Beata Średniawa

Mid-term outcomes of triple-site vs. conventional cardiac resynchronization therapy: a preliminary study.

BACKGROUND The primary objectives of this study were to compare the implantation course of triple-site (double left-single right) and conventional cardiac resynchronization devices. The secondary target was to assess mid-term outcomes of both types of cardiac resynchronization therapy (CRT). METHODS Fifty-four patients with NYHA classes III-IV, left ventricular EF<or=35% and QRS>or=120 ms were included; 27 received triple-site pacemakers (TRIV group), 27 conventional CRT devices (BIV group). Procedural course, clinical data, QRS duration, echocardiographic parameters, peak oxygen consumption (VO2max) and 6-minute walking distance (6MWD) were screened for inter-group differences. RESULTS Procedure duration was higher in TRIV than in BIV group (197.6 vs. 137.6 min, P<0.001), fluoroscopy exposure and complication-rates were similar. After 3 months of CRT, triple-site pacing was associated with a more significant (P<0.05) NYHA class reduction (by 1.4 vs. 1.0 class, respectively), increase in VO(2) max (2.9 vs. 1.1 mL/kg/min) and 6MWD (98.7 vs. 51.6 m) than conventional CRT. A higher EF and more improved intraventricular synchrony were observed in the TRIV than in the BIV group. The response rate in the TRIV group was 96.3% vs. 62.9% in the conventional group (P=0.002). Triple-site stimulation was an independent predictor of response to CRT (adjusted odds ratio 26.4, P=0.01). CONCLUSIONS Triple-site resynchronization appears to be more beneficial than conventional CRT. Upgrade to triple-site CRT may be considered in non-responders to standard resynchronization.

Quality of Life in Cardiac Resynchronization Recipients: Association with Response and Impact on Outcome

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.

Atrial fibrillation in cardiac resynchronization recipients with and without prior arrhythmic history. How much of arrhythmia is too much

BACKGROUND The aim of the study was to assess long-term incidence of atrial fibrillation (AF) in cardiac resynchronization (CRT) recipients with and without prior arrhythmic history, factors predisposing to arrhythmia, as well as to evaluate the prognostic power of cumulative arrhythmia burden, duration of the longest episode and the number of episodes. METHODS Device-collected data on AF episodes during 24 months in 96 participants of a randomized CRT-trial were analyzed (15% in NYHA class IV, sinus rhythm, median left ventricular ejection fraction 24% and QRS 169 ms). Blindly adjudicated major adverse cardiac events (MACE) and any-cause death were censoring variables. RESULTS Two-year incidence of AF was 70%, including 66% of patients without previous AF history. No baseline characteristics distinguished those who developed new onset AF. Percent of time spent in AF, but not number of episodes predicted mortality (adjusted hazard ratio [HR] 1.05 ± 95% confidence interval CI 1.01-1.10) and MACE incidence (HR 1.03 ± 1.01-1.07; p = 0.03). Duration of the longest episode also predicted mortality (HR 1.06 ± 1.01-1.12; both p = 0.03). Prognostic impact of AF load was marked only in patients with slower ventricular response (< 98/min), but was independent from CHADS2 scores, pacing burden, or prior atrioventricular nodal ablation. CONCLUSIONS Seven out of 10 CRT-patients had AF within 2 years, including two-thirds of subjects without arrhythmic history. No baseline features distinguished those who developed new onset AF. Arrhythmia burden and duration of the longest episode, but not number of episodes influenced outcomes in CRT-patients, irrespectively from pacing burden or prior atrioventricular node ablation.

Influence of Reciprocating Tachycardia on the Development of Atrial Fibrillation in Patients with Preexcitation Syndrome

Background: We sought to evaluate the influence of atrio‐ventricular reentrant tachycardia (AVRT) on atrial pressures during tachycardia and the presence of atrial fibrillation (AF) in patients with preexcitation syndrome.

The first successful implantation of an intravenous AAIR pacemaker into autologous extracardiac lateral tunnel Fontan in the child

Patients with a single ventricle have complex anatomy that requires staged palliation which is usually the Fontan procedure. This procedure has undergone a lot of modifications to improve hemodynamics. Despite these efforts, sinus node dysfunction (SND) and bradyarrythmias are still common complications after Fontan operation, therefore there is a need of pacemakers implantation. Unfortunately, the most frequent technique of creating Fontan cannale - the extracardiac lateral tunnel makes the transvenous access to the atrium difficult or impossible to achieve. We report a case of successful implantation of an endocardial atrial lead for SND in patient with an extracardiac autologous Fontan tunnel.

