Search

Sustained re-entrant tachyarrhythmias treatment has become pivotal in the grown-up congenital heart patients clinical management. Cardiac LGE-MRI tissue characterization integrated with high definition electroanatomic map could allow fast recognition and effective treatment of substrate of tachyarrhythmias. Cardiac LGE-MRI areas were suggestive of post-surgical changes both in atrium and ventricle. High-density electro-anatomical map localized areas of slow conduction identifying conducting isthmuses of re-entrant arrhythmias., Competing Interests: I.RL. and L.M. have served as a consultant for Biosense‐Webster, Boston Scientific, and Abbot Medical. Other authors have no conflict of interest to declare., (© 2021 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Heart Rhythm Society.)

Aims: As patients with heart failure (HF) and concomitant diabetes carry a poor prognosis, this post-hoc subgroup analysis aimed to compare the outcomes of patients with and without diabetes randomized in the Echocardiography Guided Cardiac Resynchronization Therapy (EchoCRT) study., Methods and Results: EchoCRT randomized patients with a QRS duration <130 ms and echocardiographic evidence of left ventricular dyssynchrony to CRT turned on (CRT=ON) vs. off (CRT=OFF) following device implantation. At study entry, 328 patients (40.5%) had diabetes. The primary outcome (all-cause death or first hospitalization for worsening HF) occurred more frequently in patients with than without diabetes (32.6% vs. 23%, P = 0.003). A significant treatment interaction was observed for the primary outcome indicating a higher risk for CRT=ON vs. CRT-OFF in patients without [26.5% vs. 19.8%, hazard ratio (HR) 1.58, 95% confidence interval (CI) 1.08-2.31] vs. with diabetes (31.4% vs. 34%; HR 0.86, 95% CI 0.58-1.27; P for interaction 0.041). This effect was mainly driven by a lower rate in HF hospitalizations, but was only of borderline significance after multivariate adjustment (P = 0.063). The most pronounced effect was observed in patients with non-ischaemic cardiomyopathy, where a significantly reduced risk of reaching the primary endpoint for CRT=ON vs. CRT-OFF was observed in patients with (HR 0.27, P = 0.003) vs. patients without diabetes (HR 1.79, P = 0.038; P for interaction 0.005). No treatment interaction by diabetes diagnosis was found for mortality endpoints., Conclusion: In EchoCRT, HF patients with a narrow QRS complex and coexisting diabetes demonstrated a signal for less harm caused by CRT compared with patients without diabetes, which was driven by differences in hospitalizations owing to HF., (© 2016 The Authors. European Journal of Heart Failure © 2016 European Society of Cardiology.)

Background: Prognosis of heart failure patients has been defined in hospital-based or retrospective studies. This study aimed to characterize prognosis of outpatients with new-onset preserved or reduced ejection fraction heart failure; to explore the role of collagen turnover biomarkers (MMP2, MMP9, TIMP1) in predicting prognosis; and to analyse their relationship with echocardiographic parameters and final diagnosis., Methods: This is an observational, prospective, longitudinal study. Outpatients with new-onset heart failure symptoms referred to a one-stop clinic were included. Echocardiography and biomarkers plasma levels determination were performed at the inclusion. A prospective follow-up was conducted to report cardiovascular events. The discriminant analysis was applied to identify the parameters related to cardiovascular outcomes., Results: A total of 172 patients (75 ± 9 years) were included, 67% with heart failure (64% preserved and 36% with reduced ejection fraction). During follow-up (median 34.5 months), 32.6% had at least one cardiovascular event and 9.9% died. Heart failure groups showed no differences in cardiovascular outcomes with a higher rate of events than nonheart failure patients. MMP2 and TIMP1 were correlated with diastolic dysfunction (Rho 0.349 and 0.294, P < 0.001). In the discriminant analysis, the combination of biomarkers with clinical, biochemical and echocardiographic parameters was useful to predict cardiovascular outcomes (AUC ROC 0.806, Wilks lambda 0.7688, P < 0.001)., Conclusions: Prognosis of outpatients with new-onset heart failure symptoms is comparable between heart failure with preserved or reduced subgroups. The addition of biomarkers specially MMP2 and high sensitive troponin I to other clinical, biochemical and echocardiographic variables can predict cardiovascular prognosis at the time of diagnosis., (© 2015 Stichting European Society for Clinical Investigation Journal Foundation.)

