Gabriele Borelli

Percutaneous Mitral Annuloplasty: An Anatomic Study of Human Coronary Sinus and Its Relation With Mitral Valve Annulus and Coronary Arteries

Background— To allow performance of “stand-alone” mitral annuloplasty with minimal invasiveness, percutaneous techniques consisting of delivery into the coronary sinus (CS) of devices intended to shrink the mitral valve annulus have recently been tested in animal models. These techniques exploit the anatomic proximity of the CS and mitral valve annulus in ovine or dogs. Knowledge of a detailed anatomic relationship between the CS, coronary arteries, and mitral valve annulus in humans is essential to define the safety and efficacy of percutaneous techniques in clinical practice. We sought to determine the qualitative and quantitative anatomic relationships between CS and surrounding structures in human hearts. Methods and Results— The distance from the CS to the mitral valve annulus and the relationship between the CS and surrounding structures were studied in 61 excised cadaveric human hearts. Maximal distance from the CS to the mitral valve annulus was found to be up to 19 mm (mean, 9.7±3.2 mm). A diagonal or ramus branch, main circumflex artery, or its branches were located between anterior interventricular vein/CS and the mitral valve annulus in 16.4% and 63.9% of cases, respectively. Conclusions— Surgical anatomy suggests that in humans the CS is located behind the left atrial wall at a significant distance from the mitral valve annulus. Percutaneous mitral annuloplasty devices probably shrink the mitral valve annulus only by an indirect traction mediated by the left atrial wall; a theoretical risk of compressing coronary artery branches exists. Chronic studies are needed to address this problem and to determine long-term efficacy of such methods.

Effectiveness of the transradial approach to reduce bleedings in patients undergoing urgent coronary angioplasty with GPIIb/IIIa inhibitors for acute coronary syndromes†

Objectives: To analyze the effectiveness of the transradial approach in reducing bleeding rates following urgent percutaneous coronary intervention (PCI) in patients with acute coronary syndromes treated with glycoprotein IIb/IIIa inhibitors (GPIs). Background: PCI and use of GPIs are recommended in acute coronary syndromes, but are strong predictors of severe hemorrhagic complications, which, in turn, are associated with reduced survival. The transradial approach represents a simple and effective solution to reduce vascular access site bleedings, particularly with GPIs. Methods: All consecutive patients undergoing urgent transradial PCI under GPI treatment were enrolled in the registry. No patients were excluded. In addition, we performed a case‐matched comparison of the transradial versus transfemoral approach using propensity analysis to adjust for known risk factors for bleeding. The primary end point was the rate of bleedings, graded according to the Thrombolysis in Myocardial Infarction (TIMI) classification. Results: Five hundred thirty‐one consecutive patients were prospectively enrolled in the registry. TIMI major, minor, and minimal bleedings were 0.2%, 1.7%, and 6.4%, respectively. Transfusion rate was 0.8%. After propensity‐matched analysis, the transradial approach was associated with significantly lower rates of all types of bleedings, while the transfemoral approach was the strongest predictor of TIMI major/minor bleedings (odds ratio 6.67; 95% confidence interval 1.72–25; P = 0.006). Conclusions: The transradial approach dramatically reduces access site bleedings, including TIMI major and minor bleedings, and transfusion rate, while preserving procedural success and clinical outcome. The transradial approach is an attractive solution to reduce bleeding complications in patients treated with GPIs.

Impact of early abciximab administration on infarct size in patients with ST-elevation myocardial infarction

BACKGROUND Early abciximab administration in patients requiring transportation to undergo primary percutaneous coronary intervention (PPCI) has been reported to improve clinical outcome. We aimed to verify whether early administration leads to reduced infarct size (IS), assessed by delayed-enhancement magnetic resonance imaging (DE-MRI). METHODS We randomized 110 patients with acute myocardial infarction with symptom-to-diagnosis time <6h to either early (55 patients) or late (55 patients) abciximab administration. DE-MRI was performed at 4 days and 6 months. The primary end point was IS at 6 months. Secondary end points were the rate of ST-segment elevation resolution ≥ 50% (STR) at 60 min after PPCI, the extent of microvascular obstruction at 4 days, and the change in IS and transmurality at 6 months vs. 4 days. RESULTS DE-MRI was performed in 103 patients after 4 days, and in 87 at 6 months. The mean IS at 6 months was 13.8 ± 9.0% in the early vs. 13.0 ± 9.9% in the Late group (P>0.2). Similarly, microvascular obstruction and the change in IS were not significantly different. The Early group showed a significantly higher STR (94.5% vs. 80.0%, P=0.04) and a larger reduction in infarct transmurality (-9.2 ± 7.0% vs. -5.9 ± 6.4%; P=0.03), while a larger reduction in IS was observed only in patients with ECG-to-Cath Lab time >60 min. CONCLUSIONS Early abciximab administration did not lead to a smaller IS at 6-month DE-MRI, and was associated with a significant reduction in IS and transmurality only in patients with longer transportation time, warranting further investigation in this patient subset.

