiac allograft vasculopathy (CAV) after heart transplantation (HT). Methods and Results— Deceleration time of diastolic flow velocity (DDT) and CFR were measured in the left anterior descending coronary artery (LAD) by CE-TTE in 66 consecutive HT patients (follow-up 19±5 months). CFR was calculated as the ratio of hyperemic to basal diastolic flow velocity. Angiographies were analyzed by a qualitative grading system; CAV was defined as changes grade II or higher. MACE were cardiac death, stent implantation, and heart failure. Patients with MACE had higher CAV incidence ( P =0.004) and grade ( P =0.008), shorter DDT ( P =0.006), and lower CFR ( P =0.008). A receiver-operating characteristic–derived DDT cutpoint ≤840 ms (area under the curve 0.793; P =0.01) was 75% specific and 86% sensitive for predicting MACE, with positive predictive value (PPV) and negative predictive value (NPV) of 33% and 97%, respectively ( P =0.002). A CFR cutpoint of ≤2.6 (area under the curve 0.746; P =0.01) was 62% specific and 91% sensitive for predicting MACE (PPV =32%, NPV =97%) ( P =0.001). Patients with CFR ≤2.6 and patients with DDT ≤840 ms had a lower survival free from MACE ( P =0.006 and P =0.009, respectively). By Cox regression, only a lower CFR predicted the risk of MACE (relative risk 3.1; 95% CI, 1.26 to 7.9; P =0.01). Conclusions— In HT patients, shorter DDT and lower CFR by CE-TTE are reliable markers for CAV-related MACE. CFR is the main independent predictor of MACE.