Gender-related differences in long-term outcome among high-risk patients with myocardial infarction treated invasively

Introduction Treating acute myocardial infarction (AMI) with percutaneous coronary intervention (PCI) has an impact on improving long-term outcome. However, patients with other comorbidities are challenging, and are considered as a high-risk population. Aim To assess gender-related differences in long-term prognosis after AMI among high-risk patients. Material and methods The single-center registry encompassed 4375 AMI patients treated with PCI. The following high-risk groups were selected: age > 70 group (n = 1081), glomerular filtration rate (GFR ) < 60 group (n = 848), diabetes mellitus (DM) group (n = 782), low ejection fraction (EF) group (n = 560) defined as EF < 35%, and incomplete coronary revascularization (ICR) group (n = 2008). Within each group, comparative analysis of long-term mortality with respect to gender and age was performed. Results There were no significant differences in long-term mortality with respect to gender among groups with age > 70 (29.0% vs. 30.3%) and GFR < 60 (37.2% vs. 42.3%) (both p = NS respectively for men vs. women). In the DM group (24.8% vs. 30.8%; p = 0.06) and EF < 35% group (36.3% vs. 44.5%; p = 0.07) there was a trend towards significance. The ICR group showed a higher mortality rate with respect to gender (19.7% vs. 27.3%; p < 0.001). Differences in survival assessed by the log-rank test were significant among ICR and EF < 35% groups. Conclusions Female gender is related to higher long-term mortality among high-risk groups, but a statistically significant difference was observed only in patients with ICR and those with EF < 35%. Female gender may be associated with worse prognosis in diabetic patients, but it needs evaluation. However, worse prognosis in women was not independent and was associated mainly with other comorbidities and worse clinical characteristics.

Implementation of mild therapeutic hypothermia for post-resuscitation care of sudden cardiac arrest survivors in cardiology units in Poland

BACKGROUND The post-cardiac arrest (CA) period is often associated with secondary damage of the brain that leads to severe neurological deficits. The current practice guidelines recommend the use of therapeutic hypothermia (TH) to prevent neurological deficit and improve survival. OBJECTIVES The aim of the study was to investigate the implementation of medical guidelines in clinical practice and to evaluate the barriers for implementation of TH in cardiology units in Poland. MATERIAL AND METHODS A telephone survey, fax and online inquiry form were used to assess the implementation of TH in cardiology units in the management of unconscious patients after cardiac arrest (CA). The questions addressed the local practice, TH protocol, reasons for not using TH and outcomes of CA patients. RESULTS We obtained information from 79 units out of 150 asked (53%). At the time of the survey, 24 units (30.8%) were using TH as part of their post-CA management. Of all CA patients, 45% underwent TH in cardiac intensive care units (CICU), 37.5% in the coronary care unit (CCU) and 12.5% in the intensive care unit (ICU). The major barrier for the implementation of TH declared by the non-cooling centers was lack of sufficient knowledge regarding the technique and protocol, as well as experience (37%); access to dedicated equipment was not perceived as an obstacle. CONCLUSIONS The number of cardiology units that provide TH for comatose CA patients is low. The main limiting factor for wider use of TH is lack of knowledge and experience. There is a clear need for urgent educational activities for cardiology units. The benefits of TH still have not reached their potential in cardiology units.

[Severe hypercholesterolaemia--when to use the proprotein convertase subtilisin-kexin type 9 protease inhibitors (PCSK9 inhibitors)? Polish Society of Cardiology experts' group statement].

