bluuebunny/crossref_metadata_2025 huggingface dataset:
Time for a new destination: foregoing surgical sympathectomy after successful stellate ganglion block in patients with refractory ventricular tachycardia
Authors: Dye C , Larsen T , Patel P , Huang H , Sharma P
Published: November 2023

Background

Electrical storm (ES) is defined as >3 episodes of sustained ventricular arrhythmias in 24 hours and is associated with increased mortality. ES portends a poor prognosis with limited effective treatment options. Stellate ganglion block (STGB) can be used in patients with ES for temporary control of VT. When STGB is successful, patients can be referred for surgical sympathectomy for longer term management. We postulated that STGB can be used as a bridge to other treatments for refractory VT.

Purpose

To evaluate the efficacy of STGB as a bridge to interventions other than surgical sympathectomy in patients with refractory VT. Additionally, we assessed STGB as an adjunctive therapy to medical optimization when the cause for ES is temporary (e.g., QT prolonging medications, acute ischemia) foregoing the need for long term interventions.

Methods

This is a single center retrospective study. We enrolled 12 consecutive patients admitted from July 2018 to September 2022 for ES that received a STGB. The primary clinical outcome was cessation of VT for 24 hours beginning 1 hour after STGB was performed. Secondary clinical outcome of the study was freedom from VT until discharge after STGB. Primary safety outcomes were major procedural complications or death within 48 hours after STGB.

Results

Sixty-seven percent of the patients were male, with a mean age of 58 years and an average left ventricular ejection fraction of 32%. Two-thirds of the patients had ischemic VT of which half were status post CABG and the other half were status post PCI. In the first 24 hours after STGB, 91% of patients were without recurrent VT. Fifty percent of patients did not have recurrent VT from 24 hours after SGB was performed until discharge. Three patients were referred for catheter ablation. No patients received surgical sympathectomy. There were no major complications or deaths within 48 hours of STGB.

Conclusion

STGB is a safe and effective procedure that can be utilized as a bridge to VT interventions other than surgical sympathectomy. For patients with ES, STGB is also effective at temporarily suppressing VT allowing time for medical optimization and the withdrawal of provoking agents which perpetuate ES. Further research is necessary to determine optimal timing and patient selection for STGB when used as a bridge for alternative VT therapies.Clinical Impact of VT after STGBElectrical Storm Characteristics
Lower intercostal spaces depicted better final r wave than V1 at left bundle branch pacing implant attempts
Authors: Ayala Valani F G , Mardigyan V , Ayala Valani L M , Ayala Paredes F
Published: November 2023

Background

Left bundle pacing lead positioning implies screwing the lead until a final ‘r’ wave is seen in V1 ECG lead (unipolar pacing), depicting the left part of the septum has been reached. That final vector should be better seen if V1 is placed parallel rather than perpendicular to the lead tip, so we used lower intercostal spaces for V1, to test this hypothesis. Failure to see the 'r' wave could increase the screwing efforts owing to perforation.

Methods

Leads V1 to V5 were positioned from 2nd to 6th right sided intercostal spaces during implants. Fluoroscopy was used to ascertain the lead most parallel to the final tip position. Inferior leads were used to confirm anterior, mid or posterior implants. A ratio between the ‘r’ wave amplitude and the QRS amplitude was used to compare the intercostal space depicting better the final ‘r’ wave.

Results

19 patients were implanted using this new set-up of precordial leads (see figure 1); 32% were female; mean age at implant was 77,6 +/-8,04 years (range 58,3-90,6 years old); all but two were Medtronic 3830 leads. Regarding the position 26%, 32% and 42% of the leads ended in the posterior, mid or anterior septum respectively. Mean unipolar pacing QRS was 126ms +/- 18,2ms and mead LVAT was 76ms +/-19ms. Only 31% of patients had the lead placed parallel to the 4th intercostal space; 13% had the lead parallel between the 4th and the 5th space; and 56% of implants, had the 5th or 6th space as the most parallel to the lead tip. Finally in a consistent way, mean ratios of ‘r’/QRS amplitude were increasing at every intercostal space from: 0,12/2nd; 0,24/3rd; 0,3/4th; 0,35/5th and 0,45/6th (except for most posterior implanted leads where ratios varied less); this finding was even greater for anterior implanted leads (see figure 2).

Conclusion

Final ‘r’ wave is better depicted when V1 is lowered to 5th or 6th intercostal space, as the leads are mostly implanted parallel to these observation sites; but the septum is also a 3-D structure and when the leads are implanted too anterior, there is almost no way to see the final ‘r’ wave in usual 4th space V1, as the vector is directed mostly in the opposite direction (posteriorly and downward), while a lower placed V1 allows some of that vector to be depicted anyways. Placing V1-V3 leads in 4th-6th intercostal spaces could prevent excessive screwing and reduced perforation rates specially in anterior implanted leads.LAO: V1 to V5 placed 2-6 R intercostal'r' not seen until 5th-6th R intercostal
Reevaluation of the indications for permanent pacemaker implantation after cardioneuroablation
Authors: Wileczek A , Stodolkiewicz-Nowarska E , Reichert A , Kustron A , Sledz J , Biernikiewicz W , Hering D , Stec S
Published: November 2023

Background

Cardioneuroablation(CNA) is promising and innovative method to cure vagally mediated bradycardia.However, according to current ESC2021 guidelines patients may have indications for permanent pacing. CNA is still referred to patients as an experimental and alternative method,not being recommended in guidelines due to too small amount of evidence.The study sought to validate criteria for permanent pacemaker(PPM) implantation,discontinuation of PPM therapy(PPMT) and risk of PPM implantation after CNA in a large population of patients qualified for electrophysiologic study(EPS),Extracardiac vagal nerve stimulation(ECVS) and CNA.

