Differential effect of biventricular and right ventricular DDD pacing on coronary flow reserve in heart failure patients treated with cardiac resynchronization therapy.

The aim of this study was to assess the effect of biventricular (BiV), compared with right ventricular (RV), pacing, on coronary flow reserve (CFR), in patients with ischemic cardiomyopathy.Left anterior descending artery coronary flow reserve was measured invasively, under BiV and RV pacing, using intracoronary adenosine to induce hyperemia.In all the patients, there was a significant difference in the pairwise comparison between CFR recorded during BiV and RV pacing. When comparing responders to non-responders, there was a significant difference as to the effect of BiV, compared with RV, pacing on CFR: mean difference (BiV minus RV CFR) .ΒiV pacing is overall associated to higher CFR, compared with RV DDD pacing. This difference is almost exclusively attributable to the beneficial effect of CRT on coronary flow reserve in CRT-responders. This effect may contribute to the beneficial action of resynchronization in the failing heart and can be viewed in the context of reports of the usefulness of upgrading RV pacemakers to CRT systems.Σκοπός της παρούσας μελέτης ήταν η εκτίμηση της επίδρασης της αμφικοιλιακής βηματοδότησης στα πλαίσια CRT, σε σύγκριση με τη βηματοδότηση από τη δεξιά κοιλία, στη στεφανιαία εφεδρεία ροής (CFR), σε ασθενείς με καλή (responders) και πτωχή (non-responders) ανταπόκριση στη CRT (δηλαδή σε ασθενείς οι οποίοι έχουν λάβει αμφικοιλιακό σύστημα βηματοδότησης και έχουν εμφανίσει ή όχι βελτίωση στην κλινική τους κατάσταση). H αμφικοιλιακή βηματοδότηση σχετίζεται με υψηλότερη CFR, σε σύγκριση με τη βηματοδότηση της δεξιάς κοιλίας, σε ασθενείς που έχουν ανταποκριθεί στη CRT, σε αντίθεση με τους μη ανταποκριθέντες, οι οποίοι φαίνεται να έχουν συνολικά χαμηλότερες τιμές CFR, ανεξάρτητα από τον τύπο βηματοδότησης. Το αποτέλεσμα αυτό μπορεί να αποτελεί έναν από τους παράγοντες που συνεισφέρουν στην επωφελή επίδραση του επανασυγχρονισμού στην καρδιακή ανεπάρκεια και μπορεί να συνεκτιμηθεί με τις προϋπάρχουσες αναφορές σχετικά με τη χρησιμότητα της αναβάθμισης εμφυτευμένων βηματοδοτών σε αμφικοιλιακά συστήματα CRT

Successful Retrieval of a Coronary Stent Dislodged in the Brachial Artery by Means of Improvised Snare and Guiding Catheter

This is a case report regarding the retrieval, by means of an improvised snare and guiding catheter, of a stent dislodged in the brachial artery during a transradial coronary intervention. A full-length guiding catheter could not be used to approach the lost stent, which was a mere 30 to 35 cm away from the sheath insertion site at the radial artery, and a commercial snare was not available at the time. Thus, we had to improvise a shortened guiding catheter and a snare, which was formed by folding an angioplasty Whisper guide wire (Abbott Laboratories, Abbott Park, IL) and was used successfully to snare the stent and retrieve it

Association of virtual histology characteristics of the culprit plaque with post-fibrinolysis flow restoration in ST-elevation myocardial infarction

Objectives: We sought to test the hypothesis that virtual histology characteristics of the culprit lesion in patients with ST-elevation myocardial infarction are associated with blood flow restoration after thrombolysis. Methods: Consecutive patients referred for coronary angiography after successful thrombolysis were included in this correlational cross-sectional study. Evaluation with intravascular ultrasound (IVUS) and virtual histology of the culprit arterial segment was performed in all cases. Results: Forty-eight patients (60.5 +/- 10.7 years) were included. TIMI flow grade 3 was found in 24 (50%). Diabetes was strongly associated with lower TIMI flow 3 rate (26.7% vs 60.6%; p = 0.029) and there was a significant difference in the time to thrombolysis (2.0 +/- 0.8 hours in those with TIMI flow 3 vs 3.0 +/- 0.7 hours in TIMI flow grades 1-2; p < 0.001). Patients with TIMI flow grades 3 and 1-2 had similar absolute total plaque volume (152.8 +/- 59.3 mm(3) vs 147.5 +/- 92.3 mm(3); p = 0.817) and absolute necrotic core (NC) volume (31.2 +/- 13.9 mm(3) vs 33.6 +/- 23.2 mm(3); p = 0.671). However, there were significant differences in the relative NC content, both in proportion to the whole plaque volume (26.3% vs 29.9%; p = 0.016) and as an area fraction at the largest NC site (31.5% vs 40.3%; p < 0.001). Conclusion: The NC content of atherosclerotic plaques is meaningful for flow restoration after the occurrence of a coronary event. This finding highlights the importance of plaque composition, as studied with virtual histology, not only for the sequence of processes leading to an acute plaque-related event, but also for thrombus formation and lysis, following the occurrence of such an event. (C) 2014 Elsevier Ireland Ltd. All rights reserved

