G. Mascioli

Valutazione economica della resincronizzazione cardiaca nei pazienti affetti da scompenso cardiaco moderato-avanzato

SummaryObjectivePatients with severe heart failure, refractory to drug treatment, can be indicated for biventricular pacing, shown to be useful in overcoming the desynchronization of the ventricular contraction pattern, which generally worsens the hemodynamic conditions of such patients.This study was aimed at assessing 1) clinical effectiveness of conventional therapy compared with biventricular pacemaker; 2) hospital ward’s budget before and after device implantation.MethodsThe study was carried out according to an observational method, on 30 patients, retrospectively 1-year before implantation and prospectively 1-year afterwards. The economic analysis was designed and carried out in the hospital perspective. End-points were: Ejection fraction, New York Heart Association (NYHA) class, no. of hospitalizations in Cardiology Ward and ICU (Intensive Care Unit), Days of hospitalization in Cardiology Ward and ICU, no. of clinic visits (outpatients), no. of day-hospital visits, no. of days free from acute events requiring hospitalization or clinic visits, health care costs.ResultsIn the 12 months following biventricular pacing, patients showed: a reduction in functional NYHA class (3.0 ± 0.3 vs 2.1 ± 0.3); a reduction in cardiovascular related hospital stays (from 42.0 ± 37.5 days to 2.8 ± 6.4); an increase in number of days free from acute events (from 104 ± 123 to 266 ± 137). Overall costs decreased from € 383,518 to € 289,890 (with implant costs) and to € 58,549 (without implant costs). In-hospital stays in Cardiology and Coronary Unit decreased by 93% and 95%, respectively.ConclusionsBiventricular pacing in heart failure patients represents an efficient approach in the hospital perspective and allows a less intensive use of clinical resources. Even if other non-hospital-sustained costs are not taken into consideration, it seems reasonable to deduce that the significant improvement in patient’s clinical condition after implantation will provide a considerable reduction of total costs also in a broader perspective.

QT dispersion on ECG Holter monitoring and risk of ventricular arrhythmias in patients with dilated cardiomyopathy

Background. QT dispersion (QTd) is increased in patients with dilated cardiomyopathy. Increased QTd has been associated with the risk of sudden death. We studied: a) the relation between QTd on 12-lead ECG and QTd-ECG Holter; b) the relation between QTd apex (QTda) and QTd end (QTde) on ECG Holter and the risk of ventricular arrhythmias in patients with dilated cardiomyopathy. Methods and Results: 65 patients with dilated cardiomyopathy (33 idiopathic and 32 post-ischemic etiology; NYHA II–III) were studied. We divided the patients into: Group A -patients with not-sustained ventricular arrhythmias-; and Group B -patients without arrhythmias-. A significant direct correlation between QTd calculated from 12-lead ECG and from ECG Holter was found in all patients. QTda/24h was not significantly different in the two groups (Gr.A 59.9±7.8 msec vs Gr.B 53.6±8.4 msec p=ns) while QTde/24h was significantly higher in Group A (Gr.A 81.9±5.9 msec vs Gr.B 44.5±6.8 msec; p<0.005). In post-ischemic etiology (32 pts; 17 with arrhythmias) the correlation between QTde/24h and ventricular arrhythmias was confirmed (Gr.A 81.4±7.8 msec vs Gr.B 42.6±6.2 msec p<0.002). Conclusions: ECG Holter recordings can evaluate QTd as well as the QTd on 12-lead ECG. An increased QTde/24h seems to be correlated with the occurence of ventricular arrhythmias in patients with dilated cardiomyopathy and can then be a useful tool to select patients at high risk for sudden death.

Right Ventricular Pacing: Is It Really That Bad?

As discussed above, the more frequently the RV apex is paced, the more likely cardiac performance will be compromised. This explains why, although maintenance of AV synchrony afforded by conventional DDDR is intuitively superior to VVIR, this has been surprisingly difficult to prove. Large randomised clinical trials have reached a consensus that there is no survival benefit in patients conventionally DDDR paced; furthermore, DDDR pacing may be associated with an increased risk of death among ICD patients.

Atrial flutter: from ECG to electroanatomical 3D mapping.

Atrial flutter is a common arrhythmia that may cause significant symptoms, including palpitations, dyspnea, chest pain and even syncope. Frequently it’s possible to diagnose atrial flutter with a 12-lead surface ECG, looking for distinctive waves in leads II, III, aVF, aVL, V1,V2. Puech and Waldo developed the first classification of atrial flutter in the 1970s. These authors divided the arrhythmia into type I and type II. Therefore, in 2001 the European Society of Cardiology and the North American Society of Pacing and Electrophysiology developed a new classification of atrial flutter, based not only on the ECG, but also on the electrophysiological mechanism. New developments in endocardial mapping, including the electroanatomical 3D mapping system, have greatly expanded our understanding of the mechanism of arrhythmias. More recently, Scheinman et al, provided an updated classification and nomenclature. The terms like common, uncommon, typical, reverse typical or atypical flutter are abandoned because they may generate confusion. The authors worked out a new terminology, which differentiates atrial flutter only on the basis of electrophysiological mechanism.

