Three-dimensional interlead distance predicts response and outcomes after cardiac resynchronization therapy

International audienc

Mortality After Atrioventricular Nodal Radiofrequency Catheter Ablation With Permanent Ventricular Pacing in Atrial Fibrillation

International audienceBackground— Atrioventricular nodal radiofrequency ablation (AVNA) with permanent ventricular pacing can be used to control rate in patients with atrial fibrillation (AF). However, long-term outcomes after AVNA are uncertain, especially in light of irreversible pacemaker dependence. Methods and Results— We examined 9122 consecutive patients with AF. The outcomes in 453 patients with AVNA (26% of whom underwent an implantable cardiac defibrillator implant and 37% underwent cardiac resynchronization therapy implant) were compared with AF patients without AVNA after propensity score 1:1 matching. During follow-up in the propensity-matched cohort (2.41±3.23 years, median 1.23, quartiles 0.33–3.12), 100 patients died (yearly rate of death 6.6%). Mode of death was available in 86% of patients, which was cardiovascular in 67% of the patients (related to heart failure in 38%, sudden death in 5%, and other cardiovascular reason in 24%) and noncardiovascular in 33%. AVNA in patients with AF was associated with a lower risk of mortality (odds ratio 0.47, 95% confidence interval, 0.29–0.77; P =0.003), a lower risk of cardiovascular mortality (odds ratio =0.41, 95% confidence interval 0.23–0.73; P =0.003), and nonsignificant lower risk of stroke and thromboembolic events (odds ratio =0.61, 95% confidence interval 0.36–1.06; P =0.08). Conclusions— In sick AF patients with multiple comorbidities, AVNA with permanent ventricular pacing for rate control seems safe during follow-up and may be associated with lower mortality

Galectin-3 level predicts response to ablation and outcomes in patients with persistent atrial fibrillation and systolic heart failure.

INTRODUCTION:Mechanisms of maintenance of both atrial fibrillation and structural left ventricular disease are known to include fibrosis. Galectin-3, a biomarker of fibrosis, is elevated both in patients with heart failure and persistent atrial fibrillation. We sought to find whether galectin-3 has a prognostic value in patients with heart failure and a reduced left ventricular ejection fraction undergoing ablation of persistent atrial fibrillation. METHODS:Serum concentrations of galectin-3 were determined in a consecutive series of patients with an ejection fraction ≤40%, addressed for ablation of persistent atrial fibrillation. Responders to ablation were patients in sinus rhythm and with an ejection fraction ≥50% at 6 months. A combined endpoint of heart failure hospitalization, transplantation and/or death was used at 12 months. RESULTS:Seventy-five patients were included (81% male, age 63±10 years, ejection fraction 34±7%, galectin-3 21±12 ng/mL). During follow-up, eight patients were hospitalized for decompensated heart failure, 1 underwent heart transplantation, and 4 died; 50 patients were considered as responders to ablation. After adjustment, galectin-3 level independently predicted both 6-month absence of response to ablation (OR = 0.89 per unit increase, p = 0.002). Patients with galectin-3 levels <26 had a 95% 1-year event-free survival versus 46% in patients with galectin-3 ≥26 ng/mL (p<0.0001). CONCLUSIONS:Galectin-3 levels independently predict outcomes in patients with reduced left ventricular systolic function addressed for ablation of persistent AF, and may be of interest in defining the therapeutic strategy in this population

Study flow-chart.

<p>Responders to ablation were arbitrarily defined as being those patients fulfilling all the following criteria at 6 months: (1) alive, (2) in sinus rhythm, and (3) with an LVEF ≥50%.</p

Rates of responders to ablation at 6 months, patients with heart failure hospitalization (HF) or heart transplantation (TX) at 12 months, and those dead from a cardiac cause at 12 months, according to galectin-3 terciles (ng/mL).

<p>Rates of responders to ablation at 6 months, patients with heart failure hospitalization (HF) or heart transplantation (TX) at 12 months, and those dead from a cardiac cause at 12 months, according to galectin-3 terciles (ng/mL).</p

One-year event-free survival (combined end-point: Cardiac death, heart transplantation and/or hospitalization for heart failure) for patients with a baseline galectin-3 level <26 (N = 62, 83%) and ≥26 ng/mL.

<p>One-year event-free survival (combined end-point: Cardiac death, heart transplantation and/or hospitalization for heart failure) for patients with a baseline galectin-3 level <26 (N = 62, 83%) and ≥26 ng/mL.</p

One-year event-free survival (combined end-point: Cardiac death, heart transplantation and/or hospitalization for heart failure) for responders (N = 50, 67%) and non-responders at 6 months.

<p>One-year event-free survival (combined end-point: Cardiac death, heart transplantation and/or hospitalization for heart failure) for responders (N = 50, 67%) and non-responders at 6 months.</p

Characteristics for all patients and for responders and non-responders at baseline and during follow-up.

<p>Characteristics for all patients and for responders and non-responders at baseline and during follow-up.</p

Position paper for management of elderly patients with pacemakers and implantable cardiac defibrillators Groupe de rythmologie et stimulation cardiaque de la Société française de cardiologie et Société française de gériatrie et gérontologie.

International audienceDespite the increasingly high rate of implantation of pacemakers (PM) and cardioverter-defibrillators (ICD) in elderly patients, data supporting their clinical and cost-effectiveness in this age stratum are ambiguous and contradictory. We reviewed the data regarding the applicability, safety, and effectiveness of the conventional pacing, ICD and cardiac resynchronization therapy (CRT) in elderly patients. Although peri-procedural risk may be slightly higher in the elderly, the procedure of implantation of PMs and ICDs is still relatively safe in this age group. In older patients with sinus node disease, a general consensus is that dual chamber pacing, along with the programming of an algorithm to minimise ventricular pacing is preferred. In very old patients presenting with intermittent or suspected AV block, VVI pacing may be appropriate. In terms of correcting potentially life-threatening arrhythmias, the effectiveness of ICD therapy is comparable in older and younger individuals. However, the assumption of persistent ICD benefit in the elderly population is questionable, as any advantage of the device on arrhythmic death may be attenuated by a higher total non-arrhythmic mortality. While septuagenarians and octogenarians have higher annual all-cause mortality rates, ICD therapy may remain effective in selected patients at high risk of arrhythmic death and with minimum comorbidities despite advanced age. ICD implantation among the elderly, as a group, may not be cost-effective, but the procedure may reach cost-effectiveness in those expected to live >5-7 years after implantation. The elderly patients usually experience a significant functional improvement after CRT, similar to that observed in middle-aged patients. Management of CRT non responders remains globally the same, while considering a less aggressive approach in terms of re interventions (revision of LV lead placement, addition of a RV or LV lead, LV endocardial pacing configuration). Overall, age, comorbidities and comprehensive geriatric assessment should be the decisive factor in making a decision on device implantation selection for survival and well-being benefit in elderly patients