Witold Streb

The Incremental Value of Right Ventricular Indices for Predicting Response to Cardiac Resynchronization Therapy

BACKGROUND Right ventricular (RV) dysfunction in chronic heart failure (HF) is associated with poor prognosis. Cardiac resynchronization therapy (CRT) is an established method of improving prognosis in HF. However, the majority of known indices predictive of response to CRT are based on left ventricular (LV) assessment. The authors hypothesized that baseline RV function and tissue Doppler-derived dyssynchrony may have incremental value over LV dyssynchrony measures for predicting CRT response. METHODS In this retrospective study, echocardiographic examinations were performed in 90 patients before pacemaker implantation and up to 18 months afterward. CRT results were evaluated using clinical criteria (death, hospitalization for decompensation, change in New York Heart Association class ≥1, and 10% decreases in both peak ventilatory oxygen uptake and 6-min walking distance) and reverse remodeling (>15% reduction in LV end-systolic volume). RESULTS Baseline RV dyssynchrony during isovolumic contraction of 26 msec facilitated the segregation of responders from nonresponders with 85% sensitivity and 100% specificity, as well as synchrony in peak deformation of 54 msec, with 89% sensitivity and 67% specificity. The minor axis of the RV inflow tract predicted reverse remodeling after CRT with sensitivity of 73% and specificity of 58% with a cutoff value of 35 mm. According to the clinical criteria, LV indices (end-diastolic and end-systolic volumes) and interventricular delay gave an overall R(2) value of 0.20 (86.2% correctly classified patients; area under the curve, 0.80). The addition of RV dyssynchrony parameters (measured in peak strain and isovolumic contraction peak velocities) significantly increased the power of the model (R(2) = 0.86; 100% of patients correctly classified; area under the curve, 1; P for change in R(2) < .0001). CONCLUSIONS The value of baseline RV function analysis is incremental to LV indices for the prediction of clinical response to CRT but not reverse remodeling. RV synchronous longitudinal deformation and RV dyssynchronous isovolumic velocity are independent predictors of clinical response to CRT.

Polish and European management strategies in patients with atrial fibrillation. Data from the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase (EORP-AF Pilot).

INTRODUCTION Despite continued efforts of the European Society of Cardiology (ESC) to unify management of patients with atrial fibrillation (AF) across Europe, interregional differences in guideline adherence are likely. OBJECTIVES The aim of the study was to compare treatment strategies depending on baseline characteristics of AF patients between Poland and other members of the European Union (EU). PATIENTS AND METHODS We analyzed the baseline data and treatment strategies in participants of the ESC registry: the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase. A total of 3119 consecutive patients with AF diagnosed within the last year were included in 67 centers from 9 countries, including 419 patients enrolled in 15 Polish centers. RESULTS A rhythm control strategy was more frequent in Poland than in other EU countries (20.8% vs 11.9%; P <0.0001). Catheter ablation for AF was also used more frequently in Polish cardiology wards (13.9% vs 8.3%; P = 0.0017), while amiodarone at discharge was used less frequently (12.0% vs 22.7%; P <0.0001). In-hospital use of vitamin K antagonists (VKAs) and non-VKA anticoagulants was less frequent in Polish patients with a CHA2DS2-VASc score of 2 or higher than in patients from other EU countries (61.1% vs 79.0%; P <0.0001), but overall anticoagulation rates at discharge were similar to those in other countries (83.3% vs 82.6%). CONCLUSIONS A rhythm control-oriented strategy in patients with AF with the use of ablation in cardiology wards is more frequent in Poland than in other EU countries. Similar to other EU countries, compliance with the ESC guidelines regarding anticoagulation in AF patients is suboptimal in Poland. Undertreatment was observed in a significant proportion of patients at high risk of stroke, while a large group of low-risk patients are overtreated. Differences between the types of recruiting centers in Poland and other EU countries might have influenced the results.