Efficacy of early and late defibrillation after cardiac arrest : the experience of Brescia Early Defibrillation Study

A 35-year-old man attended the Emergency Room with his first episode of central chest pain. The pain began 8 h prior to presentation and the 12-lead ECG showed ST-segment elevation of >1 mm in leads II, III, and aVF ( Figure , lower panel). He was treated with thrombolysis and transferred to the Coronary Care Unit. Troponin I was 60.9 pg/mL (normal <0.2 pg/mL), and creatinine kinase and MB fraction were 2888 and 235 IU, …

Cost-Effectiveness of Cardiac Resynchronisation Therapy in Heart Failure Patients

The rapidly growing incidence of heart failure (HF) is going to have an extremely large impact on costs for the management of decompensated patients. It has been calculated [1] that within the next 20 years, the prevalence of HF in Western countries will double, rising from 5.3 millions of persons suffering from this syndrome to 10.6 millions. Data furnished by the Italian Ministry of Health for the year 2000 showed that DRG 127 (cardiac failure and shock) already account for 13.5% of the total number of hospital admissions, with a mean of 9.6 hospital days: this means that – in Italy – 2.5% of the total number of hospital stays are due to HF [2]. If we consider that the course of HF is worse than that of lung cancer [3] in terms of frequent hospital re-admissions, and that hospitalisation represents the major component of the total expenditure on management of HF, it is easy to see that the economics of caring for these patients is set to grow exponentially. What is cost-effectiveness? When a new therapy is introduced into treatment, four things can happen – The new therapy is more effective than previous treatment, but at a major cost, or – It is less effective and more expensive, or – It is less effective but also less expensive, or, finally (and this is what we call cost-effective) – It is more effective and less expensive Many trials have now demonstrated that CRT is an effective tool for treating patients with episodes of acute HF refractory to optimised medical therapy. The results derived from PATH-CHF, MUSTIC, MIRACLE, and COMPANION [4–7] are all concordant and demonstrate not only that CRT can

21. Cardiac Resynchronization Therapy: Implanting & Clinical Aspects

Cardiac resynchronization therapy (CRT) has been proven to significantly reduce all – cause mortality in patients affected with severe congestive heart failure refractory to optimized medical therapy. Although proved efficacy, some concerns remain regarding skillness required to correctly perform the implant and prolonged fluoro time (FT) necessary to complete leads positioning. In our centre, to date, 251 patients (181 male, mean age 69 ± 9 yrs), implanted with a biventricular device (131 PM, 120 ICD) since October 1998, are strictly followed – up. We evaluated FT necessary to complete CRT implant in our patients, analyzing if different lead design, over – the – wire (OTW, exclusively Guidant leads) or combined (OTW+S: Medtronic 4193 and 4194 models and St. Jude 1056K leads), could affect FT or if this parameters was more influenced by operator experience. FT was available for 142 patients, in whom OTW leads were used in 69 pts and OTW + S leads were used in 73 pts. Furthermore, mean FT was evaluated for every physician who performs CRT implant in our Lab. Mean FT in the whole population was 16 ± 7 minutes and FT was not affected by the kind of LV lead used. In fact, mean FT in the OTW group was 16 ±7 minutes and in the OTW+S group was 15 ± 6 minutes (p NS). Instead, FT seems to be strictly related to operator experience. In fact, the greater the number of devices implanted, the shorter the FT. Operator 1 performed 79 implants, with a mean FT of 13 ± 7 minutes; operator 2 performed 41 implants with a mean FT of 15 ± 6 minutes and operator 3 performed 22 implant with a mean FT of 21 ± 6 minutes. Therefore, both operator 1 and 2 have FT that are significantly lower than operator 3 FT (respectively, 1 vs 3 p = 0.01 and 2 vs 3 p < 0.001), and there are no statistically significant differences between operator 1 and 2 FT. In conclusion, reduction of FT during CRT implant it is a matter of operator experience more than of lead technology.

