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

A clinical and health-economic evaluation of pulmonary vein encircling ablation compared with antiarrhythmic drug treatment in patients with persistent atrial fibrillation (Catheter Ablation for the Cure of Atrial Fibrillation-2 study)

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INTERMUSCULAR TWO-INCISION TECHNIQUE FOR S-ICD IMPLANTATION

Background The traditional technique for subcutaneous implantable cardioverter defibrillator (S-ICD) implantation, which involves three incisions and a subcutaneous pocket, is associated with possible complications, including inappropriate interventions. The aim of this prospective multicenter study was to evaluate the efficacy and safety of an alternative intermuscular two-incision technique for S-ICD implantation. Methods The study population included 36 consecutive patients (75% male, mean age 44 ± 12 years [range 20–69]) who underwent S-ICD implantation using the intermuscular two-incision technique. This technique avoids the superior parasternal incision for the lead placement and consists of creating an intermuscular pocket between the anterior surface of the serratus anterior and the posterior surface of the latissimus dorsi muscles instead of a subcutaneous pocket. Results All patients were successfully implanted in the absence of any procedure-related complications with a successful 65-J standard polarity defibrillation threshold testing, except in one, who received a second successful shock after pocket revision. During a mean follow-up of 10 months (range 3–30), no complications requiring surgical revision were observed. At device interrogation, stable sensing without interferences was observed in all patients. Two patients (5.5%) experienced appropriate and successful shock on ventricular fibrillation and in four patients (11%), a total of seven nonsustained self-terminated ventricular tachycardias were correctly detected. No inappropriate interventions were observed. Conclusions Our experience suggests that the two-incision intermuscular technique is a safe and efficacious alternative to the current technique for S-ICD implantation that may help reducing complications including inappropriate interventions and offer a better cosmetic outcome, especially in thin individuals

Morphofunctional abnormalities of mitral annulus and arrhythmic mitral valve prolapse

Background\u2014Arrhythmic mitral valve prolapse (MVP) is characterized by myxomatous leaflets and left ventricular (LV) fibrosis of papillary muscles and inferobasal wall. We searched for morphofunctional abnormalities of the mitral valve that could explain a regional mechanical myocardial stretch. Methods and Results\u2014Thirty-six (27 female patients; median age: 44 years) arrhythmic MVP patients with LV late gadolinium enhancement on cardiac magnetic resonance and no or trivial mitral regurgitation, and 16 (6 female patients; median age: 40 years) MVP patients without LV late gadolinium enhancement were investigated by morphofunctional cardiac magnetic resonance. Mitral annulus disjunction (median: 4.8 versus 1.8 mm; P1.5 (22 [61%] versus 4 [25%]; P=0.016) were higher in MVP patients with late gadolinium enhancement than in those without. A linear correlation was found between mitral annulus disjunction and curling (R=0.85). A higher prevalence of auscultatory midsystolic click (26 [72%] versus 6 [38%]; P=0.018) was also noted. Histology of the mitral annulus showed a longer mitral annulus disjunction in 50 sudden death patients with MVP and LV fibrosis than in 20 patients without MVP (median: 3 versus 1.5 mm; P<0.001). Conclusions\u2014Mitral annulus disjunction is a constant feature of arrhythmic MVP with LV fibrosis. The excessive mobility of the leaflets caused by posterior systolic curling accounts for a mechanical stretch of the inferobasal wall and papillary muscles, eventually leading to myocardial hypertrophy and scarring. These mitral annulus abnormalities, together with auscultatory midsystolic click, may identify MVP patients who would need arrhythmic risk stratification

Treatment of macro-re-entrant atrial tachycardia based on electroanatomic mapping: identification and ablation of the mid-diastolic isthmus

