Search

Background: Patients with a systemic right ventricle are prone to develop heart failure. Abnormal heart rate variability (HRV), a measure of autonomic dysfunction, is associated with morbidity and mortality in patients with left ventricular failure. The association between HRV and supraventricular arrhythmias (SVTs), which are associated with adverse events in this population, was assessed., Methods: 24-Hour Holter recordings of patients with a systemic right ventricle and healthy controls were analysed in a retrospective cohort study. HRV was calculated and compared between groups. Correlation coefficients were determined for HRV variables and clinical characteristics. The relation between HRV and SVTs was investigated with linear regression., Results: The patient group included 29 patients (69%) late after Mustard or Senning correction for transposition of the great arteries, and 13 patients with congenitally corrected transposition of the great arteries (31%). The control group included 38 subjects. HRV was significantly lower in patients compared with controls. In the patient group, lower SDANN (standard deviation of the average NN intervals calculated over 5-minute intervals) was independently associated with a higher number of supraventricular arrhythmias (95% CI -0.03 to -0.0004, p = 0.045). In exploratory correlation analysis, several HRV variables correlated with echocardiographic systemic right ventricular function (rho = 0.36, p = 0.02 for SDANN), and exercise capacity (rho = 0.39, p = 0.05 for SDANN)., Conclusion: In patients with a systemic right ventricle, HRV is lower compared with controls and (SDANN) is independently associated with supraventricular arrhythmias., Competing Interests: Declaration of competing interest None of the authors have conflict of interest to declare., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Right ventricular (RV) dysfunction is a well-known prognostic factor in several cardiac diseases. However, the prevalence of RV dysfunction in hypertrophic cardiomyopathy (HC) is unclear and its prognostic value is unknown. This study aims at addressing these issues assessing RV function with speckle tracking echocardiography. In 267 HC patients (52 ± 15 years, 68% male), standard and advanced echocardiographic measurements of RV function were performed including RV 4-chamber longitudinal strain (RV4CLS) and RV free wall longitudinal strain (RVFWLS). The primary end point was all-cause mortality and heart failure development. RV dysfunction was observed in 9% of patients based on tricuspid annular plane systolic excursion (≤17 mm), 5% based on fractional area change (<35%), 23% based on RVFWLS ≥-19%, 39% based on RVFWLS ≥-23%, and 55% based on RV4CLS ≥-20%. In total 59 (22%) patients reached the primary end point during a median follow-up of 6.7 (interquartile range 4.2 to 9.8) years. Kaplan-Meier survival curve showed a significant worse survival free of the end point for patients with impaired RV4CLS ≥-20% versus patients with preserved RV4CLS <-20% (log-rank 7.0, p = 0.008) and for patients with impaired RVFWLS ≥-19% versus patients with preserved RVFWLS <-19% (log-rank 4.4, p = 0.037). Multivariable Cox regression analysis showed that E/E' (hazards ratio [HR] 2.26 [1.30 to 3.92], p = 0.004), left ventricular global longitudinal strain LV GLS (HR 1.08 (1.01 to 1.17), p = 0.034) and RV4CLS (HR 1.08 (1.02 to 1.15), p = 0.007) were independently associated with the primary end point. In conclusion, RV dysfunction as measured by longitudinal strain is relatively frequent in HC patients. Impaired RV4CLS is - together with LV GLS and E/E' - associated with adverse outcome, which may indicate a more severe form of HC., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Only few studies aimed at identifying predictors of heart failure (HF) in hypertrophic cardiomyopathy (HC) patients. Furthermore, serial echocardiographic analyses are lacking in these patients and little is known about the natural progression of left ventricular (LV) abnormalities and their association with HF development. Aim of this study was to assess the prognostic value of LV global longitudinal strain (GLS) and other clinical and echocardiographic characteristics for the development of HF in patients with nonobstructive HC; furthermore, changes in echocardiographic parameters over time were correlated with HF development. Echocardiography was performed in 236 HC patients (68% men, age: 50 ± 14 years) at their initial visit and during follow-up (6.5(4.1 to 9.8) years). The end point of new HF development or progression to New York Heart Association class III/IV was noted and echocardiographic changes over time were compared among patients with and without HF using linear mixed model analysis. In total, 40 patients reached the HF end point. Multivariable cox regression analysis showed that age (HR 1.04(1.01 to 1.06), p = 0.016), New York Heart Association class (HR 2.30(1.07 to 4.95), p = 0.033), GLS (HR 1.15(1.05 to 1.22), p = 0.001), and left atrial volume (LAVI, HR 2.22(1.10 to 4.50), p = 0.027) were independently associated with the HF end point. Echocardiographic parameters, including GLS and LAVI, remained stable over time in patients without HF end point, but changed significantly in patients who developed HF (group-time interaction, p = 0.042 for GLS and p = 0.027 for LAVI). In conclusion, LV dysfunction is a progressive phenomenon in nonobstructive HC patients which can be detected by repeated echocardiography. Importantly, GLS and LAVI at baseline as well as their changes over time are associated with HF., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Our aim was to evaluate the effects of early abciximab administration in the ambulance on immediate, short, and long term outcomes., Background: Early abciximab administration before primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) is recommended in practice guidelines. However, optimal timing of administration remains indistinct., Methods: Within a fixed protocol for PPCI, December 2006 was the cut-off point for this prospective study. A total of 179 consecutive patients with STEMI were enrolled, 90 patients received abciximab bolus in the hospital (in-hospital group), and 89 patients received abciximab bolus in the ambulance (in-ambulance group)., Results: The two groups were comparable for baseline and angiographic characteristics. The in-ambulance group received abciximab within the golden period (median 63 min). The infarct related artery (IRA) patency at onset of the PCI was four times higher in the in-ambulance group compared to in-hospital group (odds ratio = 4.9, 95% CI 2.4-10.1). Enzymatic infarct size was smaller in the in-ambulance group (cumulative 48-h CK release 8011 vs. 11267 U/L, P = 0.004). This was associated with higher left ventricular ejection fraction (LVEF) at 90 days post-PPCI measured by myocardial scintigraphy (59% vs. 54%, P = 0.01), and lower incidence of heart failure through a median of 210 days of clinical follow-up (3% vs.11%, P = 0.04)., Conclusion: Early abciximab administration in the ambulance significantly improves early reperfusion in STEMI patients treated with PPCI. Moreover this is associated with a smaller infarct size, improved LV function and a lower risk of heart failure on clinical follow-up., ((c) 2009 Wiley-Liss, Inc.)

