Roberto Rordorf

Long term vagal stimulation in patients with advanced heart failure: first experience in man.

Experimentally, vagal stimulation (VS) is protective in chronic heart failure (HF). In man, VS is used in refractory epilepsy but has never been used in cardiovascular diseases. Increased sympathetic and reduced vagal activity predict increased mortality in HF.

Not all Beta-Blockers are Equal in the Management of Long QT Syndrome Types 1 and 2: Higher Recurrence of Events under Metoprolol

OBJECTIVES The purpose of this study was to compare the efficacy of beta-blockers in congenital long QT syndrome (LQTS). BACKGROUND Beta-blockers are the mainstay in managing LQTS. Studies comparing the efficacy of commonly used beta-blockers are lacking, and clinicians generally assume they are equally effective. METHODS Electrocardiographic and clinical parameters of 382 LQT1/LQT2 patients initiated on propranolol (n = 134), metoprolol (n = 147), and nadolol (n = 101) were analyzed, excluding patients <1 year of age at beta-blocker initiation. Symptoms before therapy and the first breakthrough cardiac events (BCEs) were documented. RESULTS Patients (56% female, 27% symptomatic, heart rate 76 ± 16 beats/min, QTc 472 ± 46 ms) were started on beta-blocker therapy at a median age of 14 years (interquartile range: 8 to 32 years). The QTc shortening with propranolol was significantly greater than with other beta-blockers in the total cohort and in the subset with QTc >480 ms. None of the asymptomatic patients had BCEs. Among symptomatic patients (n = 101), 15 had BCEs (all syncopes). The QTc shortening was significantly less pronounced among patients with BCEs. There was a greater risk of BCEs for symptomatic patients initiated on metoprolol compared to users of the other 2 beta-blockers combined, after adjustment for genotype (odds ratio: 3.95, 95% confidence interval: 1.2 to 13.1, p = 0.025). Kaplan-Meier analysis showed a significantly lower event-free survival for symptomatic patients receiving metoprolol compared to propranolol/nadolol. CONCLUSIONS Propranolol has a significantly better QTc shortening effect compared to metoprolol and nadolol, especially in patients with prolonged QTc. Propranolol and nadolol are equally effective, whereas symptomatic patients started on metoprolol are at a significantly higher risk for BCEs. Metoprolol should not be used for symptomatic LQT1 and LQT2 patients.

Failure of implantable cardioverter-defibrillator leads: A matter of lead size?

BACKGROUND Small-diameter implantable cardioverter-defibrillator (ICD) Sprint Fidelis and Riata leads have been recalled owing to an increased risk of lead failure, thus arousing the suspicion that lead size might be a critical issue. OBJECTIVE To compare the incidence of failure of small-diameter (≤8 F) and standard-diameter (>8 F) ICD leads implanted in a single center. METHODS From January 2003 to December 2010, 190 Sprint Fidelis, 182 Riata/Riata ST, 99 Optim (Riata Optim/Durata), and 419 standard-diameter leads were implanted in our center. RESULTS During a median follow-up of 33 months, the overall failure rate was 6.3%. Follow-up duration was similar for Sprint Fidelis, Riata, and standard-diameter leads but shorter for the Optim group. The failure rate was significantly higher in Sprint Fidelis leads than in both standard-diameter (4.8%/year vs 0.8%/year; P<.001) and Riata/Riata ST (4.8%/year vs 2.6%/year; P = .03) leads. The incidence of lead failure in Riata/Riata ST leads proved significantly higher than in standard-diameter leads (2.6%/year vs 0.8%/year; P = .001). No cases of lead failure were recorded in the Optim group. On multivariable analyses, small-diameter (hazard ratio [HR] 5.03, 2.53-10.01, P<.001), Sprint Fidelis (HR 6.3, 3.1-13.3, P<.001), or Riata/Riata ST (HR 4.5, 1.9-10.5, P = .001) leads and age<60 years (HR 2.3, 1.3-4.3, P = .005) were found to independently increase the risk of lead failure. CONCLUSIONS Compared with standard-diameter leads, both Sprint Fidelis and Riata/Riata ST small-diameter ICD leads are at an increased risk of failure, although the incidence of events is significantly lower in the Riata than in the Sprint Fidelis group.