Therapeutic Window for Calcium-Channel Blockers in the Management of Dilated Cardiomyopathy: A Prospective, Two-Centre Study on Non-Advanced Disease

Objective: This study aimed to investigate the usefulness of the calcium-channel blocker verapamil in non-advanced dilated cardiomyopathy (DCM). Methods: This was a randomised trial of 70 DCM patients treated with carvedilol (36 patients) and verapamil (instead of β-blocker; 34 patients) for 12 months. The remaining heart failure (HF) therapy was constant in both groups. The primary outcomes were to determine selected echocardiography parameters and functional status of patients. The secondary outcome included death, heart transplantation and re-hospitalisation due to HF progression. Results: Of the primary outcomes, only the mean ratio of early to late transmitral flow velocities increased significantly in the verapamil-treated patients as compared with the carvedilol-based therapy (1.1 ± 0.3 vs. 0.7 ± 0.2; 95% CI –0.6 to –0.1; p = 0.015). Simultaneously, the Minnesota Quality of Life improved significantly in the verapamil group (95% CI 5.2–19.9; p = 0.002). It was accompanied by the favourable effect of verapamil therapy on exercise capacity in the 6-min walk test (95% CI 21.3–110.7; p = 0.005). Conclusion: The addition of verapamil to angiotensin-converting enzyme and aldosterone inhibitors in non-advanced DCM patients has been shown to have a neutral or even positive effect in a few patients.

Evaluation of left ventricular systolic and diastolic function in patients with atrioventricular re-entrant tachycardia treated by radiofrequency current ablation.

Little is known about the long-term influence of radiofrequency current ablation (RFCA) on left ventricular (LV) systolic and diastolic function in patients with atrioventricular re-entrant tachycardia (AVRT). Method — The study group consisted of 65 patients (33 M, mean age 39 ± 11 y) with WPW syndrome and recurrent episodes of AVRT without any concomitant diseases.The control group consisted of 50 age-matched healthy volunteers. In both study and control groups transthorasic echocardiography (TTE) and Doppler were performed in order to assess LV systolic and diastolic function. In WPW patients TTE was followed by electrophysiology study and RFCA. TTE was repeated in 6-months time in the study group. Results — At 6-month follow-up a decrease in LV end-systolic diameters (1.77 ± 0.22 vs. 1.67 ± 0.22 cm/m2, P < 0.001) and volumes (20 ± 6 vs. 17 ± 5 ml, P < 0.001) and an increase in LV FS (33 ± 6 vs. 37 ± 5%, P < 0.001), EF (54 ± 6 vs. 60 ± 5%, P < 0.001), IVS (44 ± 13 vs. 49 ± 14%, P < 0.05) and LV PW thickening (58 ± 19 vs. 62 ± 16%, P < 0.05) was found. Doppler analysis revealed an increase in E wave (78 ± 17 vs. 82 ± 14 cm/s, P < 0.001), E/A ratio (1.14 ± 0.37 vs. 1.33 ± 0.24, P < 0.001) and a decrease in A wave (68 ± 19 vs. 63 ± 12 cm/s, P < 0.05), DT (219 ± 33 vs. 180 ± 20 ms, P < 0.001), IVRT (105 ± 13 vs. 88 ± 13 ms, P < 0.001), AR (26 ± 8 vs. 18 ± 12 cm/s, P < 0.001) and difference between duration of AR and A waves (5 ± 24 vs. –12 ± 21 ms, P < 0.001). No significant differences in regard to LV systolic and diastolic variables were found between patients and controls post RFCA. Conclusion — RFCA of accessory pathway in patients with WPW syndrome and AVRT is associated with improvement of LV systolic and diastolic function.