Aims This multicentre prospective study evaluated the ability of electroanatomic mapping (EAM) using a specific parameter setting to identify clearly the mid-diastolically activated isthmus (MDAI) and guide ablation of macro-re-entrant atrial tachycardia (MAT). Methods and results Consecutive patients with MAT, different from typical isthmus-dependent atrial flutter, were enrolled. EAM was performed using a specific setting of the window of interest, calculated to identify the MDAI and guide ablation of this area. Sixty-five patients exhibiting 81 MATs (mean cycle length 308 + 68 ms) were considered. Thirty-two (49.2%) had previous heart surgery. In 79 of 81 morphologies (97.5%), EAM reconstructed 95.9 + 4.3% of the tachycardia circuit and identified the MDAI; 23 of the 79 morphologies (29.1%) were double-loop re-entry. Mapping of two morphologies was incomplete due to MAT termination after catheter bumping. In 73 of 79 mapped morphologies (92.4%), abolition of the MAT was obtained by 13.2 + 12.4 applications. During the 14 + 4 month follow-up, MAT recurred in 4 of the successfully treated patients (6.8%). Conclusion EAM using a specific parameter setting proved highly effective at identifying the MDAI in MAT, even in patients with previous surgery and multiple re-entrant loops. Ablation of the MDAI yielded acute arrhythmia suppression with low rate of recurrence during follow-up

Association between air pollution and ventricular arrhythmias in high-risk patients (ARIA study): a multicentre longitudinal study

Summary Background Although the effects of air pollution on mortality have been clearly shown in many epidemiological and observational studies, the pro-arrhythmic effects remain unknown. We aimed to assess the short-term effects of air pollution on ventricular arrhythmias in a population of high-risk patients with implantable cardioverter-defibrillators (ICDs) or cardiac resynchronisation therapy defibrillators (ICD-CRT). Methods In this prospective multicentre study, we assessed 281 patients (median age 71 years) across nine centres in the Veneto region of Italy. Episodes of ventricular tachycardia and ventricular fibrillation that were recorded by the diagnostic device were considered in this analysis. Concentrations of particulate matter of less than 10 μm (PM 10 ) and less than 2·5 μm (PM 2·5 ) in aerodynamic diameter, carbon monoxide, nitrogen dioxide, sulphur dioxide, and ozone were obtained daily from monitoring stations, and the 24 h median value was considered. Each patient was associated with exposure data from the monitoring station that was closest to their residence. Patients were followed up for 1 year and then scheduled to have a closing visit, within 1 more year. This study is registered with ClinicalTrials.gov, number NCT01723761. Findings Participants were enrolled from April 1, 2011, to Sept 30, 2012, and follow-ups (completed on April 5, 2014) ranged from 637 to 1177 days (median 652 days). The incidence of episodes of ventricular tachycardia and ventricular fibrillation correlated significantly with PM 2·5 (p 10 . An analysis of ventricular fibrillation episodes alone showed a significant increase in risk of higher PM 2·5 (p=0·002) and PM 10 values (p=0·0057). None of the gaseous pollutants were significantly linked to the occurrence of ventricular tachycardia or ventricular fibrillation. In a subgroup analysis of patients with or without a previous myocardial infarction, only the first showed a significant association between particulate matter and episodes of ventricular tachycardia or ventricular fibrillation. Interpretation Particulate matter has acute pro-arrhythmic effects in a population of high-risk patients, which increase on exposure to fine particles and in patients who have experienced a previous myocardial infarction. The time sequence of the arrhythmic events suggests there is an underlying neurally mediated mechanism. From a clinical point of view, the results of our study should encourage physicians to also consider environmental risk when addressing the prevention of arrhythmic events, particularly in patients with coronary heart disease, advising them to avoid exposure to high levels of fine particulate matter. Funding There was no funding source for this study

Physical activity measured by implanted devices predicts atrial arrhythmias and patient outcome: Results of IMPLANTED (Italian Multicentre Observational Registry on Patients With Implantable Devices Remotely Monitored)

