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Aims Hypertrophic cardiomyopathy is one of the main causes of sudden death in young people. Recent clinical practice guidelines include a risk prediction model for sudden death (HCM Risk-SCD), which facilitates the decision of whether to implant a defibrillator. The aim of our study was to ascertain the percentage of events in our series of primary prevention implantable cardioverter-defibrillator recipients with hypertrophic cardiomyopathy and whether HCM Risk-SCD predicts the onset of arrhythmic events. Methods and results This was an observational, retrospective cohort study, which included 48 primary prevention defibrillator recipient patients with HCM. We compiled their demographic and clinical characteristics, estimated 5-year risk using HCM Risk-SCD, and collected the documentation on arrhythmias during follow-up. The majority was male (66.7%) and mean age at implantation was 44.44 ± 14.46 years. Non-sustained ventricular tachycardia was the most prevalent risk factor (66.67%), followed by a family history of sudden death (47.92%). Mean HCM Risk-SCD was 6.15 ± 5.01%. HCM Risk-SCD was the only factor independently associated with the onset of ventricular tachyarrhythmia, above any other classic risk factor or association [odds ratio = 1.46 (95% confidence interval 1.051–2.013); P = 0.02]. None of the 11 patients estimated as low risk using HCM Risk-SCD suffered any appropriate events ( P < 0.05). Conclusions During an average follow-up of 4 years, 16.67% presented appropriate events (4.16%/year). HCM Risk-SCD predicted the onset of events more suitably than classic risk factors.

Resumen Introduccion y objetivo Realizamos este estudio para conocer si la normalizacion de la funcion ventricular tras terapia de resincronizacion (TRC) es mantenida a largo plazo, y su impacto sobre terapias con desfibrilador (DAI) y mortalidad cardiovascular. Metodos En pacientes con miocardiopatia dilatada idiopatica con DAI-TRC, se analizo la fraccion de eyeccion (FE) basal y tras 6 meses del implante, definiendo un grupo (A) que normalizo la FE (≥ 55%) y un grupo (B) restante, con seguimiento a largo plazo, para conocer la evolucion de la FE en ambos grupos y su impacto clinico-arritmico. Resultados De 47 pacientes incluidos, 10 normalizaron la FE a los 6 meses. Los unicos factores predictores fueron el volumen telesistolico del ventriculo (OR: 0,94; IC 95%: 0,92-0,97) y orificio regurgitante mitral (OR: 0,89; IC 95%: 0,86-0,93). Tras seguimiento ecocardiografico medio de 46 meses los pacientes del grupo A mantuvieron la FE preservada (61 ± 6 vs. 64 ± 6%; p = 0,342), y no presentaron ningun evento arritmico. El grupo B, sin mejoria significativa de la FE, presento mas eventos arritmicos (0 vs. 29,7%; p = 0,039). Ademas, en el grupo A no se registro muerte cardiovascular, frente al grupo B con 12 (0 vs. 32,4%; p = 0,031). Conclusiones La normalizacion de la FE a corto plazo en pacientes con miocardiopatia dilatada idiopatica tras TRC se mantiene en el tiempo, e identifica a pacientes con un excelente pronostico a largo plazo.