Prognostic value of collagen turnover biomarkers in cardiac resynchronization therapy: A subanalysis of the TRUST CRT randomized trial population

BACKGROUND A substantial proportion of patients do not respond to cardiac resynchronization therapy (CRT). Various echocardiographic and biochemical markers including collagen turnover biomarkers were suggested to predict CRT results. However, pathological significance of collagen turnover biomarkers in CRT remains controversial. OBJECTIVE The aim of the present study was to evaluate the relationship between levels of collagen turnover biomarkers (amino-terminal propeptide of procollagen type I and amino-terminal propeptide of procollagen type III [PIIINP]), N-terminal of the prohormone brain natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein, and matrix metalloproteinases (metalloproteinase-2 and metalloproteinase-9) and echocardiographic response to CRT and clinical outcomes. METHODS The study population consisted of patients enrolled in the Triple Site Versus Standard Cardiac Resynchronization Therapy trial. Blood samples were obtained before implantation of a CRT with defibrillator. The levels of PIIINP, amino-terminal propeptide of procollagen type I, metalloproteinase-2, and metalloproteinase-9 were determined using commercially available ELISA kits. High-sensitivity C-reactive protein and NT-proBNP levels were determined in a standard way. RESULTS Samples were collected from 74 of 100 enrolled patients. The multivariate logistic regression analysis demonstrated that low PIIINP levels (odds ratio [OR] 3.56; 95% confidence interval [CI] 1.23-10.24; P = .017) and baseline ejection fraction (OR 2.14; 95% CI 1.11-4.11; P = .02) were favorably associated with echocardiographic response. PIIINP and NT-proBNP levels appeared to be independent predictors of all-cause mortality (PIIINP: OR 3.11; 95% CI 1.21-7.89; P = .033; NT-proBNP: OR 2.05; 95% CI 1.11-4.96; P = .039) and risk of major cardiac adverse event (PIIINP: OR 3.56; 95% CI 1.53-9.15; P = .007; NT-proBNP: OR 4.51; 95% CI 1.75-11.6; P = .001). PIIINP levels showed significant additive value in predicting mortality as compared with NT-proBNP levels, but they were not superior to ejection fraction in predicting response. Survival analysis with cutoff values identified by receiver operating characteristic analysis confirmed a significant benefit associated with low baseline PIIINP levels. CONCLUSION Low PIIINP levels are associated with favorable echocardiographic response and long-term survival in CRT recipients.

Usefulness of N-terminal-pro B-type natriuretic peptide as a heart failure marker in patients undergoing percutaneous left atrial appendage occlusion

BACKGROUND The left atrial appendage is involved in secretion of N-terminal-pro B-type natriuretic peptide (NT-proBNP). Percutaneous left atrial appendage occlusion (LAAO) for prevention of stroke may cause variations in NT-proBNP release. AIM This study aimed to assess the diagnostic value of NT-proBNP after LAAO. METHODS The study group comprised 53 patients in whom LAAO was performed. The patients with heart failure (HF) and reduced ejection fraction (EF) were allocated to group I (n = 16) whereas patients with no HF symptoms and EF > 40% were allocated to group II (n = 37). The symptomatic patients with EF > 40% were excluded. NT-proBNP values were measured prior to LAAO, at one-two days, and at three-month follow-up. EF, six-minute walk test (6MWT), and peak oxygen consump¬tion (VO2max) were assessed 24 h prior to LAAO and after three months. RESULTS Prior to LAAO the NT-proBNP level was higher in group I, when compared to group II (3084.74 ± 559.53 pg/mL vs. 808.02 ± 115.83 pg/ml, p < 0.01). In both groups there was a nonsignificant increase in NT-proBNP level at one-two days after LAOO (3100.14 ± 690.08 pg/mL in group I and 1012.09 ± 166.71 pg/mL in group II). At the three-month follow-up a fur¬ther increase of NT-proBNP level in group I (3852.73 ± 1025.78 pg/mL) and a decrease in group II (855.03 ± 107.49 pg/mL) was observed. The pairwise comparison between the means of 6MWT and VO2max showed no significant changes during follow-up. At baseline, NT-proBNP level of 988 pg/mL presented 87.5% sensitivity and 75.7% specificity for prediction of HF. Three months after LAAO, it increased to 1358 pg/mL (sensitivity 81.2%, specificity 78.4%). CONCLUSIONS When diagnosing HF in atrial fibrillation patients, the higher cut-off value of NT-proBNP should be used. NT-proBNP remains an appropriate diagnostic marker of HF in patients after LAAO.

