Marianne Bootsma

QRS duration and shortening to predict clinical response to cardiac resynchronization therapy in patients with end-stage heart failure

Despite current selection criteria (NYHA Class III–IV, LVEF < 35%, QRS > 120 ms with LBBB), 30% of patients do not benefit from cardiac resynchronization therapy (CRT). The use of QRS duration as selection criteria for CRT has not been evaluated systematically yet. Accordingly, the value of QRS duration at baseline (and reduction in QRS duration after CRT) to predict responders was studied. Patients were evaluated at baseline and after 6 months of CRT for NYHA Class, quality of life score, and 6‐minute walk test. QRS duration was evaluated before, directly after implantation, and after 6 months of CRT. Sixty‐one patients were included; 45 (74%) patients were classified as responders (improvement of NYHA Class, 6‐minute walking distance and quality of life score) and 16 (26%) as nonresponders. QRS duration at baseline was similar between the two groups: 179 ± 30 ms versus 171 ± 32 ms, NS. Directly after implantation, QRS duration was reduced from 179 ± 30 ms to 150 ± 26 ms (P < 0.01) in responders; nonresponders did not exhibit this reduction (171 ± 32 ms vs 160 ± 26 ms, NS). After 6 months of CRT, QRS shortening was only observed in responders (from 179 ± 30 ms to 159 ± 25 ms, P < 0.01). ROC curve analysis showed that a reduction in QRS duration > 10 ms had a high sensitivity (73%) with low specificity (44%); conversely, a > 50 ms reduction in QRS duration was highly specific (88%) but not sensitive (18%) to predict response to CRT. No optimal cutoff value could be defined. QRS duration at baseline is not predictive for response to CRT; responders exhibit a significant reduction in QRS duration after CRT, but individual response varies highly, not allowing adequate selection of responders. (PACE 2004; 27:308–313)

Risk factors and time delay associated with cardiac device infections: Leiden device registry

Aims: A nested case-control study of 75 patients with cardiac device infections (CDI) and 75 matched controls was conducted to evaluate time course, risk factors, culture results and frequency of CDI. Methods and results: CDI occurred in 75/3410 (2.2%) device implantation and revision procedures, performed between 2000 and 2007. The time delay between device procedure and infection ranged from 0 to 64 months (mean 14 (SD 16)), 21 patients (28%) had an early infection (<1 month), 26 (35%) a late infection (1–12 months) and 28 (37%) a delayed infection (>12 months). Of interest, 18 (24%) patients presented with an infection >24 months after the device-related procedure. Time delay until infection was significantly shorter when cultures were positive for micro-organisms compared to negative cultures (8 (12) vs 18 (18) months, p = 0.03). Pocket cultures in delayed infections remained more often negative (61% vs 23%, p = 0.01). Independent CDI risk factors were: device revision (odds ratio (OR) 3.67; 95% confidence interval (CI), 1.51 to 8.96), renal dysfunction defined as glomerular filtration rate <60 ml/min (OR 4.64; CI, 1.48 to 14.62) and oral anticoagulation use (OR 2.83; CI 1.20 to 6.68). Conclusion: CDI occurred in 2.2% of device procedures, with 24% occurring more than two years after the device-related procedure. Renal dysfunction, device revisions and oral anticoagulation are potent risk factors for CDI.

Sirolimus-eluting stents versus bare-metal stents in patients with ST-segment elevation myocardial infarction: 9-month angiographic and intravascular ultrasound results and 12-month clinical outcome results from the MISSION! Intervention Study.