Methods

Data were collected from POLish prospective multicentre CardioneuroAblation registry(POLCA) with comprehensive management, interdisciplinary consultations, state-of-art autonomic tests, atropine tests, EPS as well as ECVS. Shared-decision making was used to developed patient-oriented therapy with clear declaration of fulfilling indications for PPMT according to ESC guidelines,(when applicable) and CNA only as alternative and developing technique.

Results

A total of 195 consecutive adult patients(mean age:55,6+/-14,3 years; min 20,0 Q1 44,96-Q2 58,4 - Q3 67,2; max 82;107(54%)females,) underwent first CNA. Out of them, 17(8,2%) had already PPM. According to current guidelines 100/178(51%) patients had de novo indications for PPM implantation prior to CNA including: SND(n=88,45%), AVB(n=21, 10%), TBS (n=26, 13%), CI-VVS(n=41; 21%),M-VVS(n=1;0,5%), CI-CCS(n=41;21%) or mixed etiologies (n=45;23%). Indications for de novo PMT were present in 32(37%) patients above age 60. During moderate-term (23,7+/-10,3 months), no patient died, and only 10 had syncope (which was diagnosed as orthostatic or vasodepressive). Despite preprocedural positive atropine test and positive ECVS, 6 out of 195 patients (had early and elective PPM implantation due to coexistence of functional and structural bradycardia(n=3) or bradycardia recurrences(n=2) or severe sinus chronotropic incompetence(n=1).

There were 7(3,5%) major complications (tamponade (n=2), pericarditis(n=2), pericardial effusion(n=1), femoral aneurysm(n=1), pneumothorax(n=1) of CNA. Only 4 of patients with indications for PPM implantation before CNA still had those indications during follow-up. Out of 6 patients with late PPM implantations after CNA, 1 patient had syncope due to development of AVB.

Conclusions

About 51%patients referred for CNA had indications for PPM therapy. CNA in subgroup of patients with functional bradycardia is becoming alternative choice to PPMT and allowed to give up PPM implantation at least temporarily in 96%patients without prior PPMT. However some patients require PMT due to failed CNA or reinnervation,but also co-existence or development of complex structural bradyarrhythmias.
Intermuscular placement and defibrillation with the extravascular ICD: a single-centre experience
Authors: Carecci A , Lazzeri M , Quaranta A , Bertelli M , Spadotto A , Angeletti A , Massaro G , Bartoli L , Frisoni J , Martignani C , Valzania C , Diemberger I , Ziacchi M , Galie' N , Biffi M
Published: November 2023

Background

Extravascular (EV) implantable cardiac defibrillators (ICD) with substernal lead have recently proved to be a safe and effective alternative to conventional transvenous (TV) and subcutaneous defibrillators (S-ICD), owing to the possibility to deliver antitachycardia and asystole pacing while saving intravascular hardware. The proposed implantation technique for EV-ICDs is a subcutaneous pocket along the mid axillary line, although an intermuscular ICD placement can potentially reduce the risk of pocket complications, device migration and improve patient comfort and aesthetic outcomes.

Purpose

exploring the safety and feasibility of extravascular ICDs implantation with a substernal coil and an intermuscular generator placement.

Methods

Seventeen patients with a class I or IIa ICD indication either for primary (14/17) or secondary (3/17) prevention underwent EV-ICD implantation in our centre as part of the EV ICD Pivotal Study from May 2021 to November 2022. Access and tunnelling along the retrosternal space were performed based on current standard recommendations for EV-ICDs implantation. An intermuscular pocket for generator placement was obtained between the latissimus dorsi and the serratus anterior muscles beyond the left mid-axillary line.

Results

Mean age, BMI, NYHA class and left ventricular ejection fraction (LVEF) were respectively 53±9yrs, 25.3 ±6 kg/m2, 2 ±0.7, and 39±14%. The main aetiology was non ischemic cardiomyopathy (12/17), including 3 arrhythmogenic cardiomyopathy patients and one with hypertrophic cardiomyopathy.

The implantation was successful in 16 (6 females) out of 17 patients, with one implant failure due to inadequate sensing (0,5 mV); the median sensing amplitude was 2,3 mV (min = 1,3 mV; max = 5,8 mV), with R1R2 being the final sensing vector chosen for 14/16 and R2-Can for 2/16. Defibrillation Testing (DFT) was performed in all patients: a 15 J shock terminated induced ventricular fibrillation (VF) in 12/16 patients, 20 J terminated VF in 3, a single patient had VF terminated at 30 J. No patient had infection or skin erosion or complained pain/discomfort at the pocket site along an 18±4 months follow-up. Only 1/16 patients had ventricular tachycardia at follow-up, successfully treated by the device.

Conclusions

Intermuscular placement of the EV ICD may be a feasible and reliable alternative to a subcutaneous one in terms of defibrillation efficacy, enabling patient comfort and aesthetic acceptance in thin-habit or young patients. Additional long-term data and larger patient cohorts are required to confirm its advantage compared to the subcutaneous placement.
Local anesthesia during S-ICD implantation gives similar post procedural pain perception as sedation
Authors: De Veld J , Smeding L , El-Chami M F , Marquie C , Nordbeck P , Tilz R R , Lambiase P D , Quast A B E , Brouwer T F , Cassidy C , Boersma L V A , Betts T R , Burke M C , Wilde A A M , Knops R E
Published: November 2023

Introduction

The PRAETORIAN-DFT trial hypothesises that subcutaneous implantable cardioverter defibrillator (S-ICD) implant without defibrillation test (DFT) but with PRAETORIAN score is non-inferior to S-ICD implant with DFT with regard to first shock efficacy in spontaneous events. Various anesthesia protocols are used for S-ICD implant, ranging from local to general anesthesia. Sedation of the patient during S-ICD implantation is required because of DFT. Without the need for DFT, local anesthesia may suffice, thereby reducing the logistical burden associated with sedation and general anesthesia. However, data comparing the effects of various anesthesia methods are lacking.