21. Cardiac Resynchronization Therapy: Implanting & Clinical Aspects21.3 Importance of Operator Experience in Reducing Fluoro-Time During Biventricular Device Implantation

Cardiac resynchronization therapy (CRT) has been proven to significantly reduce all – cause mortality in patients affected with severe congestive heart failure refractory to optimized medical therapy. Although proved efficacy, some concerns remain regarding skillness required to correctly perform the implant and prolonged fluoro time (FT) necessary to complete leads positioning. In our centre, to date, 251 patients (181 male, mean age 69 ± 9 yrs), implanted with a biventricular device (131 PM, 120 ICD) since October 1998, are strictly followed – up. We evaluated FT necessary to complete CRT implant in our patients, analyzing if different lead design, over – the – wire (OTW, exclusively Guidant leads) or combined (OTW+S: Medtronic 4193 and 4194 models and St. Jude 1056K leads), could affect FT or if this parameters was more influenced by operator experience. FT was available for 142 patients, in whom OTW leads were used in 69 pts and OTW + S leads were used in 73 pts. Furthermore, mean FT was evaluated for every physician who performs CRT implant in our Lab. Mean FT in the whole population was 16 ± 7 minutes and FT was not affected by the kind of LV lead used. In fact, mean FT in the OTW group was 16 ±7 minutes and in the OTW+S group was 15 ± 6 minutes (p NS). Instead, FT seems to be strictly related to operator experience. In fact, the greater the number of devices implanted, the shorter the FT. Operator 1 performed 79 implants, with a mean FT of 13 ± 7 minutes; operator 2 performed 41 implants with a mean FT of 15 ± 6 minutes and operator 3 performed 22 implant with a mean FT of 21 ± 6 minutes. Therefore, both operator 1 and 2 have FT that are significantly lower than operator 3 FT (respectively, 1 vs 3 p = 0.01 and 2 vs 3 p < 0.001), and there are no statistically significant differences between operator 1 and 2 FT. In conclusion, reduction of FT during CRT implant it is a matter of operator experience more than of lead technology.

Importance of Operator Experience in Reducing Fluoro-Time During Biventricular Device Implantation

Cardiac resynchronization therapy (CRT) has been proven to significantly reduce all – cause mortality in patients affected with severe congestive heart failure refractory to optimized medical therapy. Although proved efficacy, some concerns remain regarding skillness required to correctly perform the implant and prolonged fluoro time (FT) necessary to complete leads positioning. In our centre, to date, 251 patients (181 male, mean age 69 ± 9 yrs), implanted with a biventricular device (131 PM, 120 ICD) since October 1998, are strictly followed – up. We evaluated FT necessary to complete CRT implant in our patients, analyzing if different lead design, over – the – wire (OTW, exclusively Guidant leads) or combined (OTW+S: Medtronic 4193 and 4194 models and St. Jude 1056K leads), could affect FT or if this parameters was more influenced by operator experience. FT was available for 142 patients, in whom OTW leads were used in 69 pts and OTW + S leads were used in 73 pts. Furthermore, mean FT was evaluated for every physician who performs CRT implant in our Lab. Mean FT in the whole population was 16 ± 7 minutes and FT was not affected by the kind of LV lead used. In fact, mean FT in the OTW group was 16 ±7 minutes and in the OTW+S group was 15 ± 6 minutes (p NS). Instead, FT seems to be strictly related to operator experience. In fact, the greater the number of devices implanted, the shorter the FT. Operator 1 performed 79 implants, with a mean FT of 13 ± 7 minutes; operator 2 performed 41 implants with a mean FT of 15 ± 6 minutes and operator 3 performed 22 implant with a mean FT of 21 ± 6 minutes. Therefore, both operator 1 and 2 have FT that are significantly lower than operator 3 FT (respectively, 1 vs 3 p = 0.01 and 2 vs 3 p < 0.001), and there are no statistically significant differences between operator 1 and 2 FT. In conclusion, reduction of FT during CRT implant it is a matter of operator experience more than of lead technology.

Biventricular Cardiac Resynchronization in Moderate-to-Severe Heart Failure: Analysis of Hospital Costs and Clinical Effectiveness (Brescia Study)

Heart failure is a chronic condition of complex physiopathologic origin which involves escalating clinical costs [1-3]. Cardiac resynchronization therapy is a novel treatment for the one in every six heart failure patients whose condition is refractory to optimized drug treatment, with evidence of ventricular dysynchrony which leads to a deterioration of hemodynamics and a higher risk of death [4-7]. In such hearts the regions which activate in advance will experience or receive a lower afterload, and the rapid presystolic contraction does not convert into a rise in pressure, because the other parts of the myocardium are still inactive. As a consequence, most myocardial activity is wasted in transferring the ejection from one part of the heart to another. This results in a lengthening of the ventricular pre-ejection period, a reduction of the contraction and the relaxation period, a reduction of the ejection fraction, and a rise in mitral regurgitation.