OBJECTIVES Our purpose was to evaluate the efficacy and safety of drug-eluting stents in the setting of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI). BACKGROUND There is inconsistent and limited evidence about the efficacy and safety of drug-eluting stents in STEMI patients. METHODS A single-blind, single-center, randomized study was performed to compare bare-metal stents (BMS) with sirolimus-eluting stents (SES) in 310 STEMI patients. The primary end point was in-segment late luminal loss (LLL) at 9 months. Secondary end points included late stent malapposition (LSM) at 9 months as determined by intravascular ultrasound imaging and clinical events at 12 months. RESULTS In-segment LLL was 0.68 +/- 0.57 mm in the BMS group and 0.12 +/- 0.43 mm in the SES group with a mean difference of 0.56 mm, 95% confidence interval 0.43 to 0.68 mm (p < 0.001). Late stent malapposition at 9 months was present in 12.5% BMS patients and in 37.5% SES patients (p < 0.001). Event-free survival at 12 months was 73.6% in BMS patients and 86.0% in SES patients (p = 0.01). The target-vessel-failure-free survival was 84.7% in the BMS group and 93.0% in the SES group (p = 0.02), mainly because of a higher target lesion revascularization rate in BMS patients (11.3% vs. 3.2%; p = 0.006). Rates of death, myocardial infarction, and stent thrombosis were not different. CONCLUSIONS Sirolimus-eluting stent implantation in STEMI patients is associated with a favorable midterm clinical and angiographic outcome compared with treatment with BMS. However, LSM raises concern about the long-term safety of SES in STEMI patients.

Three-dimensional catheter positioning during radiofrequency ablation in patients: first application of a real-time position management system.

Three‐Dimensional Reai‐Time Position Management. Introduction: Precise localization of target sites for radiofrequency catheter ablation (RFCA) of arrhythmias is hampered by the relative inaccuracy of X‐ray localization procedures. This study evaluated the efficacy of a three‐dimensional (3D) real‐time position management system in guiding RFCA procedures in patients.

Long‐Term Follow‐Up After Radiofrequency Catheter Ablation of Ventricular Tachycardia: A Successful Approach?

RF Catheter Ablation of VT. Introduction: Radiofrequency ablation (RFCA) of ventricular tachycardia (VT) is a potential curative treatment modality. We evaluated the results of RFCA in patients with VT.

Impact of percutaneous coronary intervention or coronary artery bypass grafting on outcome after nonfatal cardiac arrest outside the hospital.

Survivors of cardiac arrest due to ventricular arrhythmias are at risk for recurrent events. The role of revascularization in secondary prevention for survivors of cardiac arrest has been addressed in various studies with conflicting results. A total of 142 survivors of cardiac arrest with coronary artery disease were evaluated according to a standardized protocol, including 2-dimensional echocardiography, myocardial perfusion scintigraphy, coronary angiography, and electrophysiologic testing. Revascularization of scintigraphically documented ischemic myocardial regions was performed in 44 patients (31%). Final therapy was based on the results of electrophysiologic testing. Four-year survival rates were 100% for revascularized noninducible patients, 84% for revascularized inducible patients, 91% for nonrevascularized noninducible patients, and 72% for nonrevascularized inducible patients. Only 1 patient (<1% of study population) died suddenly. Recurrences were much more frequent in patients without revascularization (38% vs 7%, p <0.001) and the recurrence rate was 0% in the revascularized noninducible patients. Thus, revascularization of ischemically jeopardized myocardium in survivors of cardiac arrest resulted in excellent survival; moreover, in absence of inducible ventricular arrhythmias, the recurrence rate was 0%. Systematic evaluation of survivors of cardiac arrest due to ventricular arrhythmias allows risk stratification and guidance of subsequent antiarrhythmic therapy.

Effectiveness of resynchronization therapy in patients with end-stage heart failure

Biventricular pacing has been introduced to treat patients with end-stage heart failure, and short-term results of this technique are promising. Because data on longer follow-up are limited to 3-month follow-up, the sustained effect of biventricular pacing is unclear and long-term survival is unknown. Forty patients with end-stage heart failure in New York Heart Association (NYHA) functional class III or IV with left ventricular (LV) ejection fraction (EF) <35%, QRS duration >120 ms, and left bundle branch block morphology received a biventricular pacemaker. At baseline, and at 3 and 6 months after implantation, the following parameters were evaluated: NYHA class, Minnesota quality-of-life score, QRS duration on surface electrocardiogram, 6-minute walking distance, and LVEF. Long-term follow-up was obtained for up to 2 years. All clinical parameters improved significantly at 3 months and remained unchanged at 6-month follow-up. LVEF increased from 24 +/- 9% to 34 +/- 11%. Before implantation, patients were hospitalized (for congestive heart failure) an average of 3.9 +/- 5.3 days/year compared with 0.5 +/- 1.5 days/year after implantation. Long-term follow-up showed a survival of 87.5% at 2 years. Thus, biventricular pacing resulted in improvement of symptoms and quality of life, accompanied by improvement in 6-minute walking distance and LVEF. These effects were observed at 3 months after implantation and were maintained at 6-month follow-up. Moreover, 2-year survival was excellent.

