Francesco Solimene

Circulating microRNA changes in heart failure patients treated with cardiac resynchronization therapy: responders vs. non-responders

MicroRNAs (miRNAs) play an important role in the pathogenesis of structural alterations of the failing heart through their ability to regulate negatively the expression levels of genes that govern the process of adaptive and maladaptive cardiac remodelling. We studied whether LV reverse remodelling after CRT was associated with changes of circulating miRNAs in patients with heart failure (HF) and dyssynchrony.

Noninvasive assessment of left ventricular contractility by pacemaker stress echocardiography

Estimating contractility of the left ventricle with noninvasive techniques is an important yet elusive goal. Positive inotropic interventions are mirrored by smaller end‐systolic volumes and higher end‐systolic pressures. An increased heart rate progressively increases the force of ventricular contraction (Bowditch treppe or staircase phenomenon).

Catheter-tissue contact force for pulmonary veins isolation: a pilot multicentre study on effect on procedure and fluoroscopy time.

Aims Catheter–tissue contact is critical for effective lesion creation in radiofrequency catheter ablation (RFCA). In a multicentre prospective study, we assessed the effect of direct contact force (CF) measurement on acute procedural parameters during RFCA of atrial fibrillation (AF). Methods and results A new open-irrigated tip catheter with CF sensing (SmartTouch™, Biosense Webster Inc.) was used. All the patients underwent the first ablation procedure for paroxysmal AF with antral pulmonary vein (PV) isolation, aiming at entry and exit conduction block in all PVs. Ninety-five patients were enroled in nine centres and successfully underwent ablation. Overall procedure time, fluoroscopy time, and ablation time were 138.0 ± 67.0, 14.3 ± 11.2, and 33.8 ± 19.4 min, respectively. The mean CF value during ablation was 12.2 ± 3.9 g. Force time integral (FTI) analysis showed that patients achieving a value below the median of 543.0gs required longer procedural (158.0 ± 74.0 vs. 117.0 ± 52.0 min, P = 0.004) and fluoroscopy (17.5 ± 13.0 vs. 11.0 ± 7.7 min, P = 0.007) times as compared with those in whom FTI was above this value. Patients in whom the mean CF during ablation was >20 g required shorter procedural time (92.0 ± 23.0 vs. 160.0 ± 67.0 min, P = 0.01) as compared with patients in whom this value was <10 g. Four groin haematomas were the only complications observed. Conclusion Contact force during RFCA for PV isolation affects procedural parameters, in particular procedural and fluoroscopy times, without increasing complications.

A randomized study of cardiac resynchronization therapy defibrillator versus dual-chamber implantable cardioverter-defibrillator in ischemic cardiomyopathy with narrow QRS: the NARROW-CRT study.

Background —Current recommendations require a QRS duration of ≥120ms as a condition for prescribing cardiac resynchronization therapy (CRT). This study was designed to test the hypothesis that patients with heart failure (HF) of ischemic origin, current indications for defibrillator implantation and QRS <120ms may benefit from CRT in the presence of marked mechanical dyssynchrony. Methods and Results —Patients with intraventricular dyssynchrony on echocardiography were randomly assigned to CRT or dual-chamber defibrillator implantation (CRT-D and D-ICD arm, respectively). The primary endpoint was the HF clinical composite response, which scores patients as improved, unchanged, or worsened. The secondary endpoint was the cumulative survival from HF hospitalization and HF death. An additional secondary endpoint was the composite of HF hospitalization, HF death and spontaneous ventricular fibrillation. Twenty-three of 56 CRT-D patients showed an improvement in their clinical composite response at 1 year, compared with 9 of 55 D-ICD patients (41% versus 16%, p=0.004). After a median follow-up of 16 months, the CRT-D arm showed a non-significant higher survival from HF hospitalization and HF death (p=0.077), and a significantly higher survival from the combined endpoint of HF hospitalization, HF death and spontaneous ventricular fibrillation (p=0.028). Conclusions —In this comparison of CRT-D and D-ICD, CRT improved clinical status in some patients with ischemic cardiomyopathy, mild-to-moderate symptoms, narrow QRS duration, and mechanical dyssynchrony on echocardiography. Clinical Trial Registration —URL: http://clinicaltrials.gov; Identifier: [NCT01577446][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01577446&atom=%2Fcircae%2Fearly%2F2013%2F04%2F16%2FCIRCEP.113.000135.atomBackground—Current recommendations require a QRS duration of ≥120 ms as a condition for prescribing cardiac resynchronization therapy (CRT). This study was designed to test the hypothesis that patients with heart failure (HF) of ischemic origin, current indications for defibrillator implantation, and QRS <120 ms may benefit from CRT in the presence of marked mechanical dyssynchrony. Methods and Results—Patients with intraventricular dyssynchrony on echocardiography were randomly assigned to CRT or dual-chamber defibrillator implantation (CRT defibrillator and dual-chamber implantable cardioverter-defibrillator arm, respectively). The primary end point was the HF clinical composite response, which scores patients as improved, unchanged, or worsened. The secondary end point was the cumulative survival from HF hospitalization and HF death. An additional secondary end point was the composite of HF hospitalization, HF death, and spontaneous ventricular fibrillation. Twenty-three of 56 patients with CRT defibrillator showed an improvement in their clinical composite response at 1 year, compared with 9 of 55 patients with dual-chamber implantable cardioverter-defibrillator (41% versus 16%; P=0.004). After a median follow-up of 16 months, the CRT defibrillator arm showed a nonsignificant higher survival from HF hospitalization and HF death (P=0.077), and a significantly higher survival from the combined end point of HF hospitalization, HF death, and spontaneous ventricular fibrillation (P=0.028). Conclusions—In this comparison of CRT defibrillator and dual-chamber implantable cardioverter-defibrillator, CRT improved clinical status in some patients with ischemic cardiomyopathy, mild-to-moderate symptoms, narrow QRS duration, and mechanical dyssynchrony on echocardiography. Clinical Trial Registration—URL: http://clinicaltrials.gov. Unique identifier: NCT01577446.

