Biagio Sassone

CHADS2 and CHA2DS2-VASc scores to predict morbidity and mortality in heart failure patients candidates to cardiac resynchronization therapy

AIMS CHADS2 and CHA2DS2-VASc scores are pivotal in assessing the risk of stroke in atrial fibrillation patients, and were recently proved to predict hospitalizations and mortality in specific clinical settings. Aim of this study was to evaluate whether these scores could predict clinical outcomes [first hospitalization for heart failure (HF) and a combined event of HF hospitalization and death for any cause] in patients candidates to cardiac resynchronization therapy and implantable defibrillator (CRT-D). METHODS AND RESULTS In a retrospective multicentre Italian study, we enrolled 559 consecutive HF patients candidates to CRT-D, and we grouped them in three pre-specified risk classes: low (CHADS2/CHA2DS2-VASc 1-2), moderate (CHADS2/CHA2DS2-VASc 3-4), and high (CHADS2 5-6/CHA2DS2-VASc 5-8). All patients underwent regular follow-up at implanting centres every 6 months; data collection was extended till the 72th month of follow-up. At a median FU of 30 months, 143 patients (25.4%) were hospitalized for HF and 110 (19.5%) died. Event-free survival analysis showed a significant difference according to baseline CHADS2 and CHA2DS2-VASc scores (Log-Rank for HF P < 0.001 for CHADS2 and CHA2DS2-VASc; Log-Rank for combined end-point P = 0.001 for CHADS2, P < 0.001 for CHA2DS2-VASc). At multivariate analysis, independent predictors of endpoints were: previous atrial fibrillation (AF) or AF at implant, NYHA class, QRS duration and the CHA2DS2-VASc score (for HF hospitalization P = 0.013; for the combined event, P = 0.007), while the CHADS2 score was not independently associated with either the end-points. CONCLUSION In CRT-D patients, pre-implant CHA2DS2-VASc score is an independent predictor of major clinical events at 30-month follow-up.

Value of right ventricular–left ventricular interlead electrical delay to predict reverse remodelling in cardiac resynchronization therapy: the INTER-V pilot study

AIMS Few studies have systematically evaluated the value of intra-procedural parameters in predicting response to cardiac resynchronization therapy (CRT). We investigated whether intracardiac (electrogram) measurements of electrical delays between the positioned right ventricular (RV) and left ventricular (LV) leads at implantation could predict the mid-term CRT response. METHODS AND RESULTS Fifty-two patients underwent CRT implantation according to standard techniques and clinical indications. The RV-LV interlead electrical delay measured during spontaneous rhythm and the difference between the pacing-induced (Deltap) RV-LV interlead electrical delays measured during RV and LV pacing were defined intraoperatively using the electrical depolarizations registered at the ventricular leads on the device programmer. At 6 months, a reduction of LV end-systolic volume > or = 15% was used to define CRT responders. Responders (62%), when compared with non-responders, showed a higher proportion of ischaemic aetiology (P = 0.007) and a lower value of DeltapRV-LV interlead electrical delay (22.1 +/- 18.4 vs. 46.3 +/- 15.0 ms, P = 0.0001). At multivariate analysis, the DeltapRV-LV interlead electrical delay was the only independent predictor of response to CRT (P = 0.001). For such a parameter, the receiving operating characteristic curve analysis identified a cut-off value of 42 ms corresponding with the highest accuracy: sensitivity 90.6%; specificity 70%; positive and negative predictive value 83% and 82%, respectively. Conversely, no difference was ascertained between responders and non-responders when RV-LV interlead electrical delay was measured during spontaneous rhythm (76.1 +/- 28.5 vs. 89.6 +/- 21.2, P = 0.078). CONCLUSION Intraprocedural measuring of paced RV-LV interlead electrical delay obtained during RV and LV pacing predicts mid-term CRT response.

Cardiac device therapy in patients with left ventricular dysfunction and heart failure: 'real-world' data on long-term outcomes (mortality, hospitalizations, days alive and out of hospital).

The impact on long‐term outcomes of implantable cardioverter defibrillators (ICDs) and biventricular defibrillators for cardiac resynchronization (CRT‐D) devices in ‘real world’ patients with heart failure (HF) needs to be assessed in terms of clinical effectiveness.