Heart rate variability monitored by the implanted device predicts response to CRT and long-term clinical outcome in patients with advanced heart failure

Few data exist on the long‐term changes and the prognostic value of heart rate variability (HRV) assessed by implanted devices in heart failure (HF) patients treated with resynchronization therapy (CRT).

Positive trend in survival to hospital discharge after out-of-hospital cardiac arrest: a quantitative review of the literature

Background Seven editions of cardiopulmonary resuscitation (CPR) and emergency cardiovascular care guidelines have been published with many changes, in particular, about CPR. Objectives The aim of our study was to evaluate the temporal trend of survival to hospital discharge after out-of-hospital cardiac arrest (OHCA) as a possible effect of guidelines changes. Methods We searched PubMed for observational studies on ‘survival to hospital discharge after OHCA’. Survival to discharge was the primary outcome; prehospital return of spontaneous circulation and survival to hospital admission were our secondary endpoints. All data were analyzed according to the year of inclusion: group 1 before 2000; group 2 between 2000 and 2005; and group 3 after 2005. Mortality rates were compared between groups by means of a group frequency-weighted log-linear model. Results We considered 38 of 201 studies for a total of 156 301 patients. Survival to hospital discharge rate was 5.0% [95% confidence interval (CI) 4.9–5.2) in group 1; 6.1% (95% CI 5.9–6.4) in group 2; and 9.1% (95% CI 8.9–9.4) in group 3 (P < 0.001). A statistically significant decrease in risk of mortality in group 2 vs. group 1 (risk ratio 0.988, 95% CI 0. 985–0.0.992, P < 0.001) and in group 3 vs. group 2 (risk ratio 0.967, 95% CI 0.964–0.971, P < 0.001) was observed. Similar trends were observed for return of spontaneous circulation and survival to hospital admission. Conclusion Survival to hospital discharge after OHCA has significantly improved. Many aspects may influence survival, but surely, the reduction of time and an early and good quality CPR have positively influenced the outcome.

A comprehensive electrocardiographic, molecular, and echocardiographic study of Brugada syndrome: Validation of the 2013 diagnostic criteria

BACKGROUND The debate on the diagnostic value of high intercostal spaces (ICSs) and of the number of diagnostic leads in Brugada syndrome (BrS) has been settled by a recent expert consensus statement. OBJECTIVE To test the validity, and the underlying anatomy, of the new electrocardiographic (ECG) diagnostic criteria using echocardiographic, molecular, and clinical evidence in 1 clinical study population with BrS. METHODS We analyzed 114 patients with BrS and with a spontaneous or drug-induced type 1 ECG pattern recorded in 1 or more right precordial leads in fourth, third, and second ICSs. The right ventricular outflow tract (RVOT) was localized by using echocardiography. All probands were screened on the SCN5A gene. RESULTS The percentage of mutation carriers (MCs) and the event rate were similar regardless of the diagnostic ICS (fourth vs high ICSs: MCs 23% vs 19%; event rate 22% vs 28%) and the number of diagnostic leads (1 vs ≥2: MCs 20% vs 22%; event rate 22% vs 27%). The concordance between RVOT anatomical location and the diagnostic ICSs was 86%. The percentage of the diagnostic ECG pattern recorded was significantly increased by the exploration of the ICSs showing RVOT by echocardiography (echocardiography-guided approach vs conventional approach 100% vs 43%; P < .001). CONCLUSION The high ICSs are not inferior to the standard fourth ICS for the ECG diagnosis of BrS, and the interindividual variability depends on the anatomical location of the RVOT as assessed by using echocardiography. This approach significantly increases diagnostic sensitivity without decreasing specificity and fully supports the recently published new diagnostic criteria.