Cardiac resynchronization therapy-defibrillator improves long-term survival compared with cardiac resynchronization therapy-pacemaker in patients with a class IA indication for cardiac resynchronization therapy: data from the Contak Italian Registry

AIMS In candidates for cardiac resynchronization therapy (CRT), the choice between pacemaker (CRT-P) and defibrillator (CRT-D) implantation is still debated. We compared the long-term prognosis of patients who received CRT-D or CRT-P according to class IA recommendations of the European Society of Cardiology (ESC) and who were enrolled in a multicentre prospective registry. METHODS AND RESULTS A total of 620 heart failure patients underwent successful implantation of a CRT device and were enrolled in the Contak Italian Registry. This analysis included 266 patients who received a CRT-D and 108 who received a CRT-P according to class IA ESC indications. Their survival status was verified after a median follow-up of 55 months. During follow-up, 73 CRT-D and 44 CRT-P patients died (rate 6.6 vs. 10.4%/year; log-rank test, P = 0.020). Patients receiving CRT-P were predominantly older, female, had no history of life-threatening ventricular arrhythmias, and more frequently presented non-ischaemic aetiology of heart failure, longer QRS durations, and worse renal function. However, the only independent predictor of death from any cause was the use of CRT-P (hazard ratio, 1.97; 95% confidence interval, 1.21-3.16; P = 0.007). CONCLUSION The implantation of CRT-D, rather than CRT-P, may be preferable in patients presenting with current class IA ESC indications for CRT. Indeed, CRT-D resulted in greater long-term survival and was independently associated with a better prognosis.

Long-Term Performance of Coronary Sinus Leads Used for Cardiac Resynchronization Therapy

Background: Little is known regarding the long‐term performance of coronary sinus (CS) leads, which have an effect on the longevity of cardiac resynchronization therapy (CRT) systems.

Role of rate control and regularization through pacing in patients with chronic atrial fibrillation and preserved ventricular function : The VRR study

Aim: High heart rates in chronic atrial fibrillation (CAF) is one of the factors responsible for hemodynamic alterations and may lead to tachycardiomyopathies. The ventricular rate regulation (VRR) study evaluates the effect of ventricular rate regularization in CAF patients with preserved ventricular function, marked ventricular rate variability, and indications for pacemaker (PM) implantation owing to symptomatic pauses. Rate regularization was achieved using VRR algorithm (INSIGNIA® pacemakers, Guidant Corp., St. Paul, MN, USA).

The Italian subcutaneous implantable cardioverter-defibrillator survey: S-ICD, why not?