Efficacy of LOw-dose DObutamine Stress-Echocardiography to predict Cardiac Resynchronization Therapy Response (LODO-CRT) multicenter prospective study—Design and rationale

BACKGROUND Although cardiac resynchronization therapy (CRT) has a well-demonstrated therapeutic effect in selected patients with advanced heart failure on optimized drug therapy, nonresponder rate remains high. The LODO-CRT is designed to improve patient selection for CRT. Design and rationale of this study are presented herein. METHODS LODO-CRT is a multicenter prospective study, started in late 2006, that enrolls patients with conventional indications for CRT (symptomatic stable New York Heart Association class III-IV on optimized drug therapy, QRS > or =120 milliseconds, left ventricular [LV] dilatation, LV ejection fraction < or =35%). This study is designed to assess the predictive value of LV contractile reserve (LVCR), determined through dobutamine stress echocardiography (defined as an LV ejection fraction increase >5 units), in predicting CRT response during follow-up. Assessment of CRT effects will follow 2 sequential phases: in phase 1, CRT response end point is defined as LV end-systolic volume reduction > or =10% at 6 months; in phase 2, both LV end-systolic volume reduction and clinical status via a clinical composite score will be evaluated at 12 months follow-up. Predictive value of LVCR will be compared to other measures, such as LV dyssynchrony measures, through adjusted multivariable analysis. For the purpose of the study, target patient number is 270 (with 95% confidence, 80% power, alpha < or = .05). Enrollment should be complete by the end of 2008. CONCLUSIONS The LODO-CRT trial is testing the hypothesis that LVCR assessment, using low-dose dobutamine stress echocardiography test, should effectively predict positive response to CRT both in terms of the reverse remodeling process as well as favorable long-term clinical outcome. Moreover, the predictive value of LVCR will be compared to that of conventional intra-LV dyssynchrony measures.

Management of traumatic implantable cardioverter defibrillator lead perforation of the right ventricle after car accident: a case report

The authors reported a case of traumatic implantable cardioverter defibrillator (ICD) lead perforation of the right ventricular (RV) apex caused by a motor vehicle accident. Clinical and echocardiographic features combined with changes in electrical parameters of the offending lead were decisive for the final diagnosis. Optimal management of ICD lead RV wall perforation is currently unclear. In our report, RV perforation was responsible for cardiac tamponade. This complication was uneventfully managed by open surgical procedure.

Prognostic significance of silent myocardial ischemia in variant angina pectoris.

The present study investigates the prognostic significance of silent myocardial ischemia in variant angina. Forty-eight-hour Holter monitoring and coronary angiography were performed in 54 patients with transient ST elevation and no history of myocardial infarction admitted to the coronary care unit for worsening of symptoms. Coronary artery spasm was documented in most of these patients. Over the subsequent month, 20 patients (group 1) had a major coronary event (2 died, 6 had nonfatal myocardial infarction and 12 had urgent coronary revascularization), and the remaining 34 patients (group 2) had a good clinical outcome. From 2,578 hours of recording, 547 ischemic episodes were identified of which only 9% were associated with angina. The mean daily number of ST elevation in group 1 was similar to that in group 2 (4.8 +/- 5.1 vs 4.1 +/- 4.6; p = not significant). Conversely, the mean daily duration of such ischemic episodes was consistently greater in group 1 than in 2 (79 +/- 36 vs 37 +/- 25 minutes; p less than 0.005). The occurrence of greater than or equal to 1 long-lasting (greater than or equal to 10 minutes) episode of ST elevation was observed in 18 of 20 patients in group 1 (sensitivity 90%), but only in 4 of 34 in group 2 (specificity 88%). Significant coronary atherosclerosis (greater than 50% stenoses) was found at angiography in 18 of 20 patients in group 1, and in 18 of 34 in group 2.(ABSTRACT TRUNCATED AT 250 WORDS)

A moderate 1-km treadmill walk predicts mortality in men with mid-range left ventricular dysfunction

