Estimation of cardiac output in patients with congestive heart failure by analysis of right ventricular pressure waveforms

<p>Abstract</p> <p>Background</p> <p>Cardiac output (CO) is an important determinant of the hemodynamic state in patients with congestive heart failure (CHF). We tested the hypothesis that CO can be estimated from the right ventricular (RV) pressure waveform in CHF patients using a pulse contour cardiac output algorithm that considers constant but patient specific RV outflow tract characteristic impedance.</p> <p>Method</p> <p>In 12 patients with CHF, breath-by-breath Fick CO and RV pressure waveforms were recorded utilizing an implantable hemodynamic monitor during a bicycle exercise protocol. These data were analyzed retrospectively to assess changes in characteristic impedance of the RV outflow tract during exercise. Four patients that were implanted with an implantable cardiac defibrillator (ICD) implementing the algorithm were studied prospectively. During a two staged sub-maximal bicycle exercise test conducted at 4 and 16 weeks of implant, COs measured by direct Fick technique and estimated by the ICD were recorded and compared.</p> <p>Results</p> <p>At rest the total pulmonary arterial resistance and the characteristic impedance were 675 ± 345 and 48 ± 18 dyn.s.cm^-5, respectively. During sub-maximal exercise, the total pulmonary arterial resistance decreased (Δ 91 ± 159 dyn.s.cm^-5, p < 0.05) but the characteristic impedance was unaffected (Δ 3 ± 9 dyn.s.cm^-5, NS). The algorithm derived cardiac output estimates correlated with Fick CO (7.6 ± 2.5 L/min, R²= 0.92) with a limit of agreement of 1.7 L/min and tracked changes in Fick CO (R²= 0.73).</p> <p>Conclusions</p> <p>The analysis of right ventricular pressure waveforms continuously recorded by an implantable hemodynamic monitor provides an estimate of CO and may prove useful in guiding treatment in patients with CHF.</p

Same-day discharge vs. overnight stay following catheter ablation for atrial fibrillation: a comprehensive review and meta-analysis by the European Heart Rhythm Association Health Economics Committee

Aims: Same-day discharge (SDD) after catheter ablation of atrial fibrillation (AF) may address the growing socio-economic health burden of the increasing demand for interventional AF therapies. This systematic review and meta-analysis analyses the current evidence on clinical outcomes in SDD after AF ablation compared with overnight stay (ONS). Methods and results: A systematic search of the PubMed database was performed. Pre-defined endpoints were complications at short-term (24–96 h) and 30-day post-discharge, re-hospitalization, and/or emergency room (ER) visits at 30-day post-discharge, and 30-day mortality. Twenty-four studies (154 716 patients) were included. Random-effects models were applied for meta-analyses of pooled endpoint prevalence in the SDD cohort and for comparison between SDD and ONS cohorts. Pooled estimates for complications after SDD were low both for short-term [2%; 95% confidence interval (CI): 1–5%; I2: 89%) and 30-day follow-up (2%; 95% CI: 1–4%; I2: 91%). There was no significant difference in complications rates between SDD and ONS [short-term: risk ratio (RR): 1.62; 95% CI: 0.52–5.01; I2: 37%; 30 days: RR: 0.65; 95% CI: 0.42–1.00; I2: 95%). Pooled rates of re-hospitalization/ER visits after SDD were 4% (95% CI: 1–10%; I2: 96%) with no statistically significant difference between SDD and ONS (RR: 0.86; 95% CI: 0.58–1.27; I2: 61%). Pooled 30-day mortality was low after SDD (0%; 95% CI: 0–1%; I2: 33%). All studies were subject to a relevant risk of bias, mainly due to study design. Conclusion: In this meta-analysis including a large contemporary cohort, SDD after AF ablation was associated with low prevalence of post-discharge complications, re-hospitalizations/ER visits and mortality, and a similar risk compared with ONS. Due to limited quality of current evidence, further prospective, randomized trials are needed to confirm safety of SDD and define patient- and procedure-related prerequisites for successful and safe SDD strategies

Length of hospital stay for elective electrophysiological procedures: a survey from the European Heart Rhythm Association

Aims Electrophysiological (EP) operations that have traditionally involved long hospital lengths of stay (LOS) are now being undertaken as day case procedures. The coronavirus disease-19 pandemic served as an impetus for many centres to shorten LOS for EP procedures. This survey explores LOS for elective EP procedures in the modern era. Methods and results An online survey consisting of 27 multiple-choice questions was completed by 245 respondents from 35 countries. With respect to de novo cardiac implantable electronic device (CIED) implantations, day case procedures were reported for 79.5% of implantable loop recorders, 13.3% of pacemakers (PMs), 10.4% of implantable cardioverter defibrillators (ICDs), and 10.2% of cardiac resynchronization therapy (CRT) devices. With respect to CIED generator replacements, day case procedures were reported for 61.7% of PMs, 49.2% of ICDs, and 48.2% of CRT devices. With regard to ablations, day case procedures were reported for 5.7% of atrial fibrillation (AF) ablations, 10.7% of left-sided ablations, and 17.5% of right-sided ablations. A LOS ≥ 2 days for CIED implantation was reported for 47.7% of PM, 54.5% of ICDs, and 56.9% of CRT devices and for 54.5% of AF ablations, 42.2% of right-sided ablations, and 46.1% of left-sided ablations. Reimbursement (43–56%) and bed availability (20–47%) were reported to have no consistent impact on the organization of elective procedures. Conclusion There is a wide variation in the LOS for elective EP procedures. The LOS for some procedures appears disproportionate to their complexity. Neither reimbursement nor bed availability consistently influenced LOS

