PICKING THE BEST NOVEL ORAL ANTICOAGULANT FOR ATRIAL FIBRILLATION: EVIDENCE FROM A WARFARIN-CONTROLLED NETWORK META-ANALYSIS

Warfarin is a mainstay atrial ibrillation (AF) treatment, yet it has a narrow therapeutic window. Novel agents have been successfully tested against warfarin, yet no direct comparison among them is available. We thus performed a pair-wise and warfarin-adjusted network metaanalyses of novel oral anticoagulants for AF

Indexed maximal left atrial volume predicts response to cardiac resynchronization therapy

Aims Cardiac resynchronization therapy (CRT) has shown morbidity and mortality benefits in patients with advanced congestive heart failure (HF). Since about one-third of the patients did not appear to respond to CRT, it would seem reasonable to try to identify patients more accurately before implantation. Left atrial (LA) dimension has been proposed as a powerful outcome predictor in patients with heart disease. Accordingly, the aim of this study is to prospectively assess the predictive value of LA for selecting CRT responders. Methods Fifty two consecutive patients with refractory HF, sinus rhythm and left bundle branch block were enrolled in the study and planned for CRT implantation. Clinical and echocardiographic evaluations were performed before CRT implantation and after 6 months. Three LA volumes indexed to body surface area (iLAV) were computed to evaluate the LA complexity: maximal LAV (iLAVmax), LAV just before atrial systole (iLAVpre), and minimal LAV (iLAVpost). CRT responders were defined as those who presented a reduction of > 10% in LVESVi at 6-month follow-up. Results Responders (63%) and nonresponders (37%) had similar baseline clinical characteristics and pre-implantation LV volumes. However, baseline LA volumes were significantly associated with the extent of LV reverse remodeling: in particular, baseline iLAVmax was remarkably lower in responders than in nonresponders (50.2 ± 14.1 ml/m2 vs 65.8 ± 15.7 ml/m2, p = 0.001) resulting predictive for CRT response. Conclusion Patients with small iLAV result as better responders to CRT than larger one. iLAVmax is an independent predictor of LV reverse remodeling and allows to indentify the best candidates for CRT. © 2013 Elsevier Ireland Ltd

Evidence of reverse remodeling after long-term biventricular stimulation for resynchronization in patients with wide QRS selected on the basis of echocardiographic electromechanical delays

Background. There is increasing evidence that cardiac resynchronization therapy (CRT) may trigger an inverse remodeling process leading to decreased left ventricular (LV) volumes in patients with heart failure and wide QRS. However, it is still important to simplify patient selection and achieve a widely applicable parameter to better stratify patients who are candidates for CRT. Methods. Eighteen patients (13 males, 5 females, mean age 67.5 ± 7.2 years) with advanced heart failure due to ischemic (n = 12) or idiopathic dilated cardiomyopathy (n = 6) and complete left bundle branch block received biventricular pacing. The patients were considered eligible in the presence of echocardiographic evidence of intra- and interventricular asynchrony, defined on the basis of LV electromechanical delay. Investigations were performed before pacemaker implantation (at baseline), the day after, and 3 and 6 months later. Results. Two patients died before the first outpatient examination. There were 15 (83%) responders to reverse remodeling among the remainder. In the overall population, there was a significant and progressive improvement in LV sphericity indexes, ejection fraction, mitral regurgitation area and LV volumes (p < 0.001). The improvement in the interventricular mechanical delay after CRT was significantly correlated with the decrease in LV end-systolic volume (r2= 0.2558, p = 0.04). Conclusions. CRT reduces LV volumes in patients with advanced heart failure, complete left bundle branch block and detailed documentation of ventricular asynchrony prior to therapeutic pacing. Broadly applicable Doppler echocardiographic measures may increase the specificity of the longterm response to CRT in terms of LV performance. © 2004 CEPI Srl

Cardiac resynchronization therapy-defibrillator improves long-term survival compared with cardiac resynchronization therapy-pacemaker in patients with a class IA indication for cardiac resynchronization therapy: Data from the Contak Italian Registry

Aims In candidates for cardiac resynchronization therapy (CRT), the choice between pacemaker (CRT-P) and defibrillator (CRT-D) implantation is still debated. We compared the long-term prognosis of patients who received CRT-D or CRT-P according to class IA recommendations of the European Society of Cardiology (ESC) and who were enrolled in a multicentre prospective registry. Methods and results A total of 620 heart failure patients underwent successful implantation of a CRT device and were enrolled in the Contak Italian Registry. This analysis included 266 patients who received a CRT-D and 108 who received a CRT-P according to class IA ESC indications. Their survival status was verified after a median follow-up of 55 months. During follow-up, 73 CRT-D and 44 CRT-P patients died (rate 6.6 vs. 10.4%/year; log-rank test, P = 0.020). Patients receiving CRT-P were predominantly older, female, had no history of life-threatening ventricular arrhythmias, and more frequently presented non-ischaemic aetiology of heart failure, longer QRS durations, and worse renal function. However, the only independent predictor of death from any cause was the use of CRT-P (hazard ratio, 1.97; 95% confidence interval, 1.21–3.16; P = 0.007). Conclusion The implantation of CRT-D, rather than CRT-P, may be preferable in patients presenting with current class IA ESC indications for CRT. Indeed, CRT-D resulted in greater long-term survival and was independently associated with a better prognosis