Purpose

This prespecified analysis of the PRAETORIAN-DFT trial aims to investigate the effect of three different anesthesia methods on (post-)operative pain during S-ICD implant.

Methods

In the PRAETORIAN-DFT trial (NCT03495297), 965 patients were randomised to DFT (N=483) or no DFT with PRAETORIAN Score calculation (N=482). Choice of anesthesia protocol was per local routine and physician discretion and was listed as local anesthesia (LA), monitored anesthesia care (MAC) or general anesthesia (GA). Patients under LA who underwent DFT, had MAC or GA during the test. Pain scores were assessed using the Numerical Rating Scale (NRS), prior to implant (baseline) and at 1-3 hours, 5-7 hours and 1 day post implant. Mean change in NRS compared to baseline was calculated at every time point. Exact pain scores as well as mean change in NRS were compared between anesthesia methods using a Kruskal Wallis Test.

Results

Pre-implant pain questionnaires were completed by 97% of patients. In the complete study cohort, 149/965 (15%) of implants were performed under LA, 327/965 (34%) under MAC and 489/965 (51%) under GA. This distribution did not differ between the randomised arms (p=0.301). There was no difference in NRS or mean change compared to baseline between the groups at any time post implant. The mean change in NRS compared to baseline was highest at 5-7 hours post implant in all groups (Figure). Analysis with patients under LA and MAC or GA during DFT as independent group showed similar results.

Conclusion

There was no difference in pain perception after S-ICD implantation between implant under local anesthesia, MAC and general anesthesia. These results confirm that S-ICD implantation under local anesthesia is feasible and sedation may be no longer necessary if defibrillation testing becomes redundant.Mean changes in NRS compared to baseline
Two-year outcomes of primary prophylactic use of defibrillators with ischemic and non-ischemic cardiomyopathy: propensity score-matched analysis from NIPPON STORM Study
Authors: Kondo Y , Noda T , Sato Y , Nitta T , Aizwa Y , Ohe T , Kurita T
Published: November 2023

Background

In 2016, the DANISH study showed negative results regarding the efficacy of implantable cardioverter defibrillators (ICDs) for patients with non-ischemic cardiomyopathy (NICM) and reduced left ventricular ejection fraction (LVEF). Thus, the ESC guidelines downgraded the indication for primary ICD prophylaxis for NICM patients with reduced LVEF from Class I to IIa. However, the change might be felt somewhat improper in the real wolrd ICD therapy and decided to use the Nippon storm study, a prospective registry study in Japan, to determine whether the DANISH results are of equal value in the clinical setting.

Objective

To determine the efficacy of ICDs as primary prevention in patients with NICM, the incidence of ICD appropriate therapy in patients with NICM was compared with that in patients with ischemic cardiomyopathy (ICM) for which primary ICD efficacy is generally recognized as a Class I indication.

Methods

We selected 1274 patients with underlying cardiac disease from a total of 1548 patients enrolled in the Nippon storm study. We analyzed data of 451 patients with LVEF ≤35% owing to NICM or ICM who underwent ICD implantation of primary prophylaxis (men, 78%; age, 65±12 years; LVEF, 25±1.4%; cardiac resynchronization therapy, 20%; ICM, 33%). All patients were followed up for at least 2 years. Patient selection was performed by employing the propensity score matching method with a digit-matching algorithm for clinical factors, ie, age, sex, cardiac resynchronization therapy with a defibrillator, LVEF. After all propensity score matches had been performed, we compared baseline covariates between the 2 groups: 132 patients with NICM and 132 with ICM. The cumulative incidences of ICD therapies (including both anti-tachycardia pacing and shock therapies) were calculated using competing risk analysis, because death is a competing risk for loss to follow-up.

Results

In the matched cohort, the 2-year appropriate ICD therapy risks were 27.7% and 12.2% in NICM and ICM groups, respectively (HR = 0.390 [95% CI, 0.218–0.701; P = 0.002) (Figure A). Two-year appropriate ATP therapy risks were 25.5% and 11.4% in NICM and ICM groups, respectively (HR = 0.417 [95% CI, 0.226– 0.776; P = .005]) (Figure B), and appropriate shock therapy risks were 6.3% and 1.6% in NICM and ICM groups, respectively (HR = 0.230 [95% CI, 0.049–1.085; P = .063]) (Figure C).

Conclusion

The present subanalysis of the Nippon Storm Study revealed that the risk for appropriate ICD therapy was significantly higher in the patients with NICM than in those with ICM based on our propensity score–matching method.
Personalized cardiac resynchronization therapy guided by real-time electrocardiographic imaging for non-left bundle branch block patients
Authors: Tam T K , Au A C K , Chan Y S , Chan C P , Cheung L L , Cheng Y W , Yuen S M , Yan B P
Published: November 2023

Background

Heart failure patients with non-left bundle branch block (non-LBBB) QRS pattern have limited response rate to biventricular pacing (BVP).

Objective

A personalized cardiac resynchronization therapy (CRT) implantation approach guided by real-time electrocardiographic imaging (ECGi) was studied.

Methods

Twenty patients with left ventricular ejection fraction (LVEF) ≤35%, QRS duration ≥120ms and non-LBBB (13 right bundle branch block and 7 intraventricular conduction delay) were recruited. During CRT implantation, right atrial, right ventricular, coronary sinus, His-bundle and/or Left-bundle leads were inserted. The total activation time (TAT) with different pacing combinations were measured real-time during implantation by ECGi. The configuration producing shortest TAT would be chosen. Clinical response was defined as ≥1 New York Heart Association (NYHA) class improvement. Echocardiographic response was defined as LV end systolic volume reduction ≥15% and/or LVEF improvement ≥10% at 6-months.