The purpose of this study was to evaluate the need for a permanent pacemaker after transcatheter aortic valve implantation with the CoreValve prosthesis (Medtronic, Inc., Minneapolis, Minnesota) using the new Accutrak delivery system (Medtronic, Inc.).The need for a permanent pacemaker is a recognized complication after transcatheter aortic valve implantation with the CoreValve prosthesis.Between April 23, 2008 and May 31, 2011, 195 consecutive patients with symptomatic aortic valve stenosis underwent transcatheter aortic valve implantation using the self-expanding CoreValve prosthesis. In 124 patients, the traditional delivery system was used, and in 71 patients, the Accutrak delivery system was used.There were no significant differences in baseline electrocardiographic characteristics between the traditional system and the Accutrak patients: PR interval: 153 ± 46 mm versus 165 ± 30 mm, p = 0.12; left bundle branch block: 22 (20.2%) versus 8 (12.7%), p = 0.21; right bundle branch block: 21 (19.3%) versus 8 (12.7%), p = 0.26. The depth of the prosthesis in the left ventricular outflow tract was greater with the traditional system than with the Accutrak system (9.6 ± 3.2 mm vs. 6.4 ± 3 mm, p0.001) and the need for a permanent pacemaker was higher with traditional system than with Accutrak (35.1% vs. 14.3%, p = 0.003). The predictors of the need for a pacemaker were the depth of the prosthesis in the left ventricular outflow tract (hazard ratio [HR]: 1.2, 95% confidence interval [CI]: 1.08 to 1.34, p0.001), pre-existing right bundle branch block (HR: 3.5, 95% CI: 1.68 to 7.29, p = 0.001), and use of the traditional system (HR: 27, 95% CI: 2.81 to 257, p = 0.004).The new Accutrak delivery system was associated with less deep prosthesis implantation in the left ventricular outflow tract, which could be related to the lower rate of permanent pacemaker requirement.

Resumen La estimulacion permanente en el apex ventricular derecho es el tratamiento de eleccion de disfuncion sinusal sintomatica y los trastornos avanzados de la conduccion auriculoventricular. Sin embargo, existen datos que sugieren un efecto deletereo sobre la morbimortalidad. La asincronia mecanica, el remodelado y los efectos hemodinamicos descritos hasta la actualidad podrian justificar parcialmente estas consecuencias de la estimulacion, aunque el hecho de que la asincronia no conduzca de forma univoca al desarrollo de disfuncion ventricular e insuficiencia cardiaca (IC) no ha sido aun esclarecido. El proposito de este trabajo es conocer si la estimulacion permanente en el apex modifica la geometria y/o la funcion ventricular, y si favorece la aparicion de parametros clinicos o bioquimicos de IC en pacientes sin cardiopatia estructural. Para ello se incluiran en este estudio observacional y prospectivo pacientes en ritmo sinusal sin evidencia de cardiopatia estructural sometidos a implante de marcapasos y con un porcentaje de estimulacion en el apex ventricular derecho superior al 90%. Se realizara estudio ecocardiografico basal, a 6 y 24 meses tras el implante, analizando parametros de geometria, funcion ventricular y de asincronia. Se recogeran variables clinicas de morbilidad y mortalidad cardiovascular y parametros bioquimicos de IC (NT-proBNP). Los resultados aportaran datos sobre la evolucion de la asincronia mecanica, la funcion y la geometria ventricular izquierda y la potencial relacion con la morbimortalidad cardiovascular en pacientes sometidos a estimulacion permanente en el apex.

Introduccion y objetivos Los cambios en la conduccion auriculoventricular son frecuentes tras el implante percutaneo de la protesis aortica, pero se desconoce que mecanismos estan implicados y su evolucion. Analizamos las alteraciones electrocardiograficas y los predictores de la necesidad de marcapasos tras el implante percutaneo con la protesis aortica CoreValve®. Metodos Entre abril de 2008 y octubre de 2009 se ha tratado a 65 pacientes con estenosis aortica grave sintomatica mediante la protesis aortica CoreValve®. Se analizaron caracteristicas clinicas y electrocardiograficas y predictores de la necesidad de marcapasos por bloqueo auriculoventricular avanzado. Del analisis se excluyo a 3 pacientes por tener marcapasos y a un cuarto paciente que fallecio durante el procedimiento. Resultados La media de edad era 79 ± 7,8 anos y el EuroSCORE logistico, 20% ± 14%. El exito del implante fue del 98,4%. Tras el implante de la protesis, el 47,5% tenia bloqueo de rama izquierda y 21 pacientes (34,4%) precisaron de marcapasos definitivo. La necesidad de marcapasos se relaciono con la mayor profundidad de la protesis en el tracto de salida del ventriculo izquierdo (TSVI) (13 ± 2,5 frente a 8,8 ± 2,8 mm; p Conclusiones Tras el implante de la protesis aortica CoreValve®, un alto porcentaje de pacientes precisan de marcapasos definitivo por bloqueo auriculoventricular avanzado. El unico predictor independiente es la profundidad de la protesis en el TSVI y podria detectar precozmente la necesidad de marcapasos.

