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Background The clinical course and ventricular remodeling in inflammatory myocardial disease could be unpredictable. No single functional parameter has been confirmed as a powerful predictor of clinical course and functional recovery assessment in patients with acute inflammatory myocardial disease. Purpose The aim of the study was to assess the mechanical properties of the myocardium in patients with active myocarditis at baseline and follow-up. Methods Database from a high volume, tertiary cardiology center was analysed to identify patients with active myocarditis, based on clinical presentation and ≥1 diagnostic criteria from different categories (including electrocardiography/holter, elevated troponin T/I levels, functional or structural abnormalities on cardiac imaging or tissue characterization by cardiac magnetic resonance) between 2016 and 2019. Conventional and speckle tracking echocardiography including global longitudinal strain (GLS) mechanical dispersion (MD) was completed at baseline and at 17±13 months follow-up. MD was calculated as a standard deviation of time to peak longitudinal strain derived from all left ventricle segments in 3 apical views. Results 61 consecutive patients [50 M, 11F, end-diastolic volume 212±84 ml, end-systolic volume 130±90ml, ejection fraction (EF) 42±16%] were enrolled. During the entire follow-up 1 patient died at early observation. Implantable cardioverter-defibrillator was implanted in 5 patients (primary prevention 4, secondary 1), cardiac resynchronization therapy pacemaker in 1 patient. Despite of significant global improvement (EF 42±16% vs 52±10%, p Conclusions Mechanical dispersion and global longitudinal strain may serve as an additional markers of myocardial damage and potential predictive markers in non ischemic cardiomyopathy patients with proven inflammatory origin. Funding Acknowledgement Type of funding source: None

Background It is important to determine the risk factors that predispose elderly subjects from the general population for symptomatic atrial fibrillation and atrial flutter (AF/AFl), but population-based data for silent AF (SAF) are limited. Aim To study risk factors for symptomatic AF and SAF in a general population screen for subjects age ≥65 where continuous monitoring was performed up to 30 days with a vest-based monitor. Methods The NOMED-AF study was a cross-sectional study based on a representative population sample (n=3014; mean age 77.5±7.9 years; F=1479). In 680 subjects AF/AFl (including 279 with SAF) was diagnosed. Independent risk factors for AF/AFl and SAF were determine on weighted data using multiple logistic regression. Results The independent risk factors for AF/AFl and SAF are summarised in the Table. There are nine independent risk factors for AF/AFl and eight for SAF. Revascularization and obesity were independently associated with patients with (symptomatic) AF/AFl, and CKD was associated with SAF. Other risk factors are common for AF/AFl and SAF. Conclusions AF/AFl and SAF have slightly different associated clinical risk factors in this representative population sample aged ≥65 years. This may facilitated targeted screening programmes for high risk subgroups, particularly for SAF. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): The research has received funding from the National Centre for Research and Development under grant agreement (STRATEGMED2/269343/18/NCBR/2016)

Background Myocarditis may be a challenging diagnosis because of diversity of clinical presentations. Thus, the clinical course and ventricular remodelling in this disease seems to be unpredictable. Aims To assess predictors of left ventricular remodelling in patients after active myocarditis. Methods Database from a high-volume, tertiary cardiology center was analysed to identify patients with active myocarditis, based on clinical presentation and ≥1 diagnostic criteria from different categories (including electrocardiography/ holter, elevated troponin T/I levels, functional or structural abnormalities on cardiac imaging or tissue characterization by cardiac magnetic resonance) between 2016 and 2019. Left ventricle global longitudinal strain (GLS), mechanical dispersion (standard deviation of time to peak longitudinal strain derived from all left ventricle segments in 3 apical views) were calculated. Response (left ventricular positive remodeling measured by transthoracic echocardiography) was defined as end-systolic volume (ESV) reduction ≥15% from a baseline value or end-diastolic volume (EDV) reduction ≥15%. Results 61 consecutive patients were enrolled. The median follow-up was 1.4 years (range: 0.3–4.0). During entire follow-up period mortality rate in patients was 1.6%. Multivariate Cox regression model including significant baseline differences as covariates reported that QRS durations (HR 1.31, 95% CI 1.17–1.57, P=0.049) and mechanical dispersion (HR 1.03, 95% CI 1.01–1.07, P=0.036) were independently associated with left ventricular positive remodelling with ESV reduction. Mechanical dispersion (HR 1.04, 95% CI 1.02–1.06, P=0.040) was independently associated with left ventricular positive remodelling with EDV reduction. Conclusions Mechanical dispersion and QRS duration are independent predictors of left ventricular remodelling in patients after active myocarditis. Funding Acknowledgement Type of funding source: None