Highlights from 2022 in EHJ Open.

editorial reviewe

European Society of Cardiology: Cardiovascular Disease Statistics 2017

Background: The European Society of Cardiology (ESC) Atlas has been compiled by the European Heart Agency to document cardiovascular disease (CVD) statistics of the 56 ESC member countries. A major aim of this 2017 data presentation has been to compare high income and middle income ESC member countries, in order to identify inequalities in disease burden, outcomes and service provision. Methods: The Atlas utilizes a variety of data sources, including the World Health Organization, the Institute for Health Metrics and Evaluation, and the World Bank to document risk factors, prevalence and mortality of cardiovascular disease and national economic indicators. It also includes novel ESC sponsored survey data of health infrastructure and cardiovascular service provision provided by the national societies of the ESC member countries. Data presentation is descriptive with no attempt to attach statistical significance to differences observed in stratified analyses. Results: Important differences were identified between the high income and middle income member countries of the ESC with regard to CVD risk factors, disease incidence and mortality. For both women and men, the age-standardised prevalence of hypertension was lower in high income countries (18.3% and 27.3%) compared with middle income countries (23.5% and 30.3%). Smoking prevalence in men (not women) was also lower (26% vs 41.3%), and together these inequalities are likely to have contributed to the higher CVD mortality in middle income countries. Declines in CVD mortality have seen cancer becoming a more common cause of death in a number of high income member countries, but in middle income countries declines in CVD mortality have been less consistent where CVD remains the leading cause of death. Inequalities in CVD mortality are emphasised by the smaller contribution they make to potential years of life lost in high income compared with middle income countries both for women (13% vs. 23%) and men (20% vs. 27%). The downward mortality trends for CVD may, however, be threatened by the emerging obesity epidemic that is seeing rates of diabetes increasing across all ESC member countries. Survey data from the National Cardiac Societies (n=41) showed that rates of cardiac catheterization and coronary artery bypass surgery, as well as the number of specialist centres required to deliver them, were greatest in the high income member countries of the ESC. The Atlas confirmed that these ESC member countries, where the facilities for the contemporary treatment of coronary disease were best developed, were often those in which declines in coronary mortality have been most pronounced. Economic resources were not the only driver for delivery of equitable cardiovascular healthcare, as some middle income ESC member countries reported rates for interventional procedures and device implantations that matched or exceeded the rates in wealthier member countries. Conclusion: In documenting national CVD statistics, the Atlas provides valuable insights into the inequalities in risk factors, healthcare delivery and outcomes of CVD across ESC member countries. The availability of these data will underpin the ESC’s ambitious mission “to reduce the burden of cardiovascular disease” not only in its member countries, but also in nation states around the world

Implantable devices in heart failure : Studies on biventricular pacing and continuous hemodynamic monitoring