Aims: The beneficial effects of CRT in patients with advanced heart failure, wide QRS, and low LVEF have been clearly established. Nevertheless, mortality remains high in some patients. The aims of our study were to identify the predictors of mortality in patients treated with CRT and to design a risk score for mortality., Methods and Results: A cohort of 608 consecutive patients treated with CRT from 2000 to 2011 in our centre was prospectively analysed. Baseline clinical and echocardiography variables were analysed and mortality data were collected. During a mean follow-up of 36.2 ± 29.2 months, 174 patients died: 123/174 (71%) due to cardiovascular causes, 25/174 (14%) non-cardiac causes, and 26/174 (15%) unknown aetiology. In a multivariate analysis the predictors of mortality were NYHA class IV [hazard ratio (HR) 2.54, 95% confidence interval (CI) 1.7-3.7, P < 0.001], glomerular filtration rate (GFR) <60 mL/min/1.73 m2 (HR 1.61, 95% CI 1.14-2.30, P = 0.008), AF (HR 1.67, 95% CI 1.19-2.3, P = 0.01), age ≥70 years (HR 1.44, (95% CI 1.04-2.00, P = 0.02), and LVEF <22% (HR 1.83, 95% CI 1.33-2.52, P ≤ 0.001). The EAARN score (EF, Age, AF, Renal dysfunction, NYHA class IV) summarizes the predictors. Each additional predictor increased the mortality: one predictor, HR 3.28 (95% CI 1.37-7.8, P = 0.008); two, HR 5.23 (95% CI 2.24-12.10, P < 0.001); three, HR 9.63 (95% CI 4.1-22.60, P < 0.001); and four or more, HR 14.38 (95% CI 5.8-35.65, P < 0.001)., Conclusion: The predictors of mortality have a significant add-on predictive effect on mortality. The EAARN score could be useful to stratify the prognosis of CRT patients., (© 2014 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Aims: Increased sympathetic activation and reduced parasympathetic tone are important pathophysiological contributors to the progression of heart failure, and are associated with poor outcome in patients. The aim of this study is to determine if vagal nerve stimulation (VNS) is a promising approach to modulate autonomic function and slow cardiac remodelling and the progression of heart failure., Methods: The NECTAR-HF (NEural Cardiac TherApy foR Heart Failure) trial is designed to evaluate whether the Boston Scientific VNS device is safe and may attenuate cardiac remodelling, improve cardiac function and increase exercise capacity, in symptomatic heart failure patients (New York Heart Association Class II-III) with left ventricular systolic dysfunction (ejection fraction ≤35%) and receiving optimal medical therapy. Patients will be randomized in a 2:1 ratio to receive standard optimal medical treatment plus VNS system in an active mode vs. optimal medical treatment plus VNS system in an inactive mode, for a 6 month period. After the 6 month control period, inactive VNS systems will be activated and all patients will receive VNS. The study is powered to detect differences in the primary efficacy endpoint of change in left ventricular end systolic diameter. Secondary endpoints include ejection fraction, left ventricular volumes, quality of life scores, functional capacity, and changes in biomarkers., Conclusion: This Phase II, randomized clinical trial conducted with vagal stimulation for heart failure will provide important new information on the potential of this novel and promising technique., (© 2014 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Aims: Monitoring early signs of clinical deterioration could allow physicians to adjust medical treatment for patients at risk of acute heart failure decompensation. To date, several strategies using different surrogate measures of clinical status emerged, but none has yet been proven to predict clinical events. We hypothesized that the Physiological Diagnostic feature, which combines data from minute ventilation and physical activity sensors, predicts heart failure events in patients implanted with cardiac resynchronization therapy with defibrillation (CRT-D) devices., Methods and Results: The Clinical Evaluation of the Physiological Diagnostic feature in the PARADYM CRT device (CLEPSYDRA) trial is a multicentre, prospective, non-randomized, double-blind study comprising 521 CRT-D patients with heart failure [67.4 ± 10.1 years (mean ± SD), 82% male, New York Heart Association class III/IV 85.0%/6.7%, QRS 155.3 ± 26.6 ms, left ventricular ejection fraction 25.7 ± 7.7%]. The objective of the study was the sensitivity and false positive rate of the Physiological Diagnostic algorithm to predict heart failure events within the following month. After a mean follow-up of 17.0 ± 8.7 months, 130 (25.6%) patients experienced a heart failure event. The sensitivity of the algorithm to predict an event was 34% and the false positive rate was 2.4 per patient-year., Conclusion: Thirty-four per cent of heart failure events occurring within a month were predicted by the Physiological Diagnostic algorithm, and 2.4 alerts per patient per year were not followed by an heart failure event within the subsequent month., (© 2014 The Authors. European Journal of Heart Failure © 2014 European Society of Cardiology.)