Left Ventricular Pacing Lead Positioning in the Target Vein of the Coronary Sinus: Description of a Challenging Case

The optimal left ventricular pacing location for cardiac resynchronization therapy should be individualized according to the site of maximal mechanical delay. However, the presence of vein stenosis or kinking in coronary sinus (CS) anatomy could hamper lead implantation in the target vessel. We describe the case of a patient with dilated cardiomyopathy and a dual‐chamber pacemaker referred for upgrading to a biventricular device owing to New York Heart Association III heart failure symptoms. Tissue Doppler analysis before implantation showed that the area of maximum activation delay was located in the posterolateral region of the left ventricle. Insertion of the lead into a posterolateral vein of the CS by means of the standard over‐the‐wire approach was unsuccessful due to the presence of a stenosis at the ostium of the vein. Lead placement in an anterior vein of the CS was unsatisfactory owing to a poor local delay from QRS onset. After balloon vein angioplasty, the pacing lead passed through the stenotic tract at the ostium of the target vein and was successfully positioned in the posterolateral region. Three months after pacemaker implantation, echocardiography showed an important reduction in the indexes of both inter‐ and intraventricular asynchrony and a significant left ventricular reverse remodeling

Pharmacological therapy following catheter ablation of atrial fibrillation.

Catheter ablation has been proven to be an effective treatment for patients with drug-resistant atrial fibrillation. Nevertheless its efficacy is limited to 60–80% of patients in different studies. Whether the use of pharmacological therapy after catheter ablation of atrial fibrillation might increase the procedural success rate is still a matter of debate. There is general agreement that antiarrhythmic drugs (AADs) are useful in the management of arrhythmias occurring in the very early period after catheter ablation (blanking period). On the contrary, limited data are available on the efficacy of AADs over a longer period. Some patients remain free of arrhythmia recurrences by the use of AADs that were ineffective before catheter ablation: whether this latter situation is to be considered a partial success of catheter ablation or a treatment failure, thus demanding a redo procedure, is still an open question. Some studies have also investigated the role of non-AADs [angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, statins and corticosteroids] in preventing atrial fibrillation recurrences after catheter ablation, reporting conflicting results. Whereas there is a general consensus on the use of anticoagulation therapy in the first phase after catheter ablation, no definite data are available on the proper long-term management of anticoagulation therapy after catheter ablation. This review focuses on the still open issue of what is the optimal pharmacological treatment of patients after catheter ablation of atrial fibrillation.

Women with nonischemic cardiomyopathy have a favorable prognosis and a better left ventricular remodeling than men after cardiac resynchronization therapy

Aims Cardiac resynchronization therapy (CRT) is a well established therapy in heart failure patients who are on optimal medical therapy and have reduced left ventricular ejection fraction (LVEF) and wide QRS complexes. Although women and patients with nonischemic cardiomyopathy are under-represented in CRT trials and registries, there is evidence that these two groups of patients can benefit more from CRT. The aim of our analysis was to investigate the impact of female sex on mortality in a population that included a high percentage of patients (61%) with nonischemic cardiomyopathy. Methods We analyzed data on 507 consecutive patients (20% women) who received CRT at two Italian Heart Transplant centers and were followed up for a maximum of 48 months. Results After multivariate adjustment, women showed a trend toward better survival with regard to all-cause mortality [hazard ratio (HR) 0.32, confidence interval (CI) 0.10–1.04; P = 0.059]. However, this benefit was limited to nonischemic patients with regard to all-cause mortality (HR 0.20, CI 0.05–0.87, P = 0.032) and cardiovascular mortality (HR 0.14, CI 0.02–1.05, P = 0.056). Conclusion Female CRT recipients, at mid-term, have a favorable prognosis than male patients and this benefit appears to be more evident in nonischemic patients. Thus, we strongly believe that the apparent under-utilization of CRT in females is an anomaly that should be corrected.

Atrioventricular junction ablation in patients with atrial fibrillation treated with cardiac resynchronization therapy: positive impact on ventricular arrhythmias, implantable cardioverter-defibrillator therapies and hospitalizations: Atrioventricular junction ablation in CRT patients with AF

We sought to determine whether atrioventricular junction ablation (AVJA) in patients with cardiac resynchronization therapy (CRT) implantable cardioverter‐defibrillator (ICD) and with permanent atrial fibrillation (AF) has a positive impact on ICD shocks and hospitalizations compared with rate‐slowing drugs.