Background Atrial fibrillation (AF) confers a high healthcare burden from stroke, heart failure, dementia and hospitalisation, and one challenge is. Early detection of this arrhythmia in the community, given that it is often asymptomatic. Aim To perform population screening for atrial fibrillation and flutter (AF/AFl) using a mobile long-term continuous ECG telemonitoring vest in a representative Polish and European population aged ≥65 years (age range 65–100 years). Methods The NOMED-AF study is a cross-sectional study based on a representative sample of adults aged ≥65 years (n=3014; mean age 77.5±7.9 years; 49.1% female). All study participants were equipped with a mobile long-term continuous ECG telemonitoring vest. National and European estimations were calculated on weighted data. Results In 680 subjects AF/AFl (including 279 with SAF; 9.3%) was confirmed. In the NOMED-AF population, the prevalence of AF/AFl was 22.6%, estimated to be 19.2% for Poland [1,251,100 (95% CI: 1,158,300–1,344,000) and 480,100 (95% CI: 426,60–533,700) subjects with AF/AFl and SAF, respectively] and 20.4% for Europe [20,300,000 (95% CI 18.8–21.9 M), including 8,000,000 (95% CI: 6.9–9.3 M) subjects with AF/AFl and SAF, respectively]. The prevalence of AF/AFl was 2.56-fold higher in men than in women and the incidence of silent AF (SAF) was 4.73-fold higher in men than in women. Although the risk of either AF/AFl or SAF increased with age, the odds ratio was significantly higher in women of a particular age group than in men of the corresponding age. Based on our survey, the total number of subjects with AF/AFl in Europe is estimated to be roughly 20.3 million (95% CI 18.8–21.9M), including 8.0 million (95% CI: 6.9–9.3M) subjects with silent AF/AFl (Figure). Conclusions Approximately 1 in 5 subjects aged ≥65 years suffers from AF/AFl. The risk for AF/AFl and SAF is higher in men than that in women, but when correlated to a particular age group, the risk increases significantly in women. Continuous ECG telemonitoring allows for more credible AF/AFl and SAF detection. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): The research has received funding from the National Centre for Research and Development under grant agreement (STRATEGMED2/269343/18/NCBR/2016

Objectives: Chronic heart failure (HF) is associated with significantly increased prevalence of depression. The aim of the study was to assess the incidence and clinical impact of depression as well as the effectiveness of depression treatment in HF patients. Methods: A prospective interventional trial included 285 consecutive cardiac resynchronization therapy recipients. Patients underwent a psychiatric examination at the time of implantation and then it was routinely repeated at 3, 6, and 12 months after the procedure, and every 6 months thereafter. One hundred and thirty-five (47.4%) patients with depression were included in the depression group, whereas the control group was comprised of 150 patients free of depression. Sixty-eight (50.4%) subjects received antidepressants (treated group), whereas the observational group had 67 (49.6%) depressed patients who refused to take antidepressants. Results: Depression remission was achieved in 51 (75.0%) patients from the treated group. Long-term mortality and HF hospitalization rates were significantly higher in the depression group than in the control group (20.7 vs. 11.3% and 32.6 vs. 19.2%, respectively). However, remission from depression was associated with a 40% reduction in the relative risk of major adverse cardiac events (MACE). Conclusions: Patients with HF and concomitant depression are at higher risk of MACE compared with those free of depression. Effective antidepressant treatment may significantly improve long-term outcomes in this population.