Resumen Introduccion y objetivos Estudiar si la presencia de remodelado inverso ventricular izquierdo en el seguimiento de los pacientes sometidos a terapia de resincronizacion cardiaca (TRC) se asocia con mejor evolucion clinica. Metodos Estudio retrospectivo de 86 pacientes resincronizados por insuficiencia cardiaca avanzada con QRS superior o igual a 120 ms y fraccion de eyeccion inferior o igual al 35%, a los que se les realizo un ecocardiograma previo implante y tras 6 meses. Estudiamos la potencial relacion entre la presencia de remodelado inverso (reduccion del volumen telesistolico [VTS] ≥10%) y la presencia de eventos cardiacos adversos en el seguimiento (muerte, trasplante o ingreso por insuficiencia cardiaca). Resultados Tras seguimiento de 14±10 meses, los pacientes con peor evolucion clinica (muerte, trasplante e ingreso por insuficiencia cardiaca) presentaron basalmente mayor volumen telediastolico (259±62 vs. 205±87 ml; p=0,024) y telesistolico ventricular izquierdo (204±57 vs. 165±72 ml; p=0,034) y un QRS estimulado mas ancho (136±15 vs. 123±16 ms; p=0,02). En el seguimiento presentaron menor disminucion del VTS ventricular izquierdo (el 8±19 vs. el 32±26%; p=0,008). La presencia de remodelado inverso ventricular izquierdo (disminucion del VTS ≥10%) fue el unico factor independiente predictor de mejor evolucion clinica (odds ratio=5,4; intervalo de confianza del 95%=1,69 – 17,6). Conclusiones La presencia de remodelado inverso en pacientes sometidos a TRC se asocia con menos eventos cardiacos adversos a medio-largo plazo.

Although changes in atrioventricular conduction frequently occur after percutaneous implantation of an aortic valve prosthesis, little is known about the mechanisms involved or how these changes progress. We investigated ECG abnormalities and predictors of pacemaker need after percutaneous implantation of the CoreValve® aortic valve prosthesis.Between April 2008 and October 2009, 65 patients with symptomatic severe aortic stenosis received a CoreValve® prosthesis. Clinical and ECG parameters were recorded and predictors of pacemaker need due to advanced atrioventricular block were investigated. The analysis excluded three patients because they had pacemakers and a fourth who died during the procedure.The patients' mean age was 79 ± 7.8 years and their logistic EuroSCORE was 20 ± 14%. Implantation was successful in 98.4%. After implantation, 47.5% had left bundle branch block and 21 patients (34.4%) required a permanent pacemaker. The need for a pacemaker was associated with a greater depth of prosthesis implantation in the left ventricular outflow tract (LVOT): 13 ± 2.5 mm vs. 8.8 ± 2.8 mm (P.001). Moreover, depth was the only predictor: odds ratio 1.9, 95% confidence interval 1.19-3.05 (P.007). A cutpoint of 11.1 mm for the prosthesis depth in the LVOT had a sensitivity of 81% and a specificity of 84.6% for predicting the need for a pacemaker.After CoreValve® aortic valve prosthesis implantation, a high percentage of patients needed a permanent pacemaker for advanced atrioventricular block. The only independent predictor was the depth of the prosthesis in the LVOT, which could serve as an early indicator of pacemaker need.