Low Occurrence of Infections and Death in a Real-World Cohort of Patients with Cardiac Implantable Electronic Devices

Background. The incidence of infections and death in patients implanted with cardiac implantable electronic devices (CIEDs) is not fully known yet. Aim. To describe the incidence of CIED-related infection and death, and their potential predictors in a contemporary cohort of CIED patients. Methods. All consecutive patients implanted with a CIED at our institution were prospectively enrolled. Follow-up visits were performed 2 weeks after CIED implantation for all patients, and then every 6 months for implantable cardioverter defibrillator (ICD)/cardiac resynchronization therapy (CRT) patients and every 12 months for pacemaker (PM) patients. The adjudication of CIED-related infections was performed by two independent investigators and potential disagreement was resolved by a senior investigator. Results. Between September 2016 and August 2020, a total of 838 patients were enrolled (34.6% female; median age 77 (69.6–83.6); median PADIT score 2 (2–4)). PMs were implanted in 569 (68%) patients and ICD/CRT in 269 (32%) patients. All patients had pre-implant antibiotic prophylaxis and 5.5% had an antibiotic-eluting envelope. Follow-up data were available for 832 (99.2%) patients. After a median follow-up of 42.3 (30.2–56.4) months, five (0.6%) patients had a CIED-related infection and 212 (25.5%) patients died. Using multivariate Cox regression analysis, end-stage chronic kidney disease (CKD) requiring dialysis and therapy with corticosteroids was independently associated with a higher risk of infection (hazard ratio (HR): 14.20; 95% confidence interval (CI) 1.48–136.62 and HR: 14.71; 95% CI 1.53–141.53, respectively). Age (HR: 1.07; 95% CI 1.05–1.09), end-stage CKD requiring dialysis (HR: 6.13; 95% CI 3.38–11.13) and history of atrial fibrillation (HR: 1.47; 95% CI 1.12–1.94) were independently associated with all-cause death. Conclusions. In a contemporary cohort of CIED patients, mortality was substantially high and associated with clinical factors depicting a population at risk. On the other hand, the incidence of CIED-related infections was low

Graft-<i>versus</i>-leukemia effects after allogeneic bone marrow transplantation are active also in the presence of clones with chromosomal anomalies in addition to the Ph chromosome

Two male patients with Philadelphia-chromosome (Ph+) chronic myelogenous leukemia (CML) underwent allogeneic bone marrow transplantation (ABMT) in the first chronic phase after busulfan treatment. In both cases, the donor was a sister, and engrafting was demonstrated by chromosome analyses which showed only donor cells in the BM. Cytogenetic relapse occurred 29 and 30 months after ABMT, respectively, when host cells reappeared: in both cases, the Ph and additional anomalies typical of the blastic phase of CML were evident. We then monitored the chromosome picture for 52 and 39 months, respectively: no striking evolution occurred, and cells with the Ph and additional anomalies persisted together with donor cells, which were a minority in the first patient and a great majority in the second throughout the observation period. A clinical relapse was observed in the first patient, but the disease never progressed to a blastic phase, whereas the second patient has not relapsed 7 years after ABMT. We reviewed data from the literature on cytogenetic relapse after ABMT in CML without clinical relapse, especially the 12 patients in whom cytogenetic relapse included chromosome anomalies in addition to the Ph, as in our patients. We suggest that graft-versus-leukemia (GVL) reactions in such patients are able to arrest progression of the leukemic blastic clone and prevent a possible relapse in blastic phase

Cardiac resynchronization therapy: Implant rates, temporal trends and relationships with heart failure epidemiology

BACKGROUND: Consensus guidelines define indications for cardiac resynchronization therapy (CRT), but the variability in implant rates in 'real world' clinical practice, as well as the relationship with the epidemiology of heart failure are not defined. METHODS AND RESULTS: In Emilia-Romagna, an Italian region with around 4.4 million inhabitants, a registry was instituted to collect data on implanted devices for CRT, with (CRT-D) or without defibrillation (CRT-P) capabilities. Data from all consecutive patients resident in this region who underwent a first implant of a CRT device in years 2006-2010 were collected and standardized (considering each of the nine provinces of the region). The number of CRT implants increased progressively, with a 71% increase in 2010 compared to 2006. Between 84 and 90% of implants were with CRT-D devices. The variability in standardized implant rates among the provinces was substantial and the ratio between the provinces with the highest and the lowest implant rates was always greater than 2. Considering prevalent cases of heart failure in the period 2006-2010, the proportion of patients implanted with CRT per year ranged between 0.23 and 0.30%. CONCLUSIONS: The application in 'real world' clinical practice of CRT in heart failure is quite heterogeneous, with substantial variability even among areas belonging to the same region, with the need to make the access to this treatment more equitable. Despite the increased use of CRT, its overall rate of adoption is low, if a population of prevalent heart failure patients is selected on the basis of administrative data on hospitalizations. \ua9 2014 Italian Federation of Cardiology