We evaluated whether cardiac resynchronization therapy affects the prevalence of ventricular tachycardia in relation to reverse remodeling in patients with end-stage heart failure. Clinical, echocardiographic, and implantable cardioverter-defibrillator (ICD) data of 17 patients with ICDs were obtained before and after they had received an upgrade to an ICD-cardiac resynchronization therapy device.

Despite current selection criteria (NYHA Class III-IV, LVEF < 35%, QRS > 120 ms with LBBB), 30% of patients do not benefit from cardiac resynchronization therapy (CRT). The use of QRS duration as selection criteria for CRT has not been evaluated systematically yet. Accordingly, the value of QRS duration at baseline (and reduction in QRS duration after CRT) to predict responders was studied. Patients were evaluated at baseline and after 6 months of CRT for NYHA Class, quality of life score, and 6-minute walk test. QRS duration was evaluated before, directly after implantation, and after 6 months of CRT. Sixty-one patients were included; 45 (74%) patients were classified as responders (improvement of NYHA Class, 6-minute walking distance and quality of life score) and 16 (26%) as nonresponders. QRS duration at baseline was similar between the two groups: 179 +/- 30 ms versus 171 +/- 32 ms, NS. Directly after implantation, QRS duration was reduced from 179 +/- 30 ms to 150 +/- 26 ms (P < 0.01) in responders; nonresponders did not exhibit this reduction (171 +/- 32 ms vs 160 +/- 26 ms, NS). After 6 months of CRT, QRS shortening was only observed in responders (from 179 +/- 30 ms to 159 +/- 25 ms, P < 0.01). ROC curve analysis showed that a reduction in QRS duration > 10 ms had a high sensitivity (73%) with low specificity (44%); conversely, a > 50 ms reduction in QRS duration was highly specific (88%) but not sensitive (18%) to predict response to CRT. No optimal cutoff value could be defined. QRS duration at baseline is not predictive for response to CRT; responders exhibit a significant reduction in QRS duration after CRT, but individual response varies highly, not allowing adequate selection of responders.