Background--To determine whether daily physical activity (PA), as measured by implanted devices (through accelerometer sensor), was related to the risk of developing atrial arrhythmias during long-term follow-up in a population of heart failure (HF) patients with an implantable cardioverter defibrillator (ICD). Methods and Results--The study population was divided into 2 equally sized groups (PA cutoff point: 3.5 h/d) according to their mean daily PA recorded by the device during the 30- to 60-day period post-ICD implantation. Propensity score matching was used to compare 2 equally sized cohorts with similar characteristics between lower and higher activity patients. The primary end point was time free from the first atrial high-rate episode (AHRE) of duration 656 minutes. Secondary end points were: first AHRE 656 hours, first AHRE 6548 hours, and a combined end point of death or HF hospitalization. Data from 770 patients (65\ub115 years; 66% men; left ventricular ejection fraction 35\ub112%) remotely monitored for a median of 25 months were analyzed. A PA =3.5 h/d was associated with a 38% relative reduction in the risk of AHRE 656 minutes (72-month cumulative survival: 75.0% versus 68.1%; log rank P=0.025), and with a reduction in the risk of AHRE 656 hours, AHRE 6548 hours, and the combined end point of death or HF hospitalization (all P &lt; 0.05). Conclusions--In HF patients with ICD, a low level of daily PA was associated with a higher risk of atrial arrhythmias, regardless of the patients' baseline characteristics. In addition, a lower daily PA predicted death or HF hospitalization

Options and implications for agricultural production - Report of Task 7: Final Report

CAPRESE has led to a better understanding of the potential of using specific land management practices in preserving and increasing the stock of organic carbon in the agricultural soils of the EU. The scientific literature relating to a range of carbon sequestration measures has been synthesised and evaluated for their potential applicability. Land management has a significant impact on SOC stocks with a number of measures clearly leading to carbon emissions. Conversely, a number of practices can be used to preserve and increase SOC levels. A novel modelling platform suggests that existing assessments of the SOC stock associated with agricultural topsoil in the EU may be over-estimating the current pool by around 24%. The project shows a topsoil SOC pool of 16 Gt., 7.4 and 5.4 Gt respectively between arable and pasture. The model shows that grassland conversion to cropland can have a strong negative impact on the overall C balance in the EU and consequently should be preserved (together with peatlands). Promising management practices for sequestering SOC include cover crops, complex rotation including residue management and reduced tillage. Such measures give C sequestration rates of up to 0.5 t C ha-1 yr-1. However, their effect was strongly dependent on the spatial and temporal extent considered and the scenarios clearly show strong regional differences in the performance of measures. An integrated approach in which measures are combined, could have a significant impact. An implementation scenario of a 12% uptake of mitigation measures gave a cumulated sequestration value of 101 Mt by 2020. Increased areas and variation in implementation patterns could give rise to higher values. Extensive and comparable data on the financial aspects of the implementation and cost-benefit of measures are limited or absent. Substantial effort is required to address these issues. Simplistic scenario analysis shows that on the basis of a conservative implementation of mitigation measures, a SOC stock with a perceived trading value of €500 million could be established by 2020. Such values imply that the implementation of the practices considered would be cost efficient compared to non-agricultural mitigation measures While calculations at farm-scale are difficult, agricultural systems and proportion of land that could be made available to SOC management schemes, there is a perceived positive cost-benefit to C preservation and mitigation measures. Return for grasslands where sequestration and preservation rates are higher would clearly be greater. A cost benefit calculated with the CAPRI (FT) model. Indicated no loss in agricultural income from a 5% conversion to grassland with in turn resulted in a value of the CO2 sequestered in the soil as €20.98 t-1 CO2. Comprehensive data on the impact of the implementation of the measures on production and the market are difficult to define as these macro-scale models do not consider the technical details associated with the specific measures that need to be applied to sequester SOC. However, the studies tend to indicate that that impacts on production could occur but these would be of low magnitude and regionally variable. From an economic perspective, the financial implications of the grassland scenario implemented in CAPRI (FT) model, it can be stated that the CAP premium implications are negligible. This is derived from the fact that as most of the direct payments premiums are now decoupled from production the change in the land use derived from the scenario setting is not affecting the total amount of the direct payments. From a policy perspective, it is important that existing good stewardship of land for maintaining existing SOC stocks should be recognised as a premium in comparison to simply sequestration of OC. Such an approach would be an incentive not to engage in conversion of organic-rich soils to other uses which could lead to a decrease in SOC stocks.JRC.H.5-Land Resources Managemen

Left Bundle Branch Block definition predicts response to cardiac resynchronization therapy