Aims Cardiac resynchronization therapy (CRT) improves survival and quality of life in advanced heart failure (HF). Although mitral regurgitation (MR) reduction has been reported, its presence has been associated with non-response to CRT. This study was undertaken to assess the potential role of significant mitral regurgitation (SMR) persistence after CRT on clinical outcome, major arrhythmic events, and echocardiographic response in the mid-long term. Methods and results Seventy-six patients (28.9% women, 63 ± 11 years) with dilated cardiomyopathy in advanced HF were included. SMR, defined as regurgitant orifice area ≥0.20 cm2, was assessed at baseline and its evolution 6 months after CRT. Clinical outcome (cardiovascular death/HF readmission), major arrhythmic events, and echocardiographic response (reverse remodelling) were recorded on follow-up. Thirty-two patients (42.1%) presented baseline SMR, becoming non-significant in 11 of the 32 patients (34.3%) 6 months after CRT. Its persistence was associated with higher rates of clinical events (46.4 vs. 18.7%, P = 0.011), arrhythmic events (35.7 vs. 14.5%, P = 0.034), and less reverse remodelling (28.5 vs. 83.3%, P < 0.001). Conclusion CRT can reduce moderate or severe baseline MR to non-significant in one-third of patients. However, its persistence was associated with worse clinical evolution, greater incidence of arrhythmic events, and less reverse remodelling.

El objetivo fue comparar el efecto de la terapia de resincronizacion cardiaca en la funcion ventricular y el remodelado inverso en pacientes en ritmo sinusal y fibrilacion auricular sin ablacion del nodulo auriculoventricular. Se analizaron parametros clinicos y ecocardiograficos antes y 6 meses tras la resincronizacion de 55 pacientes: 15 en fibrilacion auricular y 40 en ritmo sinusal. La programacion del dispositivo, el estrechamiento del QRS y la asincronia ecocardiografica tras el implante fueron similares en ambos grupos. Sin embargo, aunque en ambos grupos se observo mejoria significativa del volumen telesistolico y la fraccion de eyeccion, los pacientes en ritmo sinusal presentaron mayor remodelado inverso (reduccion del volumen telesistolico del 30,9% ± 24,6% contra el 12,5% ± 18,6%; p = 0,024) y aumento relativo en la fraccion de eyeccion (el 15,4% ± 12,6% y el 5% ± 7,2%; p = 0,010). La terapia de resincronizacion en pacientes con fibrilacion auricular sin ablacion del nodulo mejora significativamente la fraccion de eyeccion y el remodelado inverso, pero menos que en ritmo sinusal.

The aim of this study was to compare the effects of cardiac resynchronization therapy on left ventricular function and reverse remodeling in patients in sinus rhythm with the effects in patients with atrial fibrillation who have not undergone atrioventricular node ablation. Echocardiographic and clinical parameters were evaluated at baseline and after 6 months of cardiac resynchronization therapy in 55 patients: 15 had atrial fibrillation and 40 were in sinus rhythm. Device programming was similar in the 2 groups, as were the reductions in QRS interval and echocardiographic measures of asynchrony observed after implantation. However, although significant improvements in end-systolic volume and ejection fraction were seen in both groups, reverse remodeling was greater in patients in sinus rhythm (reduction in end-systolic volume 30.9%+/-24.6% vs 12.5%+/-18.6%; P=.024), as was the relative increase in ejection fraction (15.4%+/-12.6% vs 5.0%+/-7.2%; P=.010). Cardiac resynchronization therapy in patients with atrial fibrillation who had not undergone atrioventricular node ablation resulted in significant improvements in ejection fraction and reverse remodeling, but these were less than those observed in patients in sinus rhythm.

Unexplained cardiac arrest (UCA) can be caused by low-penetrance genetic disorders. The aim of this cross-sectional study is to assess the usefulness of a new diagnostic protocol: Thirty-five patients were recruited from 9 Spanish centers. Electrocardiogram, echocardiogram, and coronary catheterization were used to rule out electrical or structural heart disease in all subjects. Patients underwent pharmacologic tests with epinephrine and flecainide, followed by assessment of family members using electrocardiogram and echocardiogram, and next-generation genetic sequencing to analyze 126 genes if all the other test results were negative. A firm diagnosis of channelopathy required phenotypic proof of the condition in unmasking tests, the presence of a pathogenic variant consistent with the phenotype observed, and/or co-segregation of the mutation found in a family member's phenotype. A firm diagnosis was made in 18 cases. The diagnoses were 7 Brugada syndrome, 5 catecholaminergic polymorphic ventricular tachycardia, 3 long QT syndrome, 2 early repolarization syndrome, and 1 short QT syndrome. Pharmacologic testing was the most frequent method of diagnosis. In 5 cases, the diagnosis was made based on positive genetic testing without phenotypic alterations. In conclusion, this sequential diagnostic protocol allows diagnoses to be made in approximately half of the UCA cases. These diagnoses are low clinical penetrance channelopathies. If interpreted carefully, genetic tests can be a useful tool for diagnosing UCA without a phenotype. (C) 2015 Elsevier Inc. All rights reserved.