Biventricular pacing has been introduced to treat patients with end-stage heart failure, and short-term results of this technique are promising. Because data on longer follow-up are limited to 3-month follow-up, the sustained effect of biventricular pacing is unclear and long-term survival is unknown. Forty patients with end-stage heart failure in New York Heart Association (NYHA) functional class III or IV with left ventricular (LV) ejection fraction (EF) <35%, QRS duration >120 ms, and left bundle branch block morphology received a biventricular pacemaker. At baseline, and at 3 and 6 months after implantation, the following parameters were evaluated: NYHA class, Minnesota quality-of-life score, QRS duration on surface electrocardiogram, 6-minute walking distance, and LVEF. Long-term follow-up was obtained for up to 2 years. All clinical parameters improved significantly at 3 months and remained unchanged at 6-month follow-up. LVEF increased from 24 +/- 9% to 34 +/- 11%. Before implantation, patients were hospitalized (for congestive heart failure) an average of 3.9 +/- 5.3 days/year compared with 0.5 +/- 1.5 days/year after implantation. Long-term follow-up showed a survival of 87.5% at 2 years. Thus, biventricular pacing resulted in improvement of symptoms and quality of life, accompanied by improvement in 6-minute walking distance and LVEF. These effects were observed at 3 months after implantation and were maintained at 6-month follow-up. Moreover, 2-year survival was excellent.

• QT interval variability and heart rate turbulence reflect autonomic function. • In patients with a systemic right ventricle, these measures: • Correlated with medication use and with tachy-arrhythmias. • Heart rate turbulence was independently associated with clinical events. QT interval variability (QTV) and heart rate turbulence (HRT) are measures of cardiac autonomic function, which, when abnormal, are correlated with ventricular arrhythmias and worse clinical outcome. This study aims to evaluate QTV and HRT in patients with a systemic right ventricle (RV) and to assess correlations with clinical characteristics. In a retrospective cohort study, QTV and HRT were derived from 24-h Holter registrations of patients with a systemic RV and healthy controls. QTV and HRT were compared between groups. In patients, the association between QTV, HRT, and clinical characteristics was assessed. Holter recordings from 40 patients (mean age 40 years, 16 females) and 37 healthy controls (mean age 42 years, 21 females) were analyzed. Groups were comparable in terms of age and sex. QTV was increased in patients compared with controls (p < 0.001), HRT did not differ significantly between the groups. Increased QTV and decreased HRT correlated with medication use, especially of diuretics, and with clinical events, particularly supraventricular arrhythmias. Increased QTV correlated with reduced systemic RV function. Decreased HRT was independently associated with a larger number of past clinical events (estimate −0.33, 95% CI −0.63 to −0.02, p = 0.037). QTV was higher in women in both patients and controls (p = 0.041 and p = 0.034, respectively). QTV and HRT are associated with clinical factors and events in patients with a systemic RV. Further studies are mandatory to confirm their prognostic value. [ABSTRACT FROM AUTHOR]