Background. Cardiac resynchronization therapy (CRT) was proved to be effective in patients with heart failure and left bundle branch block (LBBB). Recently, new ECG criteria have been proposed for the diagnosis of LBBB. These criteria are stricter than the current American Heart Association (AHA) criteria and thus increase the specificity of LBBB diagnosis. We assessed the rate of echocardiographic response to CRT in patients who did and did not meet new criteria (Strict-LBBB). Methods. Consecutive patients who received CRT defibrillators were enrolled in the CRT MORE registry. Patients with no-LBBB QRS morphology according to AHA, atrial fibrillation, right bundle branch block and right ventricular pacing were excluded from the analysis. Strict-LBBB was defined as: QRS ≥140ms for men and ≥130ms for women, QS or rS in V1–V2, mid-QRS notching or slurring in ≥2 contiguous leads. Patients showing a relative decrease of ≥15% in left ventricular end systolic volume (LVESV) at 12 months were defined as responders. Results. Among 335 patients with AHA LBBB, 131 (39%) had Strict-LBBB. Patients with and without Strict-LBBB showed comparable baseline characteristics except for QRS duration (166±20ms vs 152±25ms, p<0.001). At 12-month evaluation responders were 205 (61%). 85 (65%) patients had Strict-LBBB and 120 (59%) had no Strict-LBBB (p=0.267). On multivariate analysis, history of atrial fibrillation, larger LVESV, and presence of mid-QRS notching in ≥1 lead (OR 1.96; 95%CI 1.04 to 3.70, p=0.038) were independently associated with the echocardiographic response. Conclusions. Recently proposed stricter criteria for LBBB diagnosis did not improve the identification of CRT responders. Among ECG variables, only the presence of mid-QRS notching in at least 1 lead was associated with the echocardiographic response.Introduzione. La terapia di re sincronizzazione cardiaca (RCT) si è dimostrata efficace nel trattamento dei pazienti con scompenso cardiaco e blocco di branca sinistro (BBSn). Recentemente sono stati proposti nuovi criteri ECG per definire il BBSn. Questi criteri sono più restrittivi rispetto a quelli utilizzati nella definizione dell’American Heart Association (AHA), incrementando la specificità della diagnosi di BBSn. In questo studio abbiamo determinato la risposta alla RCT in termini ecocardiografici in pazienti che rispettvano (Strict-LBBB) o no (Traditional-LBBB) la nuova definizione di BBSn. Metodi. Abbiamo arruolato pazienti consecutivi sottoposti ad impianto di RCT (pacemaker o defibrillatore) inclusi nel Regustro CRT MORE. Sono stati esclusi dall’analisi pazienti che non rispettavano i criteri di BBSn secondo la definzione dell’AHA, fibrillazione atriale, blocco di branca destro e già portatori di pacemaker. Strict-LBBB è stato definito come: QRS ≥140ms per I maschi e ≥130ms per le femmine, QS o rS in V1–V2, mid-QRS notching o slurring in ≥2 derivazioni contigue. I pazienti che hanno dimostrato una riduzione relativa ≥15% del volume telesistiolico ventricolare sinistro (VTS) a 12 mesi sono stati definiti “responder”. Risultati. Tra 335 pazienti con BBSn second la definizione LBBB, 131 (39%) presentavano Strict-LBBB. I pazienti com e senza Strict-LBBB presentavano caratteristiche cliniche ed elettrocardiografiche simili a parte la durata del QRS (166±20ms vs 152±25ms, p<0.001). Al controllo a 12 mesi sono risultati “responder” 205 (61%) pazienti: 85 (65%) pazienti con Strict-LBBB e 120 (59%) con Traditional-LBBB (p=0.267). All'analisi multivariata, la storia di fibrillazione atriale, il VTS più grande, e la presenza di mid-QRS notching in ≥1 derivazione (OR 1.96; 95%CI 1.04 to 3.70, p=0.038) sono risultati indipendentemente associati alla risposta ecocardiografica. Conclusioni. La definizione più restrittiva di BBSn recentemente proposta non migliora l’identificazione dei pazienti responder” alla RCT rispetto alla definizone dell’AHA. Tra le variabili elettrocardiografiche, solo la presenza di mid-QRS notching in almeno una derivazione si correla alla risposta ecocardiografica alla CRT