Aims: A maximum percentage of ventricular pacing is mandatory to obtain a good response to CRT. Atrioventricular junction (AVJ) ablation has been recommended to attain this objective in patients with AF., The Aims of Our Study Were: (i) to determine whether the presence of complete AVJ block (induced or spontaneous) improves survival in patients with permanent AF treated with CRT and (ii) to analyse the predictors of mortality in AF patients treated with CRT., Methods and Results: From a series of 608 patients treated with CRT in our centre from 2000 to 2011, a cohort of 155 patients with permanent AF was analysed. Patients in AF were divided into two groups, AF + AVJ block [76 (49%)] and AF non-AVJ block [79 (51%)]. Mean follow-up was 30 months (interquartile range 13-51 months). During the follow-up, 62 patients died. Overall and cardiovascular mortality were similar between both groups: hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.51-1.39, P = 0.51 and HR 0.94, 95% CI 0.52-1.68, P = 0.82. Multivariate analysis identified three independent predictors of mortality: basal NYHA functional class IV (HR 2.25, 95% CI 1.12-4.22, P = 0.03), glomerular filtration rate (HR 0.98, 95% CI 0.96-0.99, P = 0.03), and LVEF (HR 0.94, 95% CI 0.89-0.99, P = 0.02)., Conclusions: AVJ block did not improve survival for patients in AF treated with CRT. Basal NYHA functional class IV, poor renal function, and LVEF were the independent predictors of mortality.

Aims: Intraventricular conduction defects (IVCDs) can impair prognosis of heart failure (HF), but their specific impact is not well established. This study aimed to analyse the clinical profile and outcomes of HF patients with LBBB, right bundle branch block (RBBB), left anterior fascicular block (LAFB), and no IVCDs., Methods and Results: Clinical variables and outcomes after a median follow-up of 21 months were analysed in 1762 patients with chronic HF and LBBB (n = 532), RBBB (n = 134), LAFB (n = 154), and no IVCDs (n = 942). LBBB was associated with more marked LV dilation, depressed LVEF, and mitral valve regurgitation. Patients with RBBB presented overt signs of congestive HF and depressed right ventricular motion. The LAFB group presented intermediate clinical characteristics, and patients with no IVCDs were more often women with less enlarged left ventricles and less depressed LVEF. Death occurred in 332 patients (interannual mortality = 10.8%): cardiovascular in 257, extravascular in 61, and of unknown origin in 14 patients. Cardiac death occurred in 230 (pump failure in 171 and sudden death in 59). An adjusted Cox model showed higher risk of cardiac death and pump failure death in the LBBB and RBBB than in the LAFB and the no IVCD groups., Conclusion: LBBB and RBBB are associated with different clinical profiles and both are independent predictors of increased risk of cardiac death in patients with HF. A more favourable prognosis was observed in patients with LAFB and in those free of IVCDs. Further research in HF patients with RBBB is warranted.

Aim: Current guidelines recommend atrioventricular junction (AVJ) ablation in patients with atrial fibrillation (AF) treated with cardiac resynchronization therapy (CRT). Our study compared the CRT response of patients in sinus rhythm (SR) vs. AF., Methods and Results: In this observational, prospective, multicentre study, patients were grouped by intrinsic rhythm. For the first 2 months, the negative chronotropic drug was optimized in the AF group. If ventricular pacing was ≤85%, AVJ ablation was recommended. Responders were defined as patients who survived without requiring heart transplant and had a ≥ 10% reduction in left ventricular end-systolic volume (LVESV) at 12 months after implantation. Of 202 patients included, 156 (77%) were in SR and 46 (23%) had AF. After drug optimization, only 13/46 (28%) of the AF patients required AVJ ablation (AF + AVJ). The percentage of responders was 83/156 (53%) for SR vs. 22/46 (48%) AF (P = 0.4). Among AF patients the response was 16/33 (48%) for AF with non-AVJ ablation vs. 6/13 (46%) AF + AVJ, P = 0.56. The LVESV decreased in all three groups: -30 ± 39 mL, -24 ± 43 mL, and -22 ± 36 mL, respectively (P = 0.75). Mortality was higher in patients with AF compared with SR: 10/46 (21%) vs. 9/156 (5.7%), log rank 10.6, P <0.05., Conclusion: Although only 28% of the patients in AF had the AVJ ablated, there were no differences in the percentage of response and echo improvement between patients in SR and AF. However, mortality was higher in patients with AF compared with patients in SR.