Weight loss and quality of life in chronic heart failure patients

Objectives To evaluate the impact of a planned body weight reduction on quality of life (QoL) in obese/overweight chronic heart failure (CHF) patients. Methods Thirty-four obese/overweight chronic heart failure patients (24 men, mean age 67.8 ± 9.4 years) underwent a 6-month dietary programme. An assessment of clinical and biochemical parameters was executed before and after dietary programme. The QoL was judged by means of the Kansas City Cardiomyopathy Questionnaire (KCCQ) at baseline and at the end of the programme. Results End-study BMI (P < 0.005) and body weight (P < 0.04) values were significantly reduced. We observed a significant improvement in the mean New York Heart Association (NYHA) functional class value (P < 0.02) and in the left ventricle ejection fraction (LVEF) (P < 0.05). The end-study KCCQ scores were significantly increased in seven out of eight domains. We identified a cut-off value of body weight loss of 3 kg to separate responder patients from the nonresponder ones. Only responder group patients showed a significant variation in BMI (P < 0.04), body weight (P < 0.03), mean NYHA class value (P < 0.05), LVEF (P < 0.05). Moreover, all KCCQ domain scores significantly increased in the responder group only. Conclusion A diet-based body weight reduction improved the quality of life and, perhaps, the cardiac function. Benefits are already evident with a small reduction in body weight.

Role of intraoperative electrical parameters in predicting reverse remodelling after cardiac resynchronization therapy and correlation with interventricular mechanical dyssynchrony

AIMS Cardiac resynchronization therapy (CRT) was shown to reverse left ventricular (LV) remodelling in heart failure (HF) patients. We aimed to investigate whether intraoperative electrical parameters (IEP) were predictive factors of LV reverse remodelling and were correlated with mechanical dyssynchrony indexes. METHODS Eighty-six patients with HF underwent CRT. At implant, several electrical and echocardiographic parameters were evaluated and, at 6 months, responders were defined by a relative increase in LV ejection fraction ≥25% compared with baseline. RESULTS Several IEPs were shown to predict LV reverse remodelling. Receiver operating curve analysis revealed the ratio between QRS duration during biventricular pacing (BVp) and right ventricular pacing (RVp) [QRS(BVp)/QRS(RVp)] as the best predictor of LV functional recovery after CRT (AUC = 0.72; 95% confidence limit 0.57-0.82; P < 0.001). Responders showed a lower value of QRS(BVp)/QRS(RVp) when compared with non-responders (0.74 ± 0.05 vs. 0.8 ± 0.1; P < 0.005) and 0.78 was the value associated with the best predictive accuracy. The interval between the onset of RV lead and LV lead electrograms (RVegm-LVegm) during baseline rhythm correlated directly with the interventricular mechanical delay (IVMD) (r = 0.68; P < 0.0001) and with its reduction (delta IVMD) at follow-up (r = 0.66; P < 0.0005). CONCLUSION Intraoperative electrical parameters can predict LV functional recovery after CRT and they are correlated with interventricular mechanical resynchronization at follow-up.

Survival and hospitalization in a nurse-led domiciliary intervention for elderly heart failure patients

Aim Heart failure in the elderly population represents a complex clinical situation associated with frequent hospitalizations and numerous comorbidities. The present study aimed to evaluate the impact of a domiciliary-based nurse-led strategy in a group of very elderly patients affected by heart failure who were regularly seen at an outpatient heart failure clinic (HFC). Methods Patients were periodically assessed in their homes by two trained nurses under supervision of the cardiologists of the HFC. During each visit, the nurses examined clinical status and adherence to medication. When necessary, they also gathered venous blood samples for laboratory analysis and recorded an electrocardiogram. In addition, they provided key information regarding disease management to patients as well as to their care givers. During the baseline visit and, subsequently, every 6 months, an echocardiogram was performed at the HFC. Results Forty-four patients (52.4% male, median age 82 years) were followed up for a mean of 25 ± 12 months. Compared to an equally long time period before randomization, during follow-up, a significant reduction in cardiac hospitalizations (from 1.83 ± 1.54 to 1.07 ± 1.39, P = 0.004), total hospitalizations (from 2.09 ± 1.71 to 1.52 ± 1.68, P = 0.003), HFC visits (from 3.31 ± 2.33 to 2.24 ± 1.38, P = 0.03) and New York Heart Association (NYHA) class (from 2.74 ± 0.70 to 2.49 ± 0.61, P = 0.04) was observed. Total 1-year mortality was 25% and was predicted by several clinical (weight loss, NYHA class), laboratory (hyperuricaemia, anaemia, renal failure, hyposodiemia) and echocardiographic (end-systolic diameter, ejection fraction, systolic pulmonary artery pressure) parameters. Multivariate analysis revealed that hyperuricaemia was as an independent predictor of mortality (odds ratio = 1.53, P = 0.038). Conclusions The present study demonstrates that a domiciliary-based strategy in elderly patients affected by heart failure guarantees clinical stability and reduces hospitalizations as well as outpatient visits.