Background The prognostic impact of improvement in health-related quality of life (QoL) and its relation to response in cardiac resynchronization therapy (CRT) recipients remains unknown. Aim To assess the correspondence between response to CRT and improvements in QoL and to verify if a change in QoL after pacing influences outcome in CRT patients. Methods Ninety-seven participants of the Triple-Site Versus Standard Cardiac Resynchronization Therapy Trial (TRUST CRT) randomized trial, in New York Heart Association class III-IV, QRS width ≥ 120 ms, left ventricular ejection fraction ≤35%, and significant mechanical dyssynchrony were included. Subjects filled out the Minnesota-QoL questionnaire prior to and 6 months after CRT with defibrillator (CRT-D) implantation. Data on major adverse cardiac events (MACEs: death, heart failure hospitalization, heart transplant) collected within the next 2.5 years and adjudicated blindly constituted the censoring variables. Results Within the first 6 months of resynchronization QoL improved in 81%, while worsening in 19% of patients. Clinical response, but not the echocardiographic one, was associated with improved QoL. During subsequent 2.5 years MACEs occurred in 37% of patients (23% died). Subjects without QoL improvement were significantly (both P < 0.05) more prone to experience MACE (61% vs 32%) and die (44% vs 18%) within the follow-up. Unimproved QoL increased the probability of future MACE by 2.7 times (95% confidence intervals [CI]: 1.26–5.83; P = 0.01) and death by 3.2 times (95% CI: 1.23–8.32; P = 0.02) independently from clinical and echocardiographic response. Conclusions Clinical response, but not the echocardiographic one, was associated with improved QoL in CRT recipients. These preliminary data suggest that lack of improvement in QoL after CRT was associated with a strongly unfavorable prognosis, regardless of functional or echocardiographic response. Our results merit further studies with a larger number of patients.

To assess the incidence of atrial fibrillation (AF) and the clinical impact of AF types on outcomes in patients with acute myocardial infarction (AMI) treated invasively, we analyzed 2,980 consecutive patients with AMI admitted to our department from 2003 through 2008. Data collected by the insurer were screened to identify patients who died during the median follow-up of 41 months. AF was recognized in 282 patients (9.46%, AF group); the remaining 2,698 patients (90.54%) were free of this arrhythmia (control group). The AF group was divided into 3 subgroups: prehospital paroxysmal AF (n = 92, 3.09%), new-onset AF (n = 109, 3.66%), and permanent AF (n = 81, 2.72%). In-hospital and long-term mortalities were significantly higher (p0.001 for the 2 comparisons) in the AF than in the control group (14.9% vs 5.3%, 37.2% vs 17.0%, respectively). Long-term mortality was significantly higher (p0.001 for the 2 comparisons) in the new-onset AF (35.8%) and permanent AF (54.3%) groups than in the control group but did not differ significantly between the prehospital AF and control groups (21.7% vs 17.0%, p = NS). Considering types of arrhythmia separately, only permanent AF (hazard ratio 2.59) was an independent risk factor for death in the studied population. In conclusion, AF occurs in 1 of 10 patients with AMI treated invasively, with nearly equal distributions among prehospital, new-onset, and permanent forms. Although arrhythmia is a marker of worse short- and long-term outcomes, only permanent AF is an independent predictor for death in this population.

The prognostic impact of improvement in health-related quality of life (QoL) and its relation to response in cardiac resynchronization therapy (CRT) recipients remains unknown.To assess the correspondence between response to CRT and improvements in QoL and to verify if a change in QoL after pacing influences outcome in CRT patients.Ninety-seven participants of the Triple-Site Versus Standard Cardiac Resynchronization Therapy Trial (TRUST CRT) randomized trial, in New York Heart Association class III-IV, QRS width ≥ 120 ms, left ventricular ejection fraction ≤ 35%, and significant mechanical dyssynchrony were included. Subjects filled out the Minnesota-QoL questionnaire prior to and 6 months after CRT with defibrillator (CRT-D) implantation. Data on major adverse cardiac events (MACEs: death, heart failure hospitalization, heart transplant) collected within the next 2.5 years and adjudicated blindly constituted the censoring variables.Within the first 6 months of resynchronization QoL improved in 81%, while worsening in 19% of patients. Clinical response, but not the echocardiographic one, was associated with improved QoL. During subsequent 2.5 years MACEs occurred in 37% of patients (23% died). Subjects without QoL improvement were significantly (both P0.05) more prone to experience MACE (61% vs 32%) and die (44% vs 18%) within the follow-up. Unimproved QoL increased the probability of future MACE by 2.7 times (95% confidence intervals [CI]: 1.26-5.83; P = 0.01) and death by 3.2 times (95% CI: 1.23-8.32; P = 0.02) independently from clinical and echocardiographic response.Clinical response, but not the echocardiographic one, was associated with improved QoL in CRT recipients. These preliminary data suggest that lack of improvement in QoL after CRT was associated with a strongly unfavorable prognosis, regardless of functional or echocardiographic response. Our results merit further studies with a larger number of patients.