Results

After ECGi guided CRT implantation, LVEF improved from 26±6% to 34±11% (both p<0.01) and NYHA class improved from 3.0±0.5 to 2.0±0.6 (p<0.01). Both clinical and echocardiographic response rates were 70%. ECGi approach resulted in better acute electrical resynchronization over BVP as measured by TAT reduction (40% vs 14%, p<0.01). Percentage of TAT reduction was found to be a strong predicator for echocardiographic response (AUC for ROC curve 0.91, 95% CI 0.78 – 1.00). A strong positive correlation between percentage TAT reduction and percentage LVEF improvement (Pearson R 0.70, p=0.001) was found.

Conclusions

ECGi guided CRT implantation in non-LBBB patients generates superior acute electrical resynchronization compared with BVP and is associated with favorable clinical and echocardiographic outcomes.
Associations of 2013 and 2021 ESC definitions of left bundle-branch block with mechanical dyssynchrony and CRT-induced reverse remodeling
Authors: Beela A , Rijks J , Vernooy K , Prinzen F , Delhaas T , Herbots L , Lumens J
Published: November 2023

Background

In 2021, a new and stricter ECG-based definition of LBBB was proposed and implemented in the European Society of Cardiology (ESC) guidelines on cardiac pacing and cardiac resynchronization therapy (CRT).

Aim

To investigate the association between the 2021 and the 2013 LBBB definitions with CRT-induced left ventricular (LV) reverse remodeling, as well as mechanical dyssynchrony.

Methods

CRT patients (n=191) were retrospectively investigated. Pre-CRT digitally stored ECGs were analyzed and categorized according to the LBBB definition of 2013 (LBBB-2013) and the 2021 (LBBB-2021). Mechanical dyssynchrony (Dyss) was assessed pre-CRT using 2D-echocardiography and was defined as the presence of apical rocking and/or septal flash. CRT-induced LV reverse remodeling was measured as the relative change of left ventricular end systolic volume (LVESV) at 12 ± 6 months after CRT compared to baseline.

Results

Patients’ characteristics were as follows; age 70 ± 10 years, 69% males and NYHA class 2.7 ± 0.5. QRS width was 156 ± 18 ms and LVEF 33 ± 11%, and 52% had ischemic etiology. Dyss was present in 59% of the population.

The percentage of the cohort that was considered to have LBBB was considerably lower according to the LBBB-2021 than according to the LBBB-2013 (18 vs. 57% respectively). Similarly, percentages of patients with LBBB+Dyss were 16 and 46% according to LBBB-2021 and LBBB-2013 respectively, with a respective Kappa coefficient of 0.16 and 0.47 (Figure A).

At CRT follow up, LBBB-2013 patients showed significantly more LV reverse remodeling compared to non-LBBB patients (P < 0.001), while there was no significant difference between patients with LBBB-2021 and non-LBBB (P = 0.09, Figure B).

Conclusion

The LBBB definition proposed in the 2021 ESC guidelines excludes many patients from a class I indication for CRT. It is less associated with mechanical dyssynchrony and with CRT-induced LV reverse remodeling than the 2013 LBBB definition. Therefore, the new LBBB definition appears to be counterproductive with regards to selection of CRT patients.
Cost-effectiveness of remote monitoring for cardiac implantable electronic devices compared with conventional follow-up: a systematic review
Authors: Arcinas L A , Alyosif M , Rennert-May E , Piccini J P , Varma N , Frazier-Mills C , Raj S J , Mark D B , Miller R J H , Chew D S
Published: November 2023

Background

Remote monitoring (RM) of cardiovascular implantable electronic devices (CIEDs) is a form of virtual patient care that involves electronic transmission of CIED diagnostics and remote assessment of this information by clinic staff. Despite expert recommendations advocating its use, adoption remains modest due to inconsistent funding policies across health systems.

Purpose

This study aims to identify and synthesize existing literature in the cost-effectiveness of RM compared with in-person clinic assessments alone in patients with CIEDs.

Methods

We conducted a systematic review of available economic evaluations (including cost-effectiveness, cost-utility, cost-consequence analyses) and costing analyses (which examines costs but not clinical benefits) of RM following CIED implantation compared to in-person clinic follow-up alone. Study outcomes included incremental costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER).

Results

Of the 1151 unique citations, a total of 27 studies were included. The studies were from Europe (n=20), USA (n=5), or Canada (n=2). Remote transmissions, when detailed in the study, were predominantly patient- and/or physician- triggered, but some also included automatic home monitor transmissions. Fourteen studies (52%) were costing analyses, and the remaining 13 studies were economic evaluations. The majority of studies (78%; n=21) reported cost-savings associated with RM compared to in-clinic follow up alone. Of the 13 economic evaluations, there were 6 cost-utility analyses, which all reported that RM provided additional QALYs for additional costs that met country-specific thresholds for good value in health care. Studies varied greatly in the costs considered, the outcomes measured, and the time horizons used.

Conclusion

Remote monitoring of patients with CIEDs was associated with cost-savings in most studies and across different healthcare systems. RM may be considered cost-effective when conventional thresholds for good value in health care are adopted. Despite heterogeneity in methods of economic evaluation in the studies included, the overall data in this systematic review supports greater implementation of RM technology to improve health system costs and efficiency.
Long-term remote monitoring vs. in-office monitoring of pacemakers: a systematic review and meta-analysis
Authors: Rivera A , Menezes Junior A , Miyawaki I A , Nascimento B N S R
Published: November 2023

Background

Remote monitoring (RM) is increasingly recognised as the standard of care for patients with cardiac implantable electronic devices (CIEDs) according to current practice guidelines, particularly in pacemaker usage which represents the majority of CIEDs. However, there is insufficient evidence to assess the long-term safety of RM compared to in-office (IO) monitoring of pacemakers over extended periods, as well as its effectiveness in reducing in-office visits for device reprogramming.

Purpose

We aimed to perform a meta-analysis to compare RM and IO monitoring of pacemakers with at least 12 months of follow-up.

