Andrea Puglisi

Prediction of response to cardiac resynchronization therapy: The selection of candidates for CRT (SCART) study

Background: The aim of this study was to evaluate the ability of baseline clinical and echocardiographic parameters to predict a positive response to CRT.

Impact of Consistent Atrial Pacing Algorithm on Premature Atrial Complexe Number and Paroxysmal Atrial Fibrillation Recurrences in Brady-Tachy Syndrome: A Randomized Prospective Cross Over Study

AbstractAim of the study: The Consistent Atrial Pacing (CAP) algorithm has been designed to achieve a high percentage of atrial pacing to suppress paroxysmal atrial fibrillation. The aim of our study was to compare the impact of DDDR+CAP versus DDDR pacing on paroxysmal atrial fibrillation recurrences and triggers in patients with Brady-Tachy Syndrome. Methods: 61 patients, 23 M and 38 F, mean age 75±9 y, affected by Brady-Tachy Syndrome, implanted with a DDDR pacemaker, were randomized to DDDR or DDDR+CAP pacing with cross over of pacing modality after 1 month. Results: 78 % of patients in DDDR pacing and 73 % in DDDR+CAP pacing (p=n.s.) were free from symptomatic paroxysmal atrial fibrillation recurrences. During DDDR+CAP pacing, the atrial pacing percentage increased from 77±29 % to 96±7 % (p<0.0001). Automatic mode switch episodes/day were 0.73±1.09 in DDDR and 0.79±1.14 (p=n.s.) in DDDR+CAP. In patients with less than 50 % of atrial pacing during DDDR, automaticmode switch episodes/day decreased during DDDR+CAP from 1.13±1.59 to 0.23±0.32 (p<0.05) and in patients with less than 90 % from 1.23±1.27 to 0.75±1.10 (p<0.001). The number of premature atrial complexes per day decreased during DDDR+CAP from 2665±4468 to 556±704 (p<0.02). Conclusion: CAP algorithm allowed continuous overdrive atrial pacing without major side effects. Triggers of paroxysmal atrial fibrillation induction, such as premature atrial complexes, were critically decreased. Paroxysmal atrial fibrillation episodes were reduced in patients with atrial pacing percentage lower than 90 % during DDDR pacing.

Persistent Atrial Fibrillation Worsens Heart Rate Variability, Activity and Heart Rate, as Shown by a Continuous Monitoring by Implantable Biventricular Pacemakers in Heart Failure Patients

Background: Atrial fibrillation (AF) induces loss of atrial contribution, heart rate irregularity, and fast ventricular rate.

Cardiac resynchronization and implantable cardioverter defibrillator therapy: Preliminary results from the InSync implantable cardioverter defibrillator italian registry

GASPARINI, M., et al.: Cardiac Resynchronization and Implantable Cardioverter Defibrillator Therapy: Preliminary Results From the InSync Implantable Cardioverter Defibrillator Italian Registry. The aim of this study was to evaluate ventricular arrhythmias occurring in recipients of the InSync ICD for the primary and secondary prevention of sudden death. The InSync ICD was implanted in 142 patients (128 men; mean age65 ± 10years) with heart failure (mean NYHA functional Class3.0 ± 0.7) and wide QRS (mean159 ± 33ms). The underlying etiology was ischemic in 55%, idiopathic in 33%, and valvular or hypertensive cardiomyopathy in 12% of patients. The numbers of arrhythmic episodes/100 patient‐months was computed with their 95% CI, assuming a Poisson distribution. Implants were performed in 48 (34%) patients who did not have an ACC/AHA guidelines Class I indication for ICD therapy. A total of 104 patients were compliant for follow‐up visits. During a 9‐month median (range 0.1–24) follow‐up of 104 compliant patients, 19 experienced a total of 94 ventricular arrhythmias, all successfully interrupted or selfterminated, with a median number of two separate episodes, corresponding to a rate of 10 episodes/100 person‐month (95% CI 8–12). A rate of 12 episodes/100 person‐months (95% CI 10–15) was measured in the subgroup of patients with ACC/AHA class I indications, versus two episodes/100 person‐months (95% CI 1–5) in the remainder of the population. Among 12 deaths, 9 were due to heart failure, 1 to a noncardiovascular cause, and 2 to unknown causes. The implantation of ICD in heart failure patients has been prominently extended to primary prevention. Patients without standard ICD indications experienced life‐threatening arrhythmic events. The impact of ICD combined with cardiac resynchronization therapy on arrhythmic profile, mortality, and costs in this subgroup of patients need to be more precisely studied, with a particular focus on the various types of underlying heart disease. (PACE 2003; 26:[Pt. II]:148–151)