reference group. They also found that normotensive individuals with preserved eGFR (≥90 ml/min/1.73 m) and moderately high ACR (30 to 299 mg/g) have an elevated risk of all-cause death [5]. The results are very similar to the results of our study. Therefore, to conclude that our results are inconsistent with the results of the previous studies may be the result of an incorrect interpretation of the results from the previous studies. Dr. Kawada requested the authors to add medication profiles for hypertension and diabetes mellitus [1]. We added the prevalence of hypertensive subjects on medication and diabetic subjects on medication in Table 2 of this paper. We are confident that the high risks of outcomes in individuals with preserved eGFR and albuminuria observed in our study reflect a true relationship. However, we agree with some of the comments by Dr. Kawada. We used too many explanatory variables in the multivariate-adjusted Poisson model and we share Dr. Kawada's concerns about type I error (overfitting) [6]. We hope the analyses were performed in the spirit of Dr. Kawada's intent. Finally, we strongly agree with the phrase “keeping a satisfactory number of events for the epidemiological study to keep the validity of the outcome” provided by Dr. Kawada. We appreciate having the opportunity to discuss the problem and we express our deepest gratitude to Dr. Kawada.

Background: Clinical practice guidelines recommend ad hoc screening of diabetes in patients admitted for macrovascular disease; however, these recommendations are rarely followed in real practice. This study was undertaken to assess whether impaired glucose metabolism, newly diagnosed after percutaneous coronary intervention (PCI) or known diabetes, provides prognostic information. Methods : We studied 374 patients who underwent PCI. An oral glucose tolerance test was carried out in the known non-diabetic patients with fasting glucose < 7 mmol/L. Results : Eighty-one percent of the patients presented impaired glucose metabolism, from which 35.3% were previously diagnosed with diabetics, 21.4% were newly detected diabetics, and 24.3% were pre-diabetics. After a mean follow-up of 35.8 ± 13.4 months, only a known history of diabetes was an independent predictor of revascularization (OR = 2.03, p = 0.025), non-fatal acute myocardial infarction (OR = 2.70, p = 0.029) and readmission due to heart failure during the follow-up (OR = 3.82, p = 0.022). Conclusions: Screening for impaired glucose metabolism after PCI permits the detection of a high proportion of patients with abnormal glucose regulations. However, previously known diabetes remains the only independent predictor of cardiovascular events in the follow-up.

Aims The combined use of an automatic defibrillator in resynchronization therapy for primary prevention in patients with idiopathic dilated cardiomyopathy is controversial. Methods and results We assessed a series of 46 patients (61 ± 10 years, 64% male) with idiopathic dilated cardiomyopathy undergoing resynchronization therapy combined with a defibrillator in primary prevention and the potential relationship between baseline characteristics and the onset of ventricular arrhythmic events. Of the 46 patients included, eight (17%) presented episodes of ventricular tachycardia/fibrillation during follow-up (19 ± 12 months). There were no baseline differences among these patients, except the proportion of males (57.9 vs. 100%, P = 0.02) and QRS width (162 ± 24 vs. 189 ± 26 ms, P = 0.008), which was the only independent predictor of arrhythmic events (OR 1.42, 95% CI 1.12–1.68; P = 0.03). Conclusion In patients with idiopathic dilated cardiomyopathy undergoing resynchronization therapy combined with a defibrillator, baseline QRS is an independent predictor of arrhythmic events.