Cryoballoon ablation of atrial fibrillation in patients with advanced systolic heart failure and cardiac implantable electronic devices

BACKGROUND Pulmonary vein isolation with cryoballoon catheter ablation (CCB) is an effective method of treatment in patients with atrial fibrillation (AF), but in patients with heart failure (HF) the role of CCB remains unknown. AIM The aim of the study was to assess the feasibility, effectiveness, and safety of CCB in patients with HF and cardiac im-plantable electronic devices (CIEDs), the impact of the procedure on symptoms, and echocardiographic parameters. METHODS Thirty consecutive HF patients with left ventricular ejection fraction (LVEF) ≤ 40% and CIED, referred for CCB of AF, were included. Procedural parameters were compared to a group of 59 consecutive patients without cardiac diseases referred for CCB (control group). RESULTS The number of veins ablated per patient was smaller and application was performed less frequently in the right inferior pulmonary vein in the HF group compared with the control group (66.7% vs. 88.1%; p = 0.01, respectively). In two (6.7%) patients from the HF group and in five (8.5%) from the control group procedure-related complications occurred (p = 0.76). After six months 21 HF patients (70%), after one year 13 (43%), and after 625 days only three (10%) were free from arrhythmia. AF burden was significantly reduced after six months compared to the pre-ablation period (18.5% vs. 52.9%; p = 0.001). New York Heart Association and European Heart Rhythm Association classes were both significantly (p < 0.001) reduced and LVEF was higher after six months in the HF patients. CONCLUSIONS Safety and feasibility of CCB for AF in HF patients with CIED are comparable to subjects with structurally nor-mal heart; however, stable positioning of the balloon in the right inferior pulmonary vein may be more challenging. Although late recurrences are common, ablation reduces arrhythmia burden and leads to a long-term improvement of symptoms and echocardiographic indices.

The influence of iatrogenic interatrial septum leaks after left atrial appendage closure on cardiac function test results

AIM Left atrial appendage occlusion (LAAO) is a technique for preventing thromboembolism in patients with atrial fibrillation and a high risk of irreversible bleeding. In some patients, a spontaneous iatrogenic transseptal leak (ITL) remains after LAAO. The aim of this study was to assess the correlation between ITL incidence and the results of cardiac function tests in patients who underwent LAAO. METHODS AND RESULTS LAOO was performed in 62 consecutive patients using the Amplatzer Amulet. Before and 3 months after LAA occlusion, the 6-min walking distance (6MWD) test was performed in all patients and oxygen consumption assessment (VO2max ) was performed in 32. All patients had transesophageal echocardiography before and 3 months after LAAO to assess ITL incidence. The patients were divided according to the presence and absence of ITL and the subgroup of patients with heart failure (HF) were further analyzed. In patients with HF and ITL, an increased VO2max (12.8 ± 5.2 vs 15.3 ± 4.7; P < 0.05) and 6MWD (350.1 ± 77.4 vs 414.3 ± 70.6; P < 0.05) was observed after the procedure comparing to the results before the procedure. The 6MWD was also significantly higher in the patients with transseptal leaks in comparison to those without (P < 0.0001). CONCLUSION The presence of transseptal leaks after LAAO does not influence overall cardiac function test results. However, in patients with HF, there is an increase in oxygen consumption and 6MWD. These results indicate that ITLs in patients with HF decrease left atrial pressure, which is the key contributor to the symptoms of heart failure during physical activity.

Prognostic Significance of Complex Ventricular Arrhythmias Complicating ST-Segment Elevation Myocardial Infarction.