Chronic heart failure is a highly symptomatic syndrome associated with increasing prevalence, frequent hospital admissions and high treatment costs. Despite recent advances in drug therapy, morbidity and mortality are still high. Thus, there is a clear need for additional therapeutic options and better diagnostic tools in order to improve the management of patients with heart failure. This thesis investigated two novel device techniques for the treatment and management of patients with chronic heart failure. Biventricular pacing Approximately 30% of patients with heart failure have wide QRS complexes on the surface ECG as a sign of disturbed intraventricular conduction. This leads to asynchronous ventricular contraction and relaxation with impaired systolic and diastolic function and increased mitral regurgitation. Biventricular pacing aims to resynchronize the ventricular activation by simultaneous stimulation of the right and left ventricle. Study I evaluated effects of this therapy on functional status and quality of life (QoL) in 16 patients with NYHA III-IV heart failure. After 6 months of biventricular pacing, NYHA-class, the 6-minute walking distance and QoL had improved significantly. This clinical improvement translated into a marked decrease in the need for hospital care the year after pacemaker implantation. Study II, a European multicenter study, confirmed these findings in 75 NYHA III heart failure patients. The clinical benefits of biventricular pacing were sustained over 12 months of treatment both in patients with sinus rhythm and atria] fibrillation. In addition, an improvement in left ventricular ejection fraction and a reduction in mitral regurgitation was observed. Study III investigated the effects of a 2-week treatment cessation of long term biventricular pacing. Myocardial blood flow (MBF) and oxygen consumption (MV02) was assessed by 11-C-acetate positron emission tomography at rest and during low dose dobutamine stress in 6 responders to biventricular pacing. Although MBF was unchanged by biventricular pacing there was significant less increase of MV02 during stress, when the pacemaker had been switched off for 2 weeks. Continuous hemodynamic monitoring An implantable hemodynamic monitor (IHM) continuously records central hemodynamic information from a pressure lead in the right ventricle. The system is implanted similar to a pacemaker. In study IV, 32 heart failure patients with an IHM were followed during 9 months. Retrospective analysis of hemodynamic trends showed significant (>20%) pressure changes in 9/12 cases of volume overload exacerbation requiring in-hospital treatment. These changes occurred 4±2 days prior to the clinical event. Hospitalizations decreased when the hemodynamic information was used for clinical decision making. Study V evaluated the potential usefulness of the IHM for the optimization of diuretic treatment in 4 patients with stable heart failure. Diuretics were decreased by 50% during the first week, completely withdrawn during the second and reinstituted in the initial dose during the third. In parallel with other clinical measures, the IHM was a sensible tool for detecting changes in volume load and was useful to find the optimal diuretic dose. In study VI an IHM was used to investigate the relationship between N-terminal pro brain natriuretic peptide (NTproBNP) and cardiac filling pressures. NT-proBNP plasma. levels measured on a single occasion varied largely between patients and were only weakly correlated with filling pressures. However, serial measurements of NT-proBNP in the same individual correlated significantly to hemodynamic parameters and reflected individual changes in cardiac filling pressures over time. Conclusions Biventricular pacing improves symptoms and exercise tolerance in patients with heart failure and intraventricular conduction delay and favorably impacts the need for hospitalizations. Clinical improvement is sustained over 12 months follow-up and may in part depend on changes in myocardial oxygen metabolism. Continuous hemodynamic monitoring is potentially useful to indicate impending volume exacerbations and to tailor diuretic therapy, which may prevent hospitalizations for heart failure. Serial measurements of NT-proBNP are correlated with hemodynamic changes in the individual patient and may be useful to guide outpatient treatment. In the future, a hemodynamic sensor may be incorporated in pacemakers or defibrillators implanted in patients with heart failure, serving as an integrated heart failure management device

Cognitive Behavioral Therapy for Symptom Preoccupation Among Patients With Premature Ventricular Contractions: Nonrandomized Pretest-Posttest Study

BackgroundPremature ventricular contractions (PVCs) are a common cardiac condition often associated with disabling symptoms and impaired quality of life (QoL). Current treatment strategies have limited effectiveness in reducing symptoms and restoring QoL for patients with PVCs. Symptom preoccupation, involving cardiac-related fear, hypervigilance, and avoidance behavior, is associated with disability in other cardiac conditions and can be effectively targeted by cognitive behavioral therapy (CBT). ObjectiveThe aim of this study was to evaluate the effect of a PVC-specific CBT protocol targeting symptom preoccupation in patients with symptomatic idiopathic PVCs. MethodsNineteen patients diagnosed with symptomatic idiopathic PVCs and symptom preoccupation underwent PVC-specific CBT over 10 weeks. The treatment was delivered by a licensed psychologist via videoconference in conjunction with online text-based information and homework assignments. The main components of the treatment were exposure to cardiac-related symptoms and reducing cardiac-related avoidance and control behavior. Self-rated measures were collected at baseline, post treatment, and at 3- and 6-month follow-ups. The primary outcome was PVC-specific QoL at posttreatment assessment measured with a PVC-adapted version of the Atrial Fibrillation Effects on Quality of Life questionnaire. Secondary measures included symptom preoccupation measured with the Cardiac Anxiety Questionnaire. PVC burden was evaluated with 5-day continuous electrocardiogram recordings at baseline, post treatment, and 6-month follow-up. ResultsWe observed large improvements in PVC-specific QoL (Cohen d=1.62, P<.001) and symptom preoccupation (Cohen d=1.73, P<.001) post treatment. These results were sustained at the 3- and 6-month follow-ups. PVC burden, as measured with 5-day continuous electrocardiogram, remained unchanged throughout follow-up. However, self-reported PVC symptoms were significantly lower at posttreatment assessment and at both the 3- and 6-month follow-ups. Reduction in symptom preoccupation had a statistically significant mediating effect of the intervention on PVC-specific QoL in an explorative mediation analysis. ConclusionsThis uncontrolled pilot study shows preliminary promising results for PVC-specific CBT as a potentially effective treatment approach for patients with symptomatic idiopathic PVCs and symptom preoccupation. The substantial improvements in PVC-specific QoL and symptom preoccupation, along with the decreased self-reported PVC-related symptoms warrant further investigation in a larger randomized controlled trial. Trial RegistrationClinicalTrials.gov NCT05087238; https://clinicaltrials.gov/study/NCT0508723