Introduction: Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is based on a set of criteria proposed by the International Task Force (TF) for Cardiomyopathies in 1994. To fulfill these criteria, presence of both electrocardiographic and anatomical abnormalities must be assessed with ECG and imaging techniques, respectively. This may be difficult in patients with early/mild forms of the disease as detectable structural abnormalities may still be absent. We evaluated in which patients presenting with right ventricular tachycardia (VT) serial reevaluation for ARVD/C is indicated. Methods and Results: Sixty consecutive patients (41 men, mean age 40±15 years) were evaluated by the TF criteria for possible ARVD/C because of presentation with a left bundle branch block (LBBB) VT, representing 1 minor criterion. The presence on the ECG of a T-wave inversion beyond lead V2 (1 minor), right precordial QRS prolongation (1 major), or an epsilon wave (1 major) was assessed together with the visualization of severe regional/global right ventricle dysfunction (1 major) or mild segmental dilatation/regional hypokinesia (1 minor) by standard imaging techniques. Initially, 22 (37%) patients were diagnosed as having ARVD/C. After 47±39 (range 6–146) months, 23 initially TF-negative patients were reevaluated because of recurrent symptoms, with 12 (52%) additional patients now meeting the TF criteria. Eleven of these 12 (92%) patients presented initially with ECG abnormalities only, but developed structural abnormalities on imaging at follow-up. Conclusion: ECG abnormalities may precede structural abnormalities warranting serial reevaluation for ARVD/C in initially TF-negative patients presenting with LBBB VT with only ECG abnormalities. [ABSTRACT FROM AUTHOR]

Objective: Evaluation of the relation between clinical characteristics and incidence of recurrent ventricular arrhythmias (VAs) or death during long-term follow-up in a cohort of 300 consecutive ischemic heart disease (IHD) patients who had survived an episode of sudden cardiac arrest (SCA). Background: Survivors of life-threatening VA are at high risk for recurrent events. Methods: A total of 300 consecutive survivors of SCA with IHD were included in a standardized screening and evaluation protocol. Multivariable Cox regression analysis was performed to determine the relation between clinical variables at baseline and the incidence of recurrent VA, all-cause mortality and the composite of both (composite endpoint). Results: The presenting arrhythmia was VT in 156 (52%) patients and VF in 144 (48%) patients. Revascularization was performed in 78 (26%) patients and an ICD was implanted in 216 (72%) patients. During follow-up (mean 30 ± 21 months) 37 (12%) patients died and 88 (29%) patients experienced a recurrence. Advanced age (adjusted hazard ratio (HR) 2.0; 1.2–3.3), history of heart failure (HR 1.8; 1.2–2.6), and amiodarone use (HR 3.1; 2.1–4.6) were independent predictors for the composite endpoint. VT as presenting arrhythmia was an independent predictor for all-cause mortality only (HR 2.4; 1.2–4.8). A decreased risk of recurrences was determined by beta-blocker use (HR 0.5; 0.4–0.8) and coronary revascularization (HR 0.3; 0.2–0.6). Conclusion: In a cohort of 300 consecutive survivors of SCA the incidence of recurrent VA and death is dependant on patient age, history of heart failure, and use of amiodarone. In contrast, use of beta-blockers and aggressive coronary revascularization improve the outcome. [ABSTRACT FROM AUTHOR]