Stent Malapposition After Sirolimus-Eluting and Bare-Metal Stent Implantation in Patients with ST-Segment Elevation Myocardial Infarction Acute and 9-Month Intravascular Ultrasound Results of the MISSION! Intervention Study

OBJECTIVES Acute and late stent malapposition (SM) after bare-metal stents (BMS) and sirolimus-eluting stents (SES) in ST-segment elevation myocardial infarction patients were studied. BACKGROUND Stent thrombosis may be caused by SM after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients. METHODS Post-procedure and follow-up intravascular ultrasound data were available in 184 out of 310 patients (60%; 104 SES, 80 BMS) included in the MISSION! Intervention Study. To determine the contribution of remodeling and changes in plaque burden to the change in lumen cross-sectional area (CSA) at SM sites, the change in lumen CSA (follow-up minus post-lumen CSA) was related to the change in external elastic membrane CSA (remodeling) and change in plaque and media CSA (plaque burden). RESULTS Acute SM was found in 38.5% SES patients and 33.8% BMS patients (p = 0.51), late SM in 37.5% SES patients and 12.5% BMS patients (p < 0.001). Acquired SM was found in 25.0% SES patients and 5.0% BMS patients (p < 0.001). Predictors of acute SM were reference diameter (SES: odds ratio [OR] 3.49, 95% confidence interval [CI] 1.29 to 9.43; BMS: OR 28.8, 95% CI 4.25 to 94.5) and balloon pressure (BMS: OR 0.74, 95% CI 0.58 to 0.94). Predictors of late SM were diabetes mellitus (SES: OR 0.16, 95% CI 0.02 to 1.35), reference diameter (BMS: OR 19.2, 95% CI 2.64 to 139.7), and maximum balloon pressure (BMS: OR 0.74, 95% CI 0.55 to 1.00). Change in lumen CSA was related to change in external elastic membrane CSA (R = 0.73, 95% CI 0.62 to 0.84) after SES implantation and to change in plaque and media CSA (R = -0.62, 95% CI -0.77 to -0.46) after BMS implantation. After SES implantation, acquired SM was caused by positive remodeling in 84% and plaque reduction in 16% of patients. CONCLUSIONS Acute SM was common after SES and BMS stent implantation in ST-segment elevation myocardial infarction patients. After SES implantation, late acquired SM is common and generally caused by positive remodeling.

Cardiac resynchronisation therapy in chronic atrial fibrillation: impact on left atrial size and reversal to sinus rhythm

Objective: To evaluate the impact of long term cardiac resynchronisation therapy (CRT) on left atrial and left ventricular (LV) reverse remodelling and reversal to sinus rhythm (SR) in patients with heart failure with atrial fibrillation (AF). Patients: 74 consecutive patients (age 68 (8) years; 67 men) with advanced heart failure and AF (20 persistent and 54 permanent) were implanted with a CRT device. Main outcome measures: Patients were evaluated clinically (New York Heart Association (NYHA) class, quality of life, six minute walk test) and echocardiographically (LV ejection fraction, LV diameters, and left atrial diameters) before and after six months of CRT. Additionally, restoration of SR was evaluated after six months of CRT. Results: NYHA class, quality of life score, six minute walk test, and LV ejection fraction had improved significantly after six months of CRT. In addition, left atrial and LV end diastolic and end systolic diameters had decreased from 59 (9) to 55 (9) mm, from 72 (10) to 67 (10) mm, and from 61 (11) to 56 (11) mm, respectively (all p < 0.01). During implantation 18 of 20 (90%) patients with persistent AF were cardioverted to SR. At follow up 13 of 18 (72%) patients had returned to AF and none had spontaneously reverted to SR; thus, only 5 of 74 (7%) were in SR. Conclusion: Six months of CRT resulted in significant clinical benefit with significant left atrial and LV reverse remodelling. Despite these beneficial effects, 93% of patients had not reverted to SR.