Methods

We systematically systematic search EMBASE, PubMed/MEDLINE, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing remote monitoring (RM) and in-office (IO) monitoring of pacemakers, with a focus on outcomes related to (1) all-cause mortality, (2) stroke, and (3) hospitalizations due to cardiovascular and device-related adverse events. Heterogeneity was assessed using I² statistics, and outcomes with high heterogeneity were analysed using a random-effects model.

Results

Six RCTs with a total of 3,059 patients were included in the meta-analysis. Of these, 1,495 patients (48.87%) underwent RM. In-office number of follow-ups per year was not significantly different between groups (OR -0.71; 95% CI -1.45 - 0.03; p = 0.06; I² = 99%; Fig. 1a) but tended to favour the RM group. No significant differences were found between RM and IO monitoring in terms of all-cause mortality (OR 1.14; 95% CI 0.83 - 1.55; p = 0.42; I² = 0%; Fig. 1b), stroke (OR 0.82; 95% CI 0.37 - 2.19; p = 0.82; I² = 38%; Fig. 2a), or hospitalizations for cardiovascular or device-related adverse events (OR 0.96; 95% CI 0.72 - 1.28; p = 0.78; I² = 0%. Fig. 2b).

Conclusion

This is the first meta-analysis comparing RM and IO monitoring for long-term pacemaker usage. Our results suggest that the number of follow-ups tended to be fewer in the RM group, and both monitoring methods appear to be similar in terms of all-cause death, stroke, and hospitalizations for cardiovascular or device-related adverse events.
Association between cardiac implantable electronic device infection and mortality: long-term follow up of a complete, state-wide cohort in Australia
Authors: Shawon M , Sotade O , Li J , Hill M , Strachan L , Challis G , King K , Ooi S , Jorm L
Published: November 2023

Introduction

The number of individuals with Cardiac Implantable Electronic Devices (CIEDs) is rising globally, and infection is a serious procedure-related complication. Only a limited number of studies based on population data have quantified the association between CIED infection and mortality, with inconsistent results.

Purpose

To assess the association between CIED infection and all-cause mortality in a large population-wide, contemporary cohort.

Methods

This retrospective cohort study used linked hospital and mortality data for New South Wales (NSW) residents. We studied all patients aged >18 years who underwent a CIED procedure in NSW public or private hospitals between January 2016 and June 2021. CIED infection was defined by the presence of relevant diagnosis codes in any hospitalisation following a CIED procedure. We followed the patients until their death or end of follow-up, whichever occurred first. Adjusted hazard ratios (aHR) with 95% confidence intervals (CIs) for associations of CIED infection with mortality were estimated using Cox regression at 1-year and end of follow-up, with CIED infection as a time-dependent variable.

Results

We followed 37,625 patients with CIED procedures (36% female, mean age (standard deviation [SD]) 75.4 [12.8] years) for an average [SD] of 2.3 [1.5] years. Of these patients, 500 (1.3%) had CIED infection, and 6,224 (16.5%) died during the study period. The overall mortality rate was 24.2% among those with an infection and 16.4% among those without an infection. Compared to other CIED patients, patients with CIED infection had a higher Kaplan-Meier mortality rate (17.0% vs. 7.1%) and adjusted hazard of mortality (aHR 2.43, 95%CI 1.84-3.21) at 12 months post-procedure. These differences were attenuated, but still remained significant at the end of follow-up (mortality rate 43.6% vs. 33.3%; aHR 1.66, 95%CI 1.39-1.99) (Figure 1).

Conclusions

In a complete, state-wide cohort of CIED patients, infection was associated with higher risks of both short- and medium-term mortality.Kaplan-Meier mortality by CIED infection
Prevalence of new-onset tricuspid regurgitation after leadless Micra pacemaker implantation
Authors: La Fazia V , Gianni C , Pierucci N , Della Rocca D G , Mohanty S , Torlapati G , Al-Ahmad A , Bassiouny M , Gallinghouse G J , Horton R , Burkhardt J D , Lakkireddy D , Forleo G B , Di Biase L , Natale A
Published: November 2023

Background

Tricuspid regurgitation (TR) has been reported as a complication of transvenous pacemaker lead implantation. However, the potential risk of TR is not known in case of leadless devices.

Purpose

We describe a case series of moderate to severe TR following implantation of the leadless Micra device.

Methods

We performed a multicenter (n=6) cross-sectional survey across the United States and Italy. Patient data were obtained by chart review and only patients with baseline and follow-up echo Doppler data were included in this analysis. All images were reviewed by the first author.

Results

A total of 158 patients receiving Micra implant were screened of which 6 (3.8%) cases of moderate to severe TR were identified by the Doppler echo. The most common presenting symptom were shortness of breath (6/6, 100%) and fatigue (5/6, 83.3%). Prominent jugular venous pulsation was observed in 1/6 (16.7%) patients indicating severe TR. Median time to development of symptoms and detection of TR was 9±3 months. None of the 6 patients developed symptoms immediately after the procedure.

Figure 1 illustrates severe TR in one of the six patients included in the study (off axis view).

Conclusion

In this small series, we observed new-onset moderate-severe TR following implantation of leadless device in approximately 4% of patients. Whether this is related to the positioning of the device, needs to be ascertained by future studies.Severe TR after Micra implant
Inflammation of conduction tissue is a major determinant of electrical instability in patients with arrhythmic phenotype of myocarditis
Authors: Frustaci A , Magnocavallo M , Rossi P , Bianchi S , Verardo R
Published: November 2023

Background

Arrhythmic presentation of myocarditis can be life-threatening although often associated with a preserved cardiac dimension and function. The involvement of conduction tissue (CT) has been suggested as pro-arrhythmic factor, but its role has not conclusively supported.

Purpose

CT inflammation in myocarditis with arrhythmic presentation.