Long-Term Follow-Up of Cardiac Resynchronization Therapy . Introduction: Cardiac resynchronization therapy (CRT) has been introduced to treat patients with end-stage heart failure, and results of this technique are promising. The aim of our study was to assess the sustained benefit of CRT in a large patient cohort with end-stage heart failure at long-term follow-up. In addition, the prognosis of responders and nonresponders was evaluated. Methods and Results: 125 patients with end-stage heart failure, NYHA class III or IV, LVEF <35%, QRS duration >120 msec and left bundle branch block morphology received a biventricular device. At baseline and 6 months after implantation the following parameters were evaluated: NYHA class, Minnesota Quality of life score, QRS duration on surface ECG, 6-minute walking distance and LVEF. Follow-up was obtained up to 3 years. After 6 months, patients were divided in clinical responders and nonresponders according to improvement in NYHA class. All clinical parameters improved significantly at 6-month follow-up. Hospitalization for heart failure was 3.8 ± 4.9 days/year before and 0.7 ± 1.6 days/year after CRT. Survival at 1-, 2-, and 3-year follow-up was 93%, 88%, and 85%, respectively. Responders (78%) showed a significantly better survival than nonresponders at 2- and 3-year follow-up (96% and 93% for responders versus 81% and 73% for nonresponders, P < 0.05). Conclusion: The improvement in functional status and symptoms after CRT is maintained at long-term follow-up (up to 3 years). The clinical improvement was associated with a significant reduction in hospitalization rate which was also maintained over the years. Preimplantation selection of responders may result in even better long-term survival. (J Cardiovasc Electrophysiol, Vol. 16, pp. 1-7, July 2005) [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to evaluate the effect of a systematic screening/treatment protocol on outcome in patients after aborted sudden death.Background: Patients after aborted sudden death are at high risk for recurrent events. In this regard, systematic screening is mandatory to reveal the underlying etiology, to detect and subsequently treat reversible causes, and to establish patient-tailored antiarrhythmic treatment.Methods: A total of 417 consecutive patients after aborted sudden death due to ventricular arrhythmias underwent echocardiography and coronary angiography. In the presence of coronary artery disease and myocardial ischemia, using stress-rest myocardial perfusion imaging/exercise testing, subsequent revascularization was performed. Patients without ischemic heart disease were further evaluated with magnetic resonance imaging, contrast echocardiography, right ventricular angiography and/or flecainide/ergonovine testing. After these diagnostic steps, final antiarrhythmic therapy was based on the outcome of electrophysiologic testing.Results: The majority of patients had ischemic heart disease (n = 300, 72%). After screening, 78 (78 of 300, 26%) patients underwent revascularization. In 69% of patients, ventricular arrhythmias were inducible during electrophysiologic testing. Therapy consisted of implantable defibrillators in 301 (72%) patients, antiarrhythmic drugs in 239 (57%) patients, and catheter ablation in 58 (14%) patients. During 5-year follow-up, only 3 (<1%) patients died suddenly. The 5-year survival rate was 82%; of 39 deaths, 10 (26%) patients died due to non-cardiac disease and 26 (67%) due to heart failure.Conclusions: Screening and treatment of patients after aborted sudden death according to a standardized protocol resulted in <1% arrhythmic deaths during 5-year follow-up. The majority of patients died of heart failure, stressing the importance of optimizing medical and surgical therapy and screening. [Copyright &y& Elsevier]

The etiology of dilated cardiomyopathy (DCM) can be grouped as either genetic or nongenetic. More than 50 pathogenic genes have been described, with sarcomeric and lamin A/C mutations being the most common. Mutation carriers for genetic DCM are often asymptomatic until cardiac disease manifests with heart failure, arrhythmias, or sudden cardiac death. Preventive strategies are promising but can only be applied and tested adequately if genetic DCM can be diagnosed at an early stage. Early diagnosis of mutation carriers that may develop overt DCM requires advanced imaging techniques that can detect subtle structural and functional abnormalities. Advanced echocardiographic techniques such as tissue Doppler imaging and speckle tracking strain analysis permit early detection of functional abnormalities, whereas cardiovascular magnetic resonance techniques provide information on tissue characterization and myocardial energetics that may be altered at an early stage. Furthermore, nuclear imaging techniques provide information on cellular function (metabolism, perfusion). Once the diagnosis of overt DCM has been established, various imaging parameters such as echocardiography-based myocardial mechanics and cardiovascular magnetic resonance-based tissue characterization have shown incremental benefit to left ventricular ejection fraction in risk stratification. Further research is required to understand how imaging techniques may help to choose management strategies that could delay progression when instituted early in the course of the disease. The present article reviews the role of imaging in the risk stratification of genetic DCM in general, with specific emphasis on DCM associated with neuromuscular disorders. [ABSTRACT FROM AUTHOR]