Aldosterone receptor antagonism and heart failure: insights from an outpatient clinic

Objective:  In randomized clinical trials, aldosterone antagonists have been shown to reduce mortality and morbidity in heart failure (HF). The aim of the present study was to examine the risk‐benefit profile of aldosterone antagonists in routine clinical practice.

070 Cardiac resynchronization therapy and left ventricular remodeling in patients with coronary artery disease and dilated cardiomyopathy

We evaluated left ventricular remodeling (LVR) in patients (pts) with heart failure (HF) of the 2 main aetiologies, coronary artery disease (CAD) and dilated cardiomyopathy (DCM) after 1 year (y) of cardiac resynchronization therapy (CRT). We enrolled 65 HF outpts with CRT indication (mean age 67.5±13.2 ys 74.6% males, M): 33 had CAD-caused HF (70.2±6.7 ys, 84.4% M) and 32 DCM (64.6±17.3 ys, 64.5% M). All underwent ECG, echocardiography, NYHA evaluation before and after 1 y of CRT. Before CRT, NYHA was similar (CAD 2.7±0.7, DCM 2.7±0.8) and after 1 y it significantly (p

076 Long term effects of cardiac resynchronization therapy in chronic heart failure patients

Cardiac resynchronization therapy (CRT) is an effective treatment of advanced heart failure (HF). Recent studies showed a positive effect of CRT on HF symptoms, left ventricular ejection function (EF,%), reduction of hospitalizations and survival. However, most studies evaluated clinical and echocardiographic response to CRT after a limited follow-up (ranging from 6 to 12 months). Thus we evaluated clinical and functional response to CRT in HF patients (pts) after a longer follow-up period (up to 3 years, ys). We enrolled 75 HF outpts with CRT indication [30% females, mean age 67.9±12.6 ys, mean NYHA class 2.8±0.7, mean EF 25.7±8.1, HF aetiology: 44% coronary artery disease (CAD), 43% dilated cardiomyopathy (DCM), 6% hypertensive cardiomyopathy (HT), 7% valvular disease (V)]. All were evaluated by means of ECG, echocardiography, NYHA functional class before CRT device implant and re-evaluated after 1 (95% of pts), 2 (80% of pts), and 3 (45% of pts) ys. After 1 y, NYHA significantly improved (from 2.8±0.7 to 2.3±0.6, p

084 - Additive role of beta blockade in determining positive response to cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) and beta blockers (BB) are effective in advanced heart failure (HF). Often, due to side effects, BB are not used or dose not increased. We evaluated the titration of BB therapy with carvedilol (Carv) in CRT Responders (R) and Not Responders (NR), recruiting 65 HF outpatients (pts) with CRT indication and on optimal treatment [70% males; age 67.9±12.6 years, ys; NYHA 2.7±0.7; aetiology 44% coronary artery disease (CAD), 43% dilated cardiomyopathy (DCM)]. All underwent ECG, echocardiography, NYHA evaluation before and after 1 y of CRT. Considering NYHA response and improvement of systolic left ventricular function (EF,%), R (ΔNYHA> 1 and/or ΔEF> 5%) and NR were defined. During follow-up, Carv was titrated. Basally R and NR were similar for age, sex, HF aetiology (R 40% CAD, 42.5% DCM; NR 48% CAD, 40% DCM), QRS duration (168±32 vs 178±29 msec), end-diastolic (EDV, ml), end-systolic (ESV) volume, EF (R 25.1±7.9 NR 27.4±8.2), BB treatment (85 vs 88%) and Carv dose (16.3±18.6 vs 13.2±10.3 mg/day). Only basal NYHA (R 2.9±0.7 NR 2.4±0.6, p=0.002) was significantly different. There was no significant difference in QRS duration postCRT (R 123±32, NR 127±36 msec). After 1 y, R showed greater variation of EDV and ESV (ΔEDV -45±46 vs -2±56 p=0.01; ΔESV -46±46 vs -1±45 p=0.003) and mitral regurgitation entity (-0.5±0.7 vs 0±0.7 p=0.02). After 1 y there was an overall increase of pts on BB (92.5 vs 92%), but R achieved a greater Carv dose (25.1±20.4 vs 14.5±7.3 mg/day p=0.002, Δdose 8.7±11 vs 1.2±10.7 p=0.009). Carv dose increase and EF improvement were correlated (r=0.40, p=0.02), while dose increase and ventricular remodeling (LVR) were negatively related (ΔEDV r=0.42 p=0.02; ΔESV r=0.45 p=0.01). In both groups CRT allows to introduce and augment BB dose, but only in R dose increase is statistically significant, correlating with LVR regression. Such results suggest an addictive role of BB titration in determining CRT positive response.