Aims The aim of the study was to assess the predictive value for outcomes of various response criteria currently used in patients undergoing cardiac resynchronization therapy (CRT). Methods and results Data from TRUST CRT randomized trial in patients with New York Heart Association (NYHA) III–IV class, QRS ≥ 120 ms, ejection fraction ≤35%, and mechanical dyssynchrony was analysed. Ninety-seven subjects who survived 6 months after implantation of CRT-defibrillator were classified as responders or non-responders depending on 15 criteria used in most of the previous trials. Blindly adjudicated data on major adverse cardiac events (MACEs) within 1 year after classification were used to calculate the predictive value of response criteria. After adjustment for baseline confounding variables only eight criteria were significantly predictive for future MACEs. Sensitivity and specificity ranged substantially for clinical (32–94% and 26–63%) and echocardiographic criteria (40–93% and 22–70%, respectively). The most powerful clinical predictor was >a NYHA class reduction ≥1 [adjusted relative risk (RR) 4.41 for non-responders; 95% confidence interval (CI) 1.75–11.04, P = 0.002], while the strongest echocardiographic predictor was a reduction in the left ventricular end-systolic index by > 15% (RR 3.49; 95% CI 1.59–7.64, P = 0.002). A combination of these two criteria did not improve the predictive value of a single parameter. Both criteria showed multiple significant interactions with baseline patients' characteristics. Conclusion Only some of the commonly used response criteria predict outcome in patients undergoing CRT. The predictive value varies substantially across different criteria, with a higher sensitivity observed for the clinical parameters and a higher specificity observed for echocardiographic parameters. Combining various criteria adds little to their prognostic value. The predictive accuracy of various criteria can be different in various subgroups due to multiple interactions with baseline characteristics. ClinicalTrials. Gov Identifier NCT00814840.

The concept of a hybrid approach, combining the most effective techniques of surgical and endocardial catheter ablation has resulted in the creation of the convergent ablation procedure. This novel, pericardioscopic, hybrid approach can be an effective option for highly symptomatic patients with persistent atrial fibrillation (PSAF) and longstanding persistent atrial fibrillation (LSPAF) for whom standalone surgical or endocardial ablation procedures offer sometimes unsatisfactory outcomes.To assess the safety, efficacy and effectiveness of a hybrid epicardial and endocardial radiofrequency ablation for the treatment of PSAF and LSPAF.Single-centre, prospective, non-randomised clinical study. Between August 2009 and December 2011, 27 patients with PSAF (n = 5) and LSPAF (n = 22) underwent hybrid ablation (HABL). Mean age was 52.52 ± 11.27 years, and the mean EHRA class was 2.5; 14 (51.8%) patients had a history of electrical cardioversion (n = 6) or catheter ablation (n = 8). Five patients had left ventricular ejection fraction (LVEF) of less than 35%. Mean AF duration for all patients was 3.46 ± 2.5 years. All patients were on antiarrhythmic drugs (AAD) and oral anticoagulation. Patients were scheduled for three, six and 12 month follow-up with seven day Holters, REVEAL® XT and ECHO measurements.The HABL procedure was feasible in all patients. At six months post procedure, 72.2% (13/18) of patients were in SR, and 66.5% (12/18) were off class I/III AADs. Four patients were in AF and one patient developed right atrial flutter. At one year post procedure, 80% (8/10) of patients were in SR and off class I/III AADs. At two year post procedure, 100% (6/6) of patients were in SR and off class I/III AADs. Rapid change in left ventricular function was noted in patients with low LVEF (≤ 35%) prior to the procedure. Patients with LVEF +40% had less apparent improvement.Hybrid, epicardial and endocardial, radiofrequency ablation is feasible and safe, effectively restoring sinus rhythm in the vast majority of patients with PSAF and LSPAF.

