Stefan Bogdan

Clinical Outcomes in Patients with Severe Renal Dysfunction Including Dialysis Following Defibrillator Implantation.

Background: Renal dysfunction is associated with increased mortality in heart failure (HF) patients. However, there are limited data regarding clinical and arrhythmic outcomes associated with implantable cardioverter defibrillator (ICD) therapy in this population. Methods: We evaluated outcomes associated with the severity of renal dysfunction with or without dialysis among 2,289 patients who were enrolled and prospectively followed up in the Israeli ICD Registry. The primary endpoint of the study was all-cause mortality. Secondary endpoints included cardiac mortality, HF hospitalization, non-cardiac hospitalization, and appropriate and inappropriate ICD therapy. Results: Severe renal dysfunction patients (estimated glomerular filtration rate <30 ml/min/1.73 m2; n = 144 patients; 6%) were older, with higher comorbidities prevalence, and more likely to suffer from advanced HF. Among severe renal dysfunction patients, those on dialysis had a lower prevalence of wide QRS and complete left bundle branch morphology, resulting in lower cardiac resynchronization therapy defibrillator (CRTD) implantation rates. Dialysis was associated with an overall increased risk for all-cause mortality (hazard ratio (HR) 3.22; 95% CI 1.69-6.13; p < 0.01) and for noncardiac hospitalizations (HR 2.80; p < 0.001) compared to all other study patients. However, within the subgroup of patients with severe renal dysfunction, the presence of dialysis was not an independent risk factor for all-cause mortality (HR 0.99; p = 0.97) as compared to non-dialysis. The rate of appropriate ICD therapy for ventricular tachyarrhythmias increased with declining renal function, with the highest rate observed among those undergoing dialysis. Conclusions: The present findings suggest that dialysis does not significantly modify the adverse outcomes associated with severe renal dysfunction following ICD/CRTD implantation.

Physiological pacing: a moving target?

This editorial refers to ‘Long-term clinical effects of ventricular pacing reduction with a changeover mode to minimize ventricular pacing in a general pacemaker population’, by M. Stockburger et al. , on page doi:10.1093/eurheartj/ehu336 During the 1990s and the early years of the 2000s, there was considerable debate on the advantages of ‘physiological’ pacing, which at that time denoted dual-chamber vs. single-chamber pacing. A series of landmark studies, including the MOST, PASE, CTOPP, and UKPACE trials, randomized patients with various indications for pacing into DDD vs. VVI pacing modes. Despite high hopes and great belief in the advantages of ‘physiological’ pacing, these studies demonstrated only a modest advantage of the ‘physiological’ approach, expressed by a reduction of atrial fibrillation (AF), mostly limited to patients with sinus node disease (SND) indication for pacing.1 While DDD pacing modes demonstrated only modest effect, the atrial-only (AAI) mode performed much better than VVI in patients with SND in a Danish trial.2 With increased understanding of the deleterious effect of ventricular pacing (mainly apical), the results of the Danish trial as well as those of the later DAVID and DAVID II trials3 were interpreted as demonstrating that the physiological advantage of atrial-based pacing is partially offset by unnecessary RV pacing, an …

Unfractionated heparin or low-molecular-weight heparin in the elderly.

With the ageing of the general population, clinicians are facing with increased frequency the challenge of administering parenteral anti-coagulation therapy in the elderly, the main indications being venous thromboembolism (VTE), acute coronary syndromes (ACS), atrial fibrillation and bridging therapy. Assessing the risk/benefit ratio is always difficult in this category of patients, because of the higher risk for hemorrhagic events, although in most cases the benefit outweighs the risk, especially in the setting of VTE. The development of early invasive strategies for treating ACS has improved outcomes, while reducing the need for prolonged anticoagulation. For ST-segment elevation acute myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) is the mainstay treatment with well documented benefits in terms of mortality reduction regardless of the patients age. However, evidence is less strong regarding early invasive treatment for over 75-year old Non-STEMI patients, resulting in a significant percentage being treated conservatively, including parenteral anticoagulation. This review will focus on the use of parenteral anticoagulation (unfractionated or low-molecular weight heparin) in older patients. We will analyze current guidelines-based parenteral anticoagulation indications, while focusing on specific considerations in the elderly, such as: frailty and comorbidities, pharmacokinetics, the hemorrhagic risk and available clinical evidence. The goal is to offer a comprehensive tool for the clinician managing parenteral anticoagulation in older patients.

Arrhythmias in Right Heart Disease

Right heart disease can be associated with increased risk for arrhythmias, both ventricular and supraventricular. Right sided arrhythmias may occur in the setting of structural disease predominantly affecting the right heart—such as cardiomyopathies (arrhythmogenic right ventricular dysplasia, cardiac sarcoidosis) and congenital heart disease (corrected tetralogy of Fallot, Ebstein’s anomaly, atrial septal defect), as well as in the absence of structural heart disease, with substrate (Mahaim fibers, Coumel type tachycardia) or without substrate (idiopathic right ventricular outflow tract ventricular tachycardia). The most common cause for right heart failure is secondary pulmonary hypertension due to left heart diseases, a setting in which the underlying left heart condition will be the main determiner for prognosis and risk of arrhythmia. Still, right heart failure secondary to pulmonary arterial hypertension is also associated with increased risk for arrhythmic events. Advanced cardiac imaging, especially cardiac MRI, as well as invasive procedures (right/left heart catherization; electrophysiological study; endomyocardial biopsy) play an important role in the differential diagnosis. Modern treatment relies on interventional techniques (implantable cardioverter defibrillator; radiofrequency ablation).