Methods

We retrospectively enrolled consecutive patients from January 2010 to June 2021 with acute myocarditis (< 1 month from the onset of symptoms). Patients were categorized according to clinical presentation in arrhythmic [frequent premature ventricular beats, non-sustained or sustained ventricular tachycardia (VT) and survivors of ventricular fibrillation, associated to preserved cardiac contractility –LVEF ≥ 50%] (Group A) and cardiomyopathy phenotype (signs and symptoms of heart failure with LVEF≤ 45%) (Group B).

All patients had a normal coronary network at angiography and an unremarkable valvular pattern at 2D-Echo.They all underwent a LV endomyocardial biopsy; sections of CT (Purkinje fibres) were identified by morphologic (Ashoff and Monkeberg criteria) findings and positive immunohistochemistry for HCN4. CT infiltration was demonstrated by the presence of CD45Ro+ T lymphocytes and the necrosis of adjacent small and loosely arranged myocytes. The extent of myocardial fibrosis, the rate of vasculitis and CT inflammation was compared between the two groups.

Results

Among 217 consecutive pts with biopsy-proven diagnosis of myocarditis, 107 (49.3%) had an arrhythmic presentation (Group A). CT was observed in 33 (30.8%) patients in the Group A and 31 (28.2%) of Group B. In patients with biopsy-evidence of CT, no significant difference was reported in the mean age (51.2±16.8 vs 53.7±14.7; p-value: 0.53) . Inflamed CT was documented in 2 (6.5%) cases in Group B and in 33 (100%) in Group A (p-value< 0.001). No statistically difference was observed between Group A and B regarding the presence of vasculitis (4 vs 1; p-value: 0.36) and myocardial fibrosis (8.8±4.2% vs 9.5±4.3%; p-value: 0.50).

Conclusion

CT inflammation is a major determinant of electrical instability in human myocarditis with arrhythmic presentation.

Figure Legend

Sustained ventricular tachycardia (A) associated to severe infiltration by CD45Ro T lymphocytes of CT in an acute myocarditis with arrhythmic presentation.
Prognostic impact of cardiovascular polypharmacy on octogenarians with heart failure with preserved ejection fraction
Authors: Nishino M , Egami Y , Matsunaga-Lee Y , Yano M , Yamada T , Yasumura Y , Seo M , Tamaki S , Hayashi T , Nakagawa A , Nakagawa Y , Sotomi Y , Nakatani D , Hikoso S , Sakata Y
Published: November 2023

Backgrounds

Drug treatments of heart failure with preserved ejection fraction (HFpEF) have a little clinical benefit, but cardiovascular polypharmacy (CP) trend is observed in elderly HFpEF. We investigated the impact of CP on octogenarian with HFpEF.

Methods

We examined 783 consecutive octogenarians (≥80 years) enrolled in the PURSUIT-HFpEF registry. We defined medications for hypertension, dyslipidemia, heart failure (HF), coronary artery disease, stroke, peripheral artery disease, and atrial fibrillation as cardiovascular medications (CM). In this study, we defined CP as ≥5 CM. We investigated whether CP was correlated with the composite end point (CE) of all-cause mortality and HF rehospitalization.

Results

The proportion with CP was 51.9% (n=406). Background characteristics correlated with CP were frailty, history of coronary artery disease, atrial fibrillation and left atrial dimension. Multivariable Cox proportional hazards analysis showed CP was significantly and independently correlated with CE (hazard ratio (HR): 1.31; 95% confidence Interval (CI): 1.01-1.70) in addition to age, clinical frailty scale, history of HF admission and N-terminal pro brain natriuretic peptide (Table). Kaplan-Meier curve analysis showed that, compared with the non-CP group, the CP group had significantly higher risk of CE and HF (HR: 1.27; 95%CI: 1.04-1.56; P=0.02 and HR: 1.46; 95%CI: 1.13-1.88; P<0.01, respectively), but not any-cause death (Figure). In addition, diuretics were correlated with CE (HR: 1.61; 95%CI: 1.17-2.22; P<0.01), but antithrombotic drugs and HFpEF medications were not.

Conclusions

CP at discharge is a prognostic factor driven by HF rehospitalization in octogenarians with HFpEF. In these patients, diuretics may be correlated with the prognosis.
Inter-atrial block and atrial fibrillation predict cardiac adverse events in heart failure with preserved ejection fraction
Authors: Weerts J , Lopez-Martinez H , Mourmans S G J , Barandiaran Aizpurua A , Domingo M , Henkens M T H M , Brunner-La Rocca H P , Knackstedt C , Bayes-Genis A , Van Empel V P M
Published: November 2023

Background

Atrial fibrillation (AF) is a prognostic risk-factor in heart failure with preserved ejection fraction (HFpEF). Earlier stages of atrial dysfunction identified by the ECG, particularly inter-atrial block (IAB), may provide additional risk predictions in HFpEF patients in sinus rhythm.

Purpose

To assess the prevalence of IAB in patients diagnosed with HFpEF compared to non-HFpEF, and to evaluate the prognostic association of IAB and AF in patients diagnosed with HFpEF.

Methods

Consecutive symptomatic patients referred for a systematic diagnostic work-up to rule-in or rule-out HFpEF were included. The diagnosis of HFpEF was based on current guidelines (including HFA-PEFF and H2FPEF algorithms) and confirmed by consensus of multiple experienced HF specialists. Patients in whom HFpEF was ruled-out were included as non-HFpEF. We excluded patients with cardiac valve interventions before or up to 1 year after baseline, or with paced rhythm during IAB assessment. ECGs at baseline were assessed in detail for P-wave duration, morphology, and presence of IAB using digital calipers by investigators blinded to clinical data. IAB was defined based on a P-wave duration of >120ms. Patients with HFpEF and non-HFpEF were grouped into either i) AF based on ECG or medical history, ii) IAB based on ECG, or iii) no IAB or AF based on ECG. Adverse events were evaluated only in HFpEF patients and included HF hospitalization, cardiac or sudden death, and a composite of both.