Abstract Aims A recommendation for a subcutaneous-implantable cardioverter-defibrillator (S-ICD) has been added to recent European Society of Cardiology Guidelines. However, the S-ICD is not ideally suitable for patients who need pacing. The aim of this survey was to analyse the current practice of ICD implantation and to evaluate the actual suitability of S-ICD. Methods and results The survey ‘S-ICD Why Not?’ was an independent initiative taken by the Italian Heart Rhythm Society (AIAC). Clinical characteristics, selection criteria, and factors guiding the choice of ICD type were collected in consecutive patients who underwent ICD implantation in 33 Italian centres from September to December 2015. A cardiac resynchronization therapy (CRT) device was implanted in 39% (369 of 947) of patients undergoing de novo ICD implantation. An S-ICD was implanted in 12% of patients with no CRT indication (62 of 510 with available data). S-ICD patients were younger than patients who received transvenous ICD, more often had channelopathies, and more frequently received their device for secondary prevention of sudden death. More frequently, the clinical reason for preferring a transvenous ICD over an S-ICD was the need for pacing (45%) or for antitachycardia pacing (36%). Nonetheless, only 7% of patients fulfilled conditions for recommending permanent pacing, and 4% of patients had a history of monomorphic ventricular tachycardia that might have been treatable with antitachycardia pacing. Conclusion The vast majority of patients needing ICD therapy are suitable candidates for S-ICD implantation. Nevertheless, it currently seems to be preferentially adopted for secondary prevention of sudden death in young patients with channelopathies.

Safety and efficacy of pulmonary vein isolation using a surround flow catheter with contact force measurement capabilities: A multicenter registry

Pulmonary vein (PV) isolation is the cornerstone of catheter ablation in patients with atrial fibrillation (AF). Surround flow and contact force (CF) measurement capabilities might enhance procedure efficacy and safety. We report on the safety and midterm efficacy of a novel ablation catheter for PV isolation in patients with AF.

Transesophageal echocardiograpy in patients with persistent atrial fibrillation undergoing electrical cardioversion on new oral anticoagulants: A multi center registry☆

Increased risk of thrombo-embolism following cardioversion foratrial fibrillation (AF) is well recognized. Therefore, anticoagulation isconsidered mandatory before elective cardioversion for AF of N48 h orAF of unknown duration. Vitamin K antagonists (VKAs) (INR 2.0 to3.0) are recommended for at least 3 weeks prior to and 4 weeks aftercardioversion, regardless of the CHA2DS2-VASc score and the method(electrical or pharmacological) used to restore sinus rhythm [1,2].Therisk of thromboembolic events is high (up to 7%) if anticoagulation isinadequate, and is reduced to less than 1% if adequate anticoagulationis achieved [3]. Recently, new oral anticoagulants (NOACs) have beenintroduced intheclinical practiceandsuggestedalso inpatientsunder-going electrical cardioversion for AF. In this context compliance andadherence to treatment are crucial, as these drugs have a relativelyshort half-life. In fact patients missing more than one drug assumptioncannotbeconsideredunderanadequatetherapeuticregimen.Moreover,differently from VKA treatment, that can be followed through INRmeasurements,there are no effective hemoreological tests to assessther-apeutic anticoagulation. One way to assess the ef ficacy of anticoagulationtherapy is the direct search for left atrial thrombus by means oftransesophageal echocardiography (TEE). The aim of our study was toevaluate the incidence of left atrial (LA) thrombus in patients referredfor electrical cardioversion, while on treatment with NOACs, using apre-procedural TEE.Between January 2014 and December 2014 we collected the TEEdata of 219 consecutive patients with persistent AF referred to sevenItalian centers for elective electrical cardioversion, while on NOACs forat least 3 weeks before electrical cardioversion. This study followedtheprinciplesoutlinedinthelatestupdateoftheDeclarationofHelsinkiand all patients signed informed consent. This study was approved byour Institutional Review Boards. Main exclusion criteria were a historyof thromboembolic events, a history of LA thrombus diagnosed byTEE, a TEE procedure performed in the 21 days before starting NOACtherapy, and the need for anticoagulation other than AF. TEE wasperformed with a 5–7-MHz multiplane transducer connected to anultrasoundsystem.Multiplestandardtomographicplaneswereimaged.TheLAappendagepeakflowvelocity,presenceofthrombiintheLA,andseverityofspontaneousechocontrastintheLAweredetermined.Atrialcavityorappendagethrombiwereconsideredtobepresentwhenwell-circumscribed, echodense, intracavitary masses that were acousticallydistinct from the underlying endocardium and pectinate muscles wereidentified.The clinical characteristics of the study population are summarizedin Table 1. The mean duration of AF was 6.2 ± 4.3 months, and themean duration of NOAC therapy was 4.1 ± 3 months. NOACs usedwere dabigatran (86 patients, 39%), rivaroxaban (61 patients, 28%),and apixaban (73 patients, 33%). The daily dabigratan dose was220mgin21patients,and300mgin65patients;thedailyrivaroxabandose was 15 mg in 2 patients, and 20 mg in 59 patients; the dailyapixaban dose was 5 mg in 1 patient, and 10 mg in 72 patients. The