The concept of cardiac resynchronisation therapy (CRT) is based on biventricular pacing in symptomatic, chronic heart failure (HF) patients with systolic left ventricular (LV) dysfunction and QRS ≥ 120 ms. The response to CRT is determined by clinical and echocardiographic parameters. The change of biochemical status (e.g. natriuretic peptides or metalloproteinase levels) caused by CRT is not well explored.To analyse the clinical and haemodynamic changes caused by CRT in relation to patients' biochemical status and to assess factors determining a favourable response to CRT.Fifty patients with chronic systolic HF (NYHA IV: two patients), wide QRS complex (160 ± 31 ms) and reduced LV ejection fraction (26 ± 5.8%) under optimal pharmacotherapy, who underwent CRT, were enrolled. Data on NT-proBNP and C-reactive protein serum levels, as well as standard echocardiography with tissue Doppler measurements, were collected before CRT and after six months of pacing. The levels of matrix metalloproteinase-9 (MMP-9) were assessed in a subgroup of 18 patients. Patients were regarded as responders if LV end-systolic volume decreased by 10% compared to baseline.Thirty five (70%) patients responded favourably to CRT. Cardiac resynchronisation therapy resulted in an improvement of max. ventilatory oxygen uptake (12.9 ± 3.8 vs 16.6 ± 4.7 mL/kg/min; p0.05), a of NT-proBNP decrease (2,579 ± 2,598 vs 1,339 ± 1,088 pg/mL, p0.05), and decrease of atrio-, inter- and intra-LV dyssynchrony. A greater baseline dyssynchrony was observed in responders. A decrease of MMP-9 level following CRT was observed in 12 (67%) patients. Significant MMP-9 decrease was observed only in the subgroup of ischaemic HF patients (26,100 ± 7,624 pg/mL vs 23,360 ± 6,258 pg/mL; p = 0.03). In patients with MMP-9 decrease during CRT, a lower C-reactive protein concentration at baseline was observed (2.12 ± 1.6 vs 4.7 ± 4.1 mg/L). The reduction in LV end-diastolic diameter correlated with the changes in MMP-9 level (r = 51; p = 0.03). Baseline left atrial end-diastolic diameter measured in parasternal long-axis view £ 46 mm had a sensitivity of 83% and a specificity of 67% in predicting MMP-9 decrease (AUC 0.83; 95% CI 0.59-0.96).The CRT induces favourable myocardial remodelling, resulting in NT-proBNP level decrease, improvement of regional and global biventricular function, and MMP-9 level reduction, in ischaemic HF patients. The changes of MMP-9 level may be predicted by baseline left atrial end-diastolic diameter and correlate with LV end-diastolic diameter change during CRT.

Aim: To assess the value of everyday monitoring of the percentage of cardiac resynchronization (CRT-D) with the use of remote monitoring. Methods: Prospective, single-center registry encompassed 305 consecutive heart failure (HF) patients who were implanted with CRT-D devices and subsequently monitored on a daily basis via remote monitoring for the median of 20.5 months. Every tele-transmission was screened for the percentage of CRT pacing and the special impact was put on: – immediate detection of low CRT pacing episodes – early correction of any condition leading to low CRT pacing (i.e. medical therapy optimization, device reprogramming, ablation procedures). In accordance with ESC guidelines, in which low CRT pacing was defined as ≤95% despite optimal medical therapy, study population was divided into three groups: – Group 1 – CRT>95% throughout the whole FU – Group 2 – CRT>95%, however, with episodes of low CRT pacing during FU – Group 3 – CRT≤95% throughout the whole FU Results: Long-term mortality and mean CRT pacing for the whole study population was 11.4% and 95.22% respectively. Although, the CRT pacing ≤95% appeared to be the independent risk factor for death [HR 0.34, p 95% improves outcomes. On the other hand, failure in achievement of optimal CRT>95% despite optimized treatment leads to 2 fold increase in HF hospitalizations and over 3 fold increase in mortality. The most important reasons for low CRT were atrial fibrillation (AF), premature ventricle contractions (PVCs) and supraventricular tachycardia (SVT) [46, 39 and 13% respectively]. View this table: Table 1 Conclusions: Continuous remote monitoring of the percentage of CRT pacing facilitates maintenance as well as regaining the optimal CRT pacing and thus reduces HF hospitalizations and increases survival.