Results

372 patients with HFpEF and 68 non-HFpEF were included (females: 67.7% vs. 64.7%, p = 0.726; mean age: 75±7 vs. 67±10 years, p<0.001). AF was more common in HFpEF than non-HFpEF (64.8% vs. 23.5%, p<0.001). In sinus rhythm, presence of IAB was comparable between HFpEF and non-HFpEF (87.0% vs. 80.8%). During a mean follow-up of 3.2±1.6 years in HFpEF patients, more adverse cardiac events were observed when AF was present (23.7%, HR 10.6 [95%CI 1.5-1334.4]) compared to IAB (10.5%, HR 4.2 [95%CI 0.56-542.6]) and no IAB (0%), p = 0.0004 (Figure 1). Pairwise comparisons confirmed these observations: AF vs. IAB p = 0.006, AF vs. no IAB p = 0.031. In HFpEF patients with sinus rhythm, a trend was found for more adverse events when IAB was present versus no IAB (p = 0.06).

Conclusion

Patients with HFpEF have a higher prevalence of AF and similar prevalence of IAB compared to symptomatic patients ruled-out for HFpEF. Presence of IAB or AF in HFpEF may predispose to adverse cardiac events in patients without severe valve disease. IAB may enrich cardiac risk stratification in addition to AF in HFpEF.Survival curves for no IAB, IAB, and AF
Worse long term prognosis in new onset HFpEF treated in HF clinics compared to HFrEF and HFmrEF patients; reflecting need for effective treatment in HFpEF. Results from the Stockholm PREFERS Study
Authors: Ekstrom M , Hage C , Lynga P , Arslan T , Persson B , Eriksson M J , Wallen H , Linde C , Persson H
Published: November 2023

Background/Introduction

Few contemporary studies are available for long term outcome in patients with new onset heart failure (HF) of the three 3 phenotypes; HF with preserved ejection fraction (HFpEF), mildly reduced (HFmrEF) and reduced EF (HFrEF). The Stockholm PREFERS study (Preserved and Reduced Ejection Fraction Epidemiological Regional Study) included new onset HF patients between 2014-18.

Purpose

To report and compare long term outcomes for patients with new onset HFpEF, vs HFmrEF and HFrEF.

Methods

Totally 547 patients, HFpEF n = 137 (25%), HFmrEF n = 61 (11%) and HFrEF n = 349 (64%) were included and followed to end of August 2021. Time to total and cardiovascular (CV) mortality and CV mortality and first HF hospitalizations were compared by log rank test and Cox regression models. All patients were followed at hospital-based HF clinics for guideline directed information and treatment. HFpEF patients were recommended optimal treatment for comorbidities including hypertension, diabetes, ischemic heart disease and atrial fibrillation, and RAAS-inhibition or diuretics. Primary endpoint: CV mortality and HF hospitalizations.

Results

Mean age was 76 (HFpEF), 71 (HFmrEF) and 67 (HFrEF) years (p<0.001). Female sex 49% (HFpEF), 30% (HFmrEF) and 30% (HFrEF) (p<0.001). Median follow up was 3.8 years (IQR 3.0;4.7). Median EF was 55%, 45% and 30% in HFpEF, HFmrEF, and HFrEF, respectively (p<0.001). All-cause mortality was 13% (n = 70), and CV mortality 7.3% (n = 40). The overall CV hospitalization rate was 13.9% (n = 76). The combined endpoint of CV mortality and HF hospitalizations was 21.2% (n = 116) and higher in HFpEF compared to HFrEF (Univariate Hazard ratio (HR) 2.3 (95% CI 2.0-2.5, p<0.001) and vs HFmrEF (HR 2.5; 2.1-2.6, p<0.001). In analysis adjusted for age, sex and diabetes, HFpEF had worse outcome vs HFrEF and HFmrEF (HR 1.5; 0.2-2.0, p<0.05).

Conclusions

New onset HFpEF patients have worse long term outcome vs new onset HFrEF and HFmrEF patients. There is a need for effective evidence based treatment in HFpEF.Figure 1
Exercise-induced pulmonary congestion is a promising marker to diagnose early stage heart failure in patients referred to rule out myocardial ischemia
Authors: Granger C , Legrand L , Allali Y , Wallet T , Guedeney P , Pousset F , Berman E , Helft G , Le Feuvre C , Isnard R , Collet J P , Montalescot G , Hammoudi N
Published: November 2023

Backgrounds

Pulmonary congestion assessed by B-lines using lung ultrasound (LUS) is a hallmark of heart failure (HF). Latent HF at rest can be unmasked during exercise but the diagnosis remains challenging. Exercise-induced B-lines could help diagnose HF with preserved left ventricular ejection fraction (LVEF) at an early stage. The patients in whom coronary artery disease is suspected are also at risk of HF.

Objectives

To assess exercise-induced pulmonary congestion in patients referred to rule out myocardial ischemia.

Methods

Data of stress echocardiography combined with LUS at rest and immediately after exercise in patients with LVEF≥50% referred for investigation of inducible myocardial ischemia in a tertiary center of cardiology, during a 3-years period of time, were retrospectively analyzed. Patients with induced myocardial ischemia, hypertrophic cardiomyopathy or moderate to severe valvular disease were excluded. B-lines were assessed by scanning 2 chest sites. Exercise-induced pulmonary congestion was defined as an increase of B-lines ≥ 2 between baseline and exercise.

Results

A total of 1114 patients were included. Mean age was 63±11 years, 54% of patients had hypertension and 27% diabetes. Exercise-induced pulmonary congestion was identified in 131 (12%) patients. Age, left atrial volume index (LAVi), resting and 20W septal E/e’>15 and peak tricuspid regurgitation velocity (TRV) were associated with exercise-induced B-lines. In a multivariate logistic regression analysis, LAVi (Odds ratio (OR) = 1.03; 95%confidence interval (CI): 1.01–1.06; p = 0.003) and peak TRV (OR = 3.8; 95%CI: 1.4–10.1; p = 0.009) were independent predictors of exercise-induced pulmonary congestion.