The prevalence of heart failure considerably increased over the last three decades because of the aging population and the improved survival rate after acute cardiac events. Clinical and research programs more frequently are directed to patients with severely impaired functional capacity. Nevertheless, heart failure with mid-range left ventricular dysfunction (HFmrEF) has been recently defined as a distinct clinical entity. Cardiorespiratory fitness (CRF), usually best reflected by peak oxygen consumption (VO2peak), has been shown to be a powerful and independent prognostic marker in patients with heart failure. CRF has been linked to both cardiovascular and non-cardiovascular outcomes in ambulatory patients with heart failure. VO2peak is strongly related to walking capacity in older adults, and among heart failure patients. The walking speed maintained during a submaximal 1-km treadmill walk (1 k-TWT) has been demonstrated to be a valid and simple tool for VO2peak estimation, 12–14 and is inversely related to survival, and hospitalization, in outpatients with cardiovascular disease and preserved left ventricular ejection fraction (LVEF). We examine the association between VO2peak estimated by the 1 k-TWT and all-cause mortality in men with HFmrEF. We studied 209 medically stable male outpatients aged 65 10 years, with LVEF 40% 5%, referred to our exercise-based secondary prevention program. Each patient performed the moderate perceptually-regulated (11–13 on the 6–20 Borg scale) 1 k-TWT. Time to walk 1-km, mean and maximal heart rates during the walk, age, height, and weight were entered into the equations for VO2 peak estimation. Based on the VO2peak, the sample was subdivided into tertiles and mortality risks were calculated during a median follow up of 9.4 years. The local Ethics Committee approved the study protocol, and all patients gave written informed consent. Survival decreased in a graded fashion from the highest VO2peak tertile to the lowest tertile (p< 0.0001, Figure 1). During the follow-up period, 23, 11, and 3 all-cause deaths occurred among the lowest, intermediate, and highest VO2peak tertile respectively. Mortality rate was independent from traditional cardiovascular risk factors, including LVEF and clinical history. Compared with the lowest tertile (mean walking speed 2.8 km/h), the full-adjusted mortality risk decreased for the second (mean walking speed 3.8 km/h), and third tertile (mean walking speed 4.6 km/h), with hazard ratios of 0.64 (95% confidence interval (CI): 0.33–1.20, p1⁄4 0.18), and 0.26 (95% CI: 0.08–0.80, p1⁄4 0.02), respectively (p for trend< 0.0001). These results are similar to those obtained by other studies in which VO2peak was determined by maximal cardiopulmonary exercise testing. Consistent with previous studies, we observed a 24.5% reduction in all cause mortality associated with each 1-Metabolic equivalent (MET) increment in VO2peak (p1⁄4 0.04). In conclusion, our findings show that VO2peak estimated from a simple moderate 1 k-TWT predicts

A quadricuspid aortic valve in an asymptomatic 40-year-old man: a case report

BackgroundIntegrated transthoracic and transesophageal echocardiography enables identification and characterization of a quadricuspid aortic valve anomaly.Case presentationA totally asymptomatic 40-year-old white man was referred to our Division of Cardiology after accidental finding of a heart murmur. Transesophageal echocardiography detected a quadricuspid aortic valve characterized by four cusps of equal size and severe aortic valvular regurgitation, without any further anomalies. He underwent a successful aortic valve repair.ConclusionsQuadricuspid aortic valve anomaly is a rare congenital cardiac defect that can cause progressive valvular complications.

Impact of pacemaker longevity on expected device replacement rates: Results from computer simulations based on a multicenter registry (ESSENTIAL)

The rate of device replacement in pacemaker recipients has not been investigated in detail.

[Focal acute myocarditis mimicking ST-elevation myocardial infarction: a case report and literature review].

Myocarditis is associated with a broad spectrum of clinical and electrocardiographic manifestations, ranging from completely asymptomatic courses to signs of myocardial infarction or cardiogenic shock. Endomyocardial biopsy is considered the gold standard for the diagnosis of myocarditis; however, in clinical practice, cardiovascular magnetic resonance (CMR) plays a leading role, being the most accurate noninvasive method for tissue characterization. We report the case of a 22-year-old patient hospitalized for acute precordial pain associated with ST-segment elevation in leads DI and aVL, mimicking acute myocardial infarction, in whom CMR led to the correct diagnosis of acute focal myocarditis.