Daily distribution of atrial arrhythmic episodes in sick sinus syndrome patients: implications for atrial arrhythmia monitoring

AIMS Disorders such as paroxysmal atrial fibrillation (AF) and atrial tachyarrhythmias (AT) are difficult to investigate because of their intermittent, and sometimes asymptomatic, nature. The aim of this study was to investigate the daily temporal distribution of AT/AF episodes--onset and occurrence--by analysing data from 250 pacemaker-implanted, brady-tachy syndrome patients who have been enrolled in the Burden II Study. METHODS AND RESULTS Data were analysed accounting for the mode switch list which includes date, time, and duration of each mode switch episode. Chi-squared tests for goodness of fit were used to determine whether AT/AF episode were uniformly distributed. The population analysed in the present study suggests the occurrence of a circadian rhythm of paroxysmal AF episodes, similar to that described for other cardiovascular diseases, with clustering of events in the morning from 08:00 and (to a lesser degree) in the afternoon (03:00 to 18:00). The relative risk of AT/AF onset is 13% higher during daytime, 40% lower at night (P < 0.000001). CONCLUSION The use of monitoring devices based on daily electrocardiogram (ECG) recording could be optimized with these data, thus increasing the probability to detect AT/AF episodes.

Results of the SCART study: selection of candidates for cardiac resynchronisation therapy.

Objective To prospectively determine whether prespecified electrocardiographic, echocardiographic and tissue Doppler imaging (TDI) selection criteria may predict a positive response to cardiac resynchronisation therapy (CRT). Methods In this multicentre, prospective, non-randomised study, 96 heart failure patients with New York Heart Association class III–IV symptoms, an ejection fraction of ≤35%, and at least one marker of ventricular dyssynchrony according to prespecified electrocardiographic, echocardiographic or TDI criteria were enrolled. The primary endpoint was an improvement in the clinical composite score at 6 months. Results At enrolment, 70 patients fulfilled the electrocardiographic criterion (QRS duration ≥150 ms), 77 patients showed echocardiographic signs of dyssynchrony, and 37 patients met the TDI dyssynchrony criteria. The overall responder rate was 78/96 (81%). In particular, the primary endpoint was reached in 68 patients who fulfilled the echocardiographic criteria as compared with 10 patients who did not (88 vs. 53%, P = 0.001). The patients who met the echocardiographic criteria showed a significant greater reduction in left ventricular end-systolic diameter (P = 0.029) and a higher improvement in quality of life (P = 0.017) than patients who did not. Neither electrocardiographic nor TDI criteria seemed to predict a positive response to CRT. Conclusions In our patient population, mechanical indexes of dyssynchrony as assessed by echocardiography appeared to identify CRT responders. Although TDI is useful for evaluating ventricular dyssynchrony after CRT, the prespecified TDI inclusion criteria adopted in this investigation did not increase the number of CRT responders.

12. Cardiac Resynchronization Therapy: Surgical Approach

The aim of the study was to evaluate effectiveness and long term benefit of CRT in patients undergone cardiac surgery enrolled in the InSync/InSync ICD Italian Registries (IIR). Methods 952 patients enrolled were followed for 21±16 months: at implant a CS procedure was reported in clinical history of 168 (18%) patients (110 CABG, 67 valvular surgery, 10 other). Results ![Graphic][1] During follow-up, 153 pts (16%) died for any cause: 119 (15%) in no-CS group and 34 (20%) in CS group. All-cause mortality rate was 9 per 100 pts/year in no-CS and 13 in CS (p<0.05). Relative risk: 1.41 (95% CI 0.92 to 2.15; p=0.115) in CS group versus no-CS group. Conclusions CABG surgery represents an independent mortality risk factor in CRT therapy [1]: /embed/graphic-1.gif

12. Cardiac Resynchronization Therapy: Surgical Approach12.6 Cardiac Resynchronization Therapy After Cardiac Surgery: Insync Registries Data on Long Term Follow-Up