Objectives: We attempted to assess the efficacy of combined cardiac resynchronization therapy-implantable cardioverter-defibrillator (CRT-ICD) in heart failure patients with and without ventricular arrhythmias. Background: Because CRT and ICDs both lower all-cause mortality in patients with advanced heart failure, combination of both therapies in a single device is challenging. Methods: A total of 191 consecutive patients with advanced heart failure, left ventricular ejection fraction <35%, and a QRS duration >120 ms received CRT-ICD. Seventy-one patients had a history of ventricular arrhythmias (secondary prevention); 120 patients did not have prior ventricular arrhythmias (primary prevention). During follow-up, ICD therapy rate, clinical improvement after 6 months, and mortality rate were evaluated. Results: During follow-up (18 ± 4 months), primary prevention patients experienced less appropriate ICD therapies than secondary prevention patients (21% vs. 35%, p < 0.05). Multivariate analysis revealed, however, no predictors of ICD therapy. Furthermore, a similar, significant, improvement in clinical parameters was observed at 6 months in both groups. Also, the mortality rate in the primary prevention group was lower than in the secondary prevention group (3% vs. 18%, p < 0.05). Conclusions: As 21% of the primary prevention patients and 35% of the secondary prevention patients experienced appropriate ICD therapy within 2 years after implant, and no predictors of ICD therapy could be identified, implantation of a CRT-ICD device should be considered in all patients eligible for CRT. [Copyright &y& Elsevier]

Objectives: The purpose of this research was to evaluate right ventricular (RV) remodeling after six months of cardiac resynchronization therapy (CRT). Background: Cardiac resynchronization therapy is beneficial in patients with end-stage heart failure. The effect of CRT on RV size is currently unknown. Accordingly, the effects of CRT on RV size, severity of tricuspid regurgitation, and pulmonary artery pressure were evaluated. Methods: Fifty-six consecutive patients with end-stage heart failure (52% ischemic cardiomyopathy), left ventricular (LV) ejection fraction (EF) ≤35%, QRS duration >120 ms, and left bundle branch block were included. Clinical parameters, LV volumes, LVEF, LV dyssynchrony, and RV chamber size were assessed at baseline and after six months of CRT; LV dyssynchrony was assessed using tissue Doppler imaging. Results: Clinical parameters improved significantly; LV dyssynchrony was acutely reduced after CRT and remained unchanged at six-month follow-up. Left ventricular EF improved significantly from 19 ± 6% to 26 ± 8% (p < 0.001), and LV end-diastolic volume decreased from 257 ± 98 ml to 227 ± 86 ml (p < 0.001). Right ventricular annulus decreased significantly from 37 ± 9 mm to 32 ± 10 mm, RV short-axis from 29 ± 11 mm to 26 ± 7 mm, and RV long-axis from 89 ± 11 mm to 82 ± 10 mm (all p < 0.001). Left ventricular and RV reverse remodeling were only observed in patients with substantial LV dyssynchrony at baseline. Finally, significant reductions in severity of tricuspid regurgitation and pulmonary artery pressure were observed. Conclusions: Cardiac resynchronization therapy results in significant reverse LV and RV remodeling after six months of CRT in patients with LV dyssynchrony. Moreover, CRT leads to a reduction of the severity of tricuspid regurgitation and a decrease in pulmonary artery pressure. [Copyright &y& Elsevier]

We evaluated whether long-term cardiac resynchronization therapy affects the inducibility of ventricular tachyarrhythmias in relation to reverse remodeling in cardiac arrest survivors with either ischemic or idiopathic dilated cardiomyopathy. Clinical, electrophysiologic, and echocardiographic data of 18 patients were obtained before and after 6 months of cardiac resynchronization. [Copyright &y& Elsevier]