Lead extraction by selective operation of a nanosecond-pulsed 355nm laser

Lead extraction (LE) is necessary for patients who are suffering from a related infection, or in opening venous occlusions that prevent the insertion of additional lead. In severe cases of fibrous encapsulation of the lead within a vein, laser-based cardiac LE has become one of the foremost methods of removal. In cases where the laser radiation (typically at 308 nm wavelength) interacts with the vein wall rather than with the fibrotic lesion, severe injury and subsequent bleeding may occur. Selective tissue ablation was previously demonstrated by a laser operating in the UV regime; however, it requires the use of sensitizers (e.g.: tetracycline). In this study, we present a preliminary examination of efficacy and safety aspects in the use of a nanosecond-pulsed solid-state laser radiation, at 355 nm wavelength, guided in a catheter consisting of optical fibers, in LE. Specifically, we demonstrate a correlation between the tissue elasticity and the catheter advancement rate, in ex-vivo experiments. Our results indicate a selectivity property for specific parameters of the laser radiation and catheter design. The selectivity is attributed to differences in the mechanical properties of the fibrotic tissue and a normal vein wall, leading to a different photomechanical response of the tissue’s extracellular matrix. Furthermore, we performed successful in-vivo animal trials, providing a basic proof of concept for using the suggested scheme in LE. Selective operation using a 355 nm laser may reduce the risk of blood vessel perforation as well as the incidence of major adverse events.

Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (CRT) targets dyssynchrony correction in heart failure patients with reduced left ventricular systolic function and electrical disease. In the following chapter we will analyze the pathophysiology of dyssynchrony and dyssynchrony assessment, the extent of clinical evidence in cardiac resynchronization therapy and current CRT guidelines, the issue of non-response to CRT, how to improve patient selection and CRT delivery.

The REPLACE Death After Replacement Evaluation Score for Predicting Mortality After Device Replacement or Upgrade: Should All Implantable Devices Be Replaced?

The use of cardiovascular implantable electronic devices (CIED) has made remarkable progress during the past 20 years. Overall, devices, leads, and delivery systems have evolved resulting in easier implantation, improved long-term reliability and better battery life span. Article see p 1048 Implantable cardioverter defibrillators (ICD), initially reserved for highly selected patients, where the benefit of secondary prevention outweighed potential side effects, are now a safe and widespread therapy that has become part of the standard care in patients with heart failure and severe systolic dysfunction. Present-day guidelines1,2 take into account all evidence from multiple large randomized trials (the Multicenter Automatic Defibrillator Implantation Trials [MADIT I, MADIT II], the Multicenter Unsustained Tachycardia Trial [MUSTT], and the Sudden Cardiac Death in Heart Failure Trial [SCD-HeFT]) that favor their use for the primary prevention of sudden cardiac death in patients with heart failure, which is currently the main indicator for ICD in developed countries.3,4 Cardiac resynchronization therapy (CRT) has been shown to improve clinical status, left ventricular performance, and to reduce mortality in patients with heart failure and systolic dysfunction and wide QRS. After the initial studies that focused on patients with clinically severe heart failure (New York Heart Association class III or IV), the MADIT-CRT trial, the Resynchronization–Defibrillation for Ambulatory Heart Failure Trial (RAFT), and the Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction trial (REVERSE) clearly proved that CRT’s beneficial effects also extend to those less severe patients (baseline New York Heart Association class II), which led to the recent update of CRT guidelines.1 All the evidence resulted in a dramatic increase of the number of complex device implantations in developed countries.5,6 Since its creation in 2006, the NCDR ICD Registry has recently reported having accrued a …

192 Right ventricular septal pacing – success rate and influence to LV electrical activation

Purpose Right ventricular (RV) apex pacing is associated with LV dyssynchrony. Alternate RV pacing sites (mid RV septum; the RV outflow tract (RVOT)) were considered, with no clear benefit. The aim of this study is to find a reliable method of septal lead placement ant to identify those pacing sites which provide a better LV electrical activation. Methods 50 consecutive patients reffered for pacemaker implants due to AV block were included. Patients with history of heart failure or LVEF Results 92%(46) of the patients had the RV lead in septal position (32 in mid RV and 14 in RVOT) while 8% (4 pts) had the RV lead on the RVOT free wall as shown by echo. An anteriorly oriented lead in the left anterior oblique fluoroscopic projection was specific for free wall position while a positive QRS in DI in RVOT position was suggestive for free wall position on the ECG. No correlation was made between paced QRS axis and LV dyssinchron. A QRS duration of>160 ms was associated with significant LV dyssinchrony (SPWMD>130 ms and septal to lateral t>70 ms). Conclusions RV lead placement on the RV septum can be reliably achieved using a specialy shaped stilet and LAO projection for confirmation. A wide paced QRS is correlated with significant intra LV dyssinchrony and therefore the pacing site with the narrowest QRS should be sought.