The aim of the study was to assess the clinical significance of complex ventricular arrhythmias (VAs) (sustained ventricular tachycardia [sVT] and ventricular fibrillation [VF]) in patients with ST-segment elevation myocardial infarction (STEMI) depending on timing of arrhythmia. We analyzed 4,363 consecutive patients with STEMI treated invasively between 2004 and 2014. The median follow-up was 69.6 months (range: 0 to 139.8 months). The study population was divided into 2 main groups; VA group encompassed 476 patients (10.91%) with VAs, whereas 3,887 subjects (89.09%) without VT or VF were included into the control group. In VA population, prereperfusion VA (34.24%; n = 163) was the most common arrhythmia, whereas reperfusion-induced, early postreperfusion, and late postreperfusion VAs were diagnosed in 103 (21.64%), 103 (21.64%), and 107 (22.48%) patients, respectively. Every type of sVT or VF complicating STEMI portended significantly worse in-hospital prognosis, however a late onset arrhythmia was associated with the highest (over fivefold) and reperfusion-induced VA with the lowest (less than threefold) increase in mortality risk compared with the control group. On the contrary, long-term mortality was significantly increased only in subjects with late postreperfusion and prereperfusion VAs compared with VA-free population (43.93% and 36.81%, respectively vs 22.58%; p <0.001). Apart from cardiogenic shock on admission, late postreperfusion (hazard ratio 3.39) and prereperfusion VAs (hazard ratio 2.76) were the strongest independent predictors of death in the analyzed population. In conclusion, 1 in 10 patients with STEMI treated invasively was affected by sVT or VF. The clinical impact of VAs was strongly dependent on timing of arrhythmia.

Percutaneous left atrial appendage occlusion procedures in patients with heart failure

BACKGROUND Atrial fibrillation (AF) is the most common supraventricular tachyarrhythmia. Percutaneous left atrial appendage occlusion (LAAO) may be considered for stroke prophylaxis in patients with nonvalvular AF (NVAF), especially in contraindications for oral anticoagulants (OAC) or high risk of bleeding. The data about implantation, safety, efficacy, and follow-up are limited. Moreover, there are no studies on patients with NVAF and heart failure with severe left ventricular systolic dysfunction (left ventricular ejection fraction [LVEF] ≤ 35%). AIM To assess the safety, efficacy, and mid-term outcomes of LAAO procedures with Amplatzer Cardiac Plug (ACP) and Amplatzer Amulet device in patients with NVAF and heart failure with LVEF ≤ 35% (group I) and to perform a comparative analysis of the patients who had LAAO with NVAF and LVEF > 35%. METHODS The analysis included 80 patients (group I: 19, group II: 61) with NVAF. The patients were enrolled for the study if they had: CHA2DS2VASc ≥ 2 and high risk of bleeding assessed in HAS-BLED (≥ 3) or less points in HAS-BLED but coexisting contraindications for OAC, or thromboembolic complications while using OAC. Time of follow-up was six months. RESULTS In the studied population, the median CHA2DS2VASc score was 4 and the average HAS-BLED score was 3.2. Device implantation was successful in all patients from group I and in 59/61 patients from group II. The periprocedural clinical ef-ficacy (no thromboembolic complications) was 100% in group I and 98.4% in group II. Serious periprocedural complications (cardiac tamponade: 2.5%, device embolisation: 1.25%, unexplained death: 1.25%) occurred only in patients from group II (p = NS). The mid-term clinical efficacy was 100% in group I and 98.3% in group II (p = NS). During follow-up, one transient ischaemic attack and three deaths not related to the procedure occurred. CONCLUSIONS Percutaneous LAAO is an effective and safe procedure in patients with NVAF and severe systolic heart failure. No significant periprocedural and mid-term differences, in terms of safety and efficacy, between the group with severe systolic heart failure (LVEF ≤ 35%) and the group without severe left ventricular systolic dysfunction (LVEF > 35%) were found.