The aim of the study was to evaluate effectiveness and long term benefit of CRT in patients undergone cardiac surgery enrolled in the InSync/InSync ICD Italian Registries (IIR). Methods 952 patients enrolled were followed for 21±16 months: at implant a CS procedure was reported in clinical history of 168 (18%) patients (110 CABG, 67 valvular surgery, 10 other). Results ![Graphic][1] During follow-up, 153 pts (16%) died for any cause: 119 (15%) in no-CS group and 34 (20%) in CS group. All-cause mortality rate was 9 per 100 pts/year in no-CS and 13 in CS (p<0.05). Relative risk: 1.41 (95% CI 0.92 to 2.15; p=0.115) in CS group versus no-CS group. Conclusions CABG surgery represents an independent mortality risk factor in CRT therapy [1]: /embed/graphic-1.gif

Cardiac Resynchronization Therapy After Cardiac Surgery: Insync Registries Data on Long Term Follow-Up

The aim of the study was to evaluate effectiveness and long term benefit of CRT in patients undergone cardiac surgery enrolled in the InSync/InSync ICD Italian Registries (IIR). Methods 952 patients enrolled were followed for 21±16 months: at implant a CS procedure was reported in clinical history of 168 (18%) patients (110 CABG, 67 valvular surgery, 10 other). Results ![Graphic][1] During follow-up, 153 pts (16%) died for any cause: 119 (15%) in no-CS group and 34 (20%) in CS group. All-cause mortality rate was 9 per 100 pts/year in no-CS and 13 in CS (p<0.05). Relative risk: 1.41 (95% CI 0.92 to 2.15; p=0.115) in CS group versus no-CS group. Conclusions CABG surgery represents an independent mortality risk factor in CRT therapy [1]: /embed/graphic-1.gif

A10-2 Differences in ventricular arrhythmias developed by ischemic and non-ischemic heart failure patients implanted with biventricular cardioverter-defibrillators: The insync icd italian registry

Aim To evaluate the ventricular arhythmic events developed by ischemic (I) and non-ischemic (NI) heart failure (HF) patients (pts) implanted with an ICD for cardiac resyncronization therapy (CRT) {Medtronic InSync ICD} for primary (PP) or secondary prevention (SP) of sudden death. Methods 219 pts (91% male, age 65&10 yrs, NYHA 3.0&0.6, EF 26&7%, QRS 161&31 ms) were implanted and followed in the InSync ICD Italian Registry. Etiology was I in 58% and N-I in 42% of pts. 115 pts (53%) were implanted for SP (23 prior cardiac arrest, 66 recurrent sustained VT, 26 upgrade of ICD); 104 (47%) for PP. Results Over a median period of 13&7 months, pts with at least 6 months FU and compliant data were 130 (48 I, 62 NI). The efficacy of CRT was evident in term of functional improvement. 14 pts died for pump failure. 23 pts (11 I, 12 N-I) developed 88 ventricular arhythmic events (VAE): 75 VT, 13 VF. There were no statistical differences in term of baseline clinical condition, ICD indication (3 pts implanted for primary prevention in both groups) and VT/VF detection window programming between I and NI pts. 28 VAE (all VT: cycle length 337&50 ms) were recorded in I pts: 5 self-terminated, 11 terminated with ATP (9 with 1” ATP) and 12 with shock; 60 VAE (47 VT: cycle length 361&58 ms; 13 VF: cycle length 250&14 ms) in NI pts: 18 VT and 1 VF self-terminated, 17 VT terminated with ATP (16 with 1” ATP), 12 VT and 12 VF with shock. The main differences were: 1) more VAE in N-I group (60 vs 28; p=O.OOS); 2) higher percentage of VAE in NI group self-terminated (38% vs 17%; p=O.O6); 3) higher efficacy of 1” ATP in N-I group (84% vs 47%; p=O.O17); 4) less delivered therapies per patient in NI group (1.2&0.6 vs 1.6&0.7; p=O.O04) Conclusions: Our data indicate that in pts with HF, following CRT+ICD, the arhythmic profile may be different in I vs NI pts. In comparison with I pts, NI pts tend to have more arhythmic episodes but a substantial proportion of VT terminates spontaneously or is more easily terminated by ATP.