Aims: Monitoring systems integrated into electronic implantable devices for heart failure (HF) have significantly expanded the possibility of obtaining diagnostic information and can be used to enhance patient follow-up. The ability to obtain advance warning of worsening HF is currently being explored using a variety of diagnostic parameters. A novel device-based algorithm, physiological diagnostic (PhD), combines data from minute ventilation and accelerometer sensors to provide an indicator of the overall status of HF patients and detect clinically relevant acute HF events. The objective of this study was to evaluate the effectiveness of the PhD algorithm for detecting HF events in patients with HF., Methods: CLEPSYDRA is a multicentre, prospective, non-randomized, single-arm double-blinded study in 62 centres in Europe, the USA, and Canada. Patients with moderate-to-severe HF, on stable optimal pharmacological therapy, QRS≥120 ms, and ejection fraction≤0.35% will be included. Patients will be followed at 3-month intervals until study end, or for a minimum of 13 months. The primary endpoint is the sensitivity of the PhD (proportion of HF-related clinical events occurring within a 4-week period after a PhD HF indication). Secondary endpoints include the sensitivity of PhD with regard to HF events related to oral treatment modification, and adverse events. The first patient was included in October 2009. At the time of manuscript submission (Week 26, 2010), 214 patients had been enrolled. Study results are expected in 2012., Perspective: CLEPSYDRA will provide essential data on the utility of the PhD algorithm in a HF population with blinded investigators and patients. A successful outcome will demonstrate the potential for the algorithm to be implemented in clinical practice. This would improve clinical management and further the ability to generate dynamic and reliable risk profiles for patients with HF.

Aims: Matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) play a role in left ventricular structural remodelling. The aim of our study was to analyse MMP-2 and TIMP-1 levels as predictors of poor response to cardiac resynchronization therapy (CRT)., Methods and Results: A cohort of 42 CRT patients from our centre was prospectively evaluated at baseline and after 12-month follow-up. MMP-2 and TIMP-1 assays were performed prior to CRT implant. Cardiac resynchronization therapy responders were defined as patients who survived, were not transplanted, and increased their basal 6 min walking distance test (6MWDT) by >or=10% or improved their NYHA functional class. Overall, 25 patients (60%) were classed as responders. At 12-month follow-up, six patients (14.2%) had died and one (2.4%) patient had been transplanted. Compared with responders, non-responders had higher levels of TIMP-1 (277 +/- 59 vs. 216 +/- 46 ng/mL, P = 0.001), MMP-2 (325 +/- 115 vs. 258 +/- 56 ng/mL, P = 0.02), and creatinine (1.76 +/- 0.8 vs. 1.25 +/- 0.3 mg/dL, P = 0.01). In a multivariate analysis, TIMP-1 was the only independent predictor of non-response to CRT [OR 0.97, 95% (CI 0.96-0.99) P = 0.005]. TIMP-1>or=248 ng/mL predicted non-response with 71% sensitivity and 72% specificity., Conclusion: TIMP-1 is an independent predictor of non-response in patients treated with CRT.

Aims: We hypothesized that a very advanced stage of dilated cardiomyopathy is associated with lower response to cardiac resynchronization therapy (CRT)., Methods and Results: A consecutive cohort of 147 patients was studied before device implantation and at 12 months follow-up. All patients were in NYHA functional class III-IV and had left-ventricular (LV) systolic dysfunction (LV ejection fraction 24 +/- 7%) and a wide QRS (171 +/- 29 ms). A patient who was alive without heart transplantation and had improved by at least 10% in the 6 min walking test at 12 months follow-up was considered a clinical responder. Fifty-four patients (36%) did not respond to CRT (15 cardiac deaths, 4 heart transplantations). Quality of life indicators (>41 points), LV end-diastolic volumes (>200 mL) and mitral regurgitant orifice area (>16 mm(2)) at baseline were independent predictors of response to CRT. Patients were assigned 1 point for each predictive parameter. Patients with higher scores showed a significantly higher likelihood of non-response to CRT (chi(2) = 12 891, P = 0.005)., Conclusion: The results show that non-responder patients have a more advanced stage of the disease, which suggests that CRT should be indicated earlier in the disease process.