Conclusion

Exercise-induced pulmonary congestion could be diagnosed in patients with preserved LVEF referred to rule out inducible myocardial ischemia. Exercise B-lines are linked with left ventricular diastolic dysfunction indices.
Tristetraprolin in cardiomyocytes has a protective role in pressure-overloaded hearts
Authors: Omiya S , Otsu K
Published: November 2023

Background

Elevated circulating levels of TNFα, IL-6 and the soluble TNF receptors predict adverse outcomes in patients with heart failure. However, the targeted anti TNF approaches resulted in worsening heart failure or death. The entire scenario of how the expression levels of inflammatory cytokines are maintained in failing hearts must be elucidated to develop novel and effective treatments for heart failure. Although transcriptional control is a determinant of the kinetics of proinflammatory cytokine gene expression, the stability of the mRNA also has a key function in coordinating immune responses. Tristetraprolin (TTP) has been shown to control mRNA decay by associating with the 3’- untranslated region and critical for the decay of the mRNAs for cytokines. The role of TTP in nonimmune cells such as cardiomyocytes remains to be elucidated.

Purpose

The purpose of this study is to examine the in vivo role of proinflammatory cytokine degradation by TTP in cardiomyocytes during cardiac remodelling under pressure overload.

Methods

Cardiomyocyte-specific TTP–deficient mice were generated. The mice were subjected to pressure overload by means of transverse aortic constriction (TAC) to induce heart failure. Cardiac remodelling was assessed by echocardiography as well as histological and molecular analyses 4 weeks after operation. Cytokine mRNA levels were examined by quantitative PCR.

Results

Cardiomyocyte-specific TTP–deficient mice showed no cardiac phenotypes under baseline conditions. However, the mice exhibited severe systolic dysfunction, indicated by left ventricular fractional shortening, after 4 weeks of pressure overload by means of TAC compared with control littermates (fractional shortening, control littermates 35.8% versus cardiomyocyte-specific TTP-deficient mice 19.9%, p = 0.000). In addition, those hearts showed increases in collagen deposition and the mRNA levels of Col1a2 and Nppb (1.4 times (p = 0.023), 1.5 times (p = 0.033), and 2.0 times (p = 0.020), respectively) compared to corresponding control hearts. Four weeks after TAC, the Il6 mRNA level was upregulated 2.7 times (p = 0.000), but not other cytokine mRNAs, including Tnfα, in cardiomyocyte-specific TTP–deficient hearts compared to controls.

Conclusions

The degradation of cytokine mRNA by TTP in cardiomyocytes plays a protective role in failing hearts and the TTP–mediated pathway in cardiomyocytes might be a therapeutic target to treat patients with heart failure.
PDE2 is cardioprotective in chronic heart failure
Authors: Groener M , Firneburg R , Cachorro E , Rentzsch P , Bantel A , El-Armouche A , Kaemmerer S
Published: November 2023

Background

Patients with chronic heart failure (HF) often develop life-threatening arrhythmia due to structural and electrophysiological cardiac remodelling. The chronic activation of the sympathetic nervous system is initially able to compensate the reduced myocardial contraction. Finally, long-term activation of the β-adrenergic pathway leads to deleterious activation of cAMP-dependent kinases and dysregulation of intracellular Ca2+ handling promoting HF progression and development of arrhythmia. Interestingly, phosphodiesterase 2 (PDE2), an enzyme to hydrolyze cAMP, is upregulated in human HF. Thus, PDE2 might reduce enhanced cAMP levels and pro-arrhythmic Ca2+ releases in HF.

Purpose

We investigated the effects of genetic PDE2 deletion on cardiac function, cellular contraction and arrhythmia occurrence in murine HF model.

Methods

HF was induced via high fat (60 %) diet (HFD) and the treatment with NO-synthase inhibitor L-NAME (0.5 g/l) for 5 weeks in cardiomyocyte-specific PDE2-knockout mice (KO) and control mice (WT). We characterized cardiac function by echocardiography, arrhythmia development by ECG-telemetry, cellular contraction by video-based analysis of sarcomere-shortening and cellular Ca2+ releases using Ca2+ imaging techniques.

Results

After 5 weeks HFD and L-NAME, mice gained weight, displayed increased blood pressure and reduced systolic and diastolic cardiac function. Interestingly, PDE2 KO showed reduced contractility and ejection fraction compared to WT mice after 5 weeks HF. On cellular level, the contraction of isolated cardiomyocytes slightly increased in HF indicating cardiac hypertrophy. However, the β-adrenergic stimulation with isoprenaline (ISO) enhanced cellular contraction only in non-failing WT mice, but was blunted in cells from failing WT hearts reflecting a desensitization of the β-adrenergic pathway. In contrast, the ISO-induced increase in cellular contraction was preserved in failing hearts from KO mice. Interestingly, PDE2 inhibition with BAY 60-7550 increased the ISO-induced cellular contraction in HF from WT, which was not observed in cells from non-failing mice. In HF, the expression of Ca2+ cycling proteins like phospholamban (PLB) were affected. Failing PDE2 KO mice showed higher phosphorylation levels of PLB compared to WT mice with HF. In diseased hearts, pro-arrhythmic triggers like spontaneous Ca2+ waves and Ca2+ sparks were increased. Importantly, diseased PDE2 KO mice developed more arrhythmia in-vivo upon arrhythmia provocation than WT animals.

Conclusion

Cardiac PDE2 deletion was detrimental in HF showing reduced cardiac function and higher number of arrhythmia. PDE2 stimulation might serve as potential therapeutical target in HF limiting the consequences of chronic β-adrenergic hyperactivation.