The severe hypercholesterolaemia can be recognised when low density lipoprotein cholesterol (LDL-C) serum levels are equal to or above 5 mmol/L (≥ 190 mg/dL). The prevalence of LDL-C ≥ 5 mmol/L is 3.8% in Polish population aged 18-79 years. Among these adults there are patients with familial hypercholesterolaemia (FH). According to meta-analysis of 6 Polish population surveys prevalence of heterozygous FH (HeFH) diagnosed using Dutch Lipid Clinic criteria is 0.4% (95% Cl 0.28-0.53%) in men and women aged 20-74 years, i.e. one in every 250 people. As HeFH is a wellknown cause of premature coronary heart disease the rigorous treatment targets for LDL-C have been established in clinical guidelines. Their achievements, even with a high dose of high efficacy statin therapy is difficult or even impossible. New strong hypolipidaemic drugs i.e. PCSK9 inhibitors have been initiated against this chalange. Both drugs, evolocumab and alirocumab, have been extensively studied in numerous phase 2 and phase 3 trials. Fewer studies with bococizumab are available until now. The PCSK9 inhibitors, as monotherapy as well in combination with statins were associated with mean LDL-C reduction about 60%. It means that the majority of patients (70-90%) with severe hypercholesterolaemia (including HeFH), treated with statins, after addition of PCSK9 inhibitors were able to achieve an LDL-C < 2.5 mmol/L (< 100 mg/dL) or < 1.8 mmol/L (< 70 mg/dL) level. Another group of patients who may benefit from PCSK9 inhibitors include those who need lipid lowering therapy, but who are statin intolerant, especially because of statin-associated muscle symptoms (SAMS). In our statement we have accepted the diagnosis of SAMS proposed recently by European Atherosclerosis Society. Today the longest clinical trial with evolocumab (11 months) was the open OSLER study, and with alirocumab ODYSSEY LONG TERM (78 weeks). In the first one the reduction of cardiovascular events by 53% (95% Cl 22-72%) was observed, and in the second one by 48% (10-69%). Neurocognitive events were reported more frequently with both drugs than with placebo. This adverse effect will be the subject of observation in ongoing studies. We still await the results of 4 ongoing large placebo controlled phase 3 trials investigating whether PCSK9 inhibitors on background of statin therapy reduce cardiovascular events. Meanwhile evolocumab, as well as alirocumab have been accepted to use in clinical practice by European Medicine Agency. In this situation the experts of Polish Society of Cardiology have prepared the statement on the use PCSK9 inhibitors with indication in the first place for HeFH patients, statin intolerant and those at high risk who are not able to reach LDL-C target level with a high potent high dose statin.

NOninvasive Monitoring for Early Detection of Atrial Fibrillation: rationale and Design of the NOMED-AF study

1Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland 2Silesian Park of Medical Technology Cardio-Med Silesia, Zabrze, Poland 31st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland 4Department of Preventive Medicine and Education, Medical University of Gdansk, Gdansk, Poland 5Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Krakow, Poland 6Department of Cardiology, Pomeranian Medical University, Szczecin, Poland 7Comarch Healthcare SA, Krakow, Poland 8Comarch SA, Krakow, Poland 9Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom

Trying to predict the unpredictable: Variations in device-based daily monitored diagnostic parameters can predict malignant arrhythmic events in patients undergoing cardiac resynchronization therapy

BACKGROUND The aim of this study was to evaluate the value of device-based diagnostic parameters in predicting ventricular arrhythmias in cardiac resynchronization therapy (CRT) recipients. METHODS Ninety-six CRT-D patients participating in TRUST CRT Trial were analyzed. The inclusion criteria were: heart failure in NYHA ≥ 3 class, QRS ≥ 120 ms, LVEF £ 35% and significant mechanical dyssynchrony. Patients were divided into those with (n = 31, 92 arrhythmias) and without (n = 65) appropriate ICD interventions within follow-up of 12.03 ± 6.7 months. Daily monitored device-based parameters: heart rate (HR), thoracic impedance (TI), HR variability and physical activity were analyzed in 4 time windows: within 10, 7, 3 days and 1 day before appropriate ICD interventions. RESULTS A consistent pattern of changes in three monitored factors was observed prior to arrhythmia: 1) a gradual increase of day HR (from 103.43% of reference within 10-day window to 105.55% one day before, all p < 0.05 vs. reference); 2) variations in night HR (104.75% in 3 days, 107.65% one day before, all p < 0.05) and 3) TI decrease (from 97.8% in 10 days to 96.81% one day before, all p < 0.05). The combination of three parameters had better predictive value, which improved further after exclusion of patients with atrial fibrillation (AF). The predictive model combining HR and TI together with LVEF and NT-proBNP was more prognostic than the model involving LVEF and NT-proBNP alone (difference in AUC 0.05, 95% CI 0.0005-0.09, p = 0.04). CONCLUSIONS Daily device-monitored parameters show significant variations prior to ventricular arrhythmia. Combination of multiple parameters improves arrhythmia predictive performance by its additive value to baseline risk factors, while presence of AF diminishes it.