Arrhythmogenic Right Ventricular Dysplasia: MRI Findings

Arrhythmogenic right ventricular dysplasia (ARVD) is a heart muscle disorder of unknown cause that is characterized pathologically by fibrofatty replacement of the right ventricular myocardium. Clinical manifestations include structural and functional malformations of the right ventricle, electrocardiographic abnormalities, and presentation with ventricular tachycardias with left bundle branch pattern or sudden death. The disease is often familial with an autosomal inheritance. In addition to right ventricular dilatation, right ventricular aneurysms are typical deformities of ARVD and they are distributed in the so-called “triangle of dysplasia”, i. e., right ventricular outflow tract, apex, and infundibulum. Ventricular aneurysms at these sites can be considered pathognomonic of ARVD. Another typical hallmark of ARVD is fibrofatty infiltration of the right ventricular free wall. These functional and morphologic characteristics are relevant to clinical imaging investigations such as contrast angiography, echocardiography, radionuclide angiography, ultrafast computed tomography, and magnetic resonance imaging (MRI). Among these techniques, MRI allows the clearest visualization of the heart, in particular because the right ventricle is involved, which is usually more difficult to explore with the other imaging modalities. Furthermore, MRI offers the specific advantage of visualizing adipose infiltration as a bright signal of the right ventricular myocardium. MRI provides the most important anatomic, functional, and morphologic criteria for diagnosis of ARVD within one single study. As a result, MRI appears to be the optimal imaging technique for detecting and following patients with clinical suspicion of ARVD.ZusammenfassungDie arrhythogene rechtsventrikuläre Dysplasie (ARVD), eine Herzmuskelerkrankung unlarer Ätiologie, ist pathologisch durch fettige Degeneration des rechtsventrikulären Myokards gekennzeichnet. Die klinischen Symptome umfassen strukturelle und funktionelle Malformationen des rechten Ventrikels, krankhafte elektrokardiographische Befunde und das Auftreten ventrikulärer Tachykardien mit Linksschenkelblock oder plötzlichem Herztod. Die Krankheit tritt familiär gehäft auf und wird autosomal vererbt. Neben der rechtsventrikulären Dilatation stellen rechtsventrikuläre Aneurysmen typische Fehlbildungen bei ARVD dar. Sie sind im so genannten “Dysplasiedreieck”, das heißt rechtem ventrikulärem Ausflusstrakt, Herzspitze und Infundibulum, verteilt. Dort lokalisierte ventrikuläre Aneurysmen können als pathognomonisch für die ARVD angesehen werden. Ein weiteres typisches Merkmal der ARVD ist die fettige Degeneration der freien rechten Ventrikelwand. Diese funktionellen und strukturellen Charakteristika sind bei der klinischen Untersuchung mit bildgebenden Verfahren wie Kontrastangiographie, Echokardiographie, Radionuklidangiographie, ultraschneller Computertomographie und Magnetresonanztomographie (MRT) von Bedeutung. Unter diesen Verfahren erlaubt die MRT die deutlichste Darstellung des Herzens, insbesondere bei Beteiligung des rechten Ventrikels, der sich mit den anderen bildgebenden Methoden in der Regel schwerer untersuchen lässt. Darüber hinaus bietet die MRT den wesentlichen Vorteil der Darstellung der fettigen Degeneration als helles Signal im rechtsventrikulären Myokard. Die MRT liefert die wichtigsten anatomischen, funktionellen und morphologischen Kriterien zur Diagnose einer ARVD in einem einzigen Untersuchungsgang. Daher scheint sie das beste bildgebende Verfahren zur Identifizierung und Nachsorge von Patienten mit klinischem Verdacht auf ARVD zu sein.