The impact of vagotonic, adrenergic, and random type of paroxysmal atrial fibrillation on left atrial ablation outcomes

Background: Accumulating data have shown that the autonomic nervous system is strongly implicated in the genesis of atrial fibrillation (AF). The aim of this study was to assess the efficacy of a single ablation procedure in patients with vagotonic, adrenergic and random type of paroxysmal AF. Methods and results: The clinical records of consecutive patients with symptomatic, drug-refractory paroxysmal AF who underwent pulmonary vein antral isolation were analysed. The study population consisted of 104 patients (64 males, mean age 57.9 +/- 10.9 years) with paroxysmal AF. Based on AF triggers, patients were classified in those with vagotonic (31.7%), adrenergic (17.3%) and random AF (51%). Subjects with adrenergic and random AF tended to be older (p: 0.104) and displayed a higher incidence of hypertension (p: 0.088) compared with those with vagotonic AF. Following a mean follow-up period of 14.7 +/- 7.4 months, 74 patients were free from arrhythmia recurrence (71.2%). Late arrhythmia recurrence (N3 months from the index procedure) occurred in 33.3%, 16.7% and 30.2% of patients with vagotonic, adrenergic and random AF, respectively (p: 0.434). Cox regression analysis showed that early AF recurrence [hazard ratio (HR) 15.76; 95% confidence interval (CI) 5.45645.566, p<0.001], left atrial volume (HR 0.969; 95% CI 0.942-0.996, p: 0.025) and statin use (HR 6.828; 95% CI 2.078-22.437 p: 0.002) were independent predictors of late arrhythmia recurrence. Conclusions: In this study cohort, the type of paroxysmal AF was not associated with arrhythmia recurrence following left atrial ablation. (C) 2013 Elsevier Ireland Ltd. All rights reserved

Interatrial conduction time and incident atrial fibrillation: A prospective cohort study

BACKGROUND Atrial electrical conduction properties have been implicated in atrial fibrillation (AF) pathogenesis. OBJECTIVE The purpose of this study was to prospectively assess the potential association of interatrial conduction time (IACT) with incident AF. METHODS The study included persons referred for invasive electrophysiologic study (EPS), aged >= 50 years, without AF history or valvular disease. IACT was defined as the interval between the high right atrium electrogram and the distal coronary sinus atrial electrogram. RESULTS Six hundred twelve subjects were included (median follow-up 43 months, interquartile range 40-47). AF incidence was 21.7 cases per 1000 person-years. IACT was a significant predictor of AF with a c-statistic of 0.770 (95% confidence interval 0.702-0.838). In time-dependent analysis, IACT was a significant stratifier of AF risk (log-rank 28.0, P < .001). The corresponding incidences of AF in each tertile of IACT were 3, 17, and 46 per 1000 person-years, respectively (all differences between tertiles were significant). IACT remained significant in multivariable Cox regression analysis, after adjustment for age, sex, hypertension, and left atrial diameter, with each millisecond of prolonged IACT corresponding to 7% (95% confidence interval 2%-12%) higher adjusted risk of incident AF. CONCLUSION IACT is independently associated with incident AF. The invasive nature of the measurement is a limitation for its use as a clinical risk stratifier (although it could be used in patients referred for EPS), but these results are of interest in themselves because they suggest a strong pathophysiologic connection between atrial conduction times and substrate alterations ultimately leading to AF

Cardioprotective Role of Remote Ischemic Periconditioning in Primary Percutaneous Coronary Intervention Enhancement by Opioid Action

ObjectivesWe sought to determine the potential of remote ischemic periconditioning (RIPC), and its combination with morphine, to reduce reperfusion injury in primary percutaneous coronary interventions.BackgroundRemote ischemic post-conditioning is implemented by applying cycles of ischemia and reperfusion on a remote organ, which result in release of circulating factors inducing the effects of post-conditioning on the myocardium.MethodsA total of 96 patients (59 men) were enrolled. The patients were randomized to groups as follows: 33 to each treatment group (Group A: RIPC; Group B: RIPC and morphine) and 30 to the control group (Group C). Measures of efficacy were achievement of full ST-segment resolution (primary), and reduction of ST-segment deviation score and peak troponin I during hospitalization.ResultsA higher proportion of patients in Groups A (73%) and B (82%) achieved full ST-segment resolution after percutaneous coronary intervention, compared with control patients (53%) (p = 0.045). Peak troponin I was lowest in Group B, 103.3 ± 13.3 ng/ml, in comparison to peak levels in Group A, 166.0 ± 28.0 ng/ml, and the control group, 255.5 ± 35.5 ng/ml (p = 0.0006). ST-segment deviation resolution was 87.3 ± 2.7% in Group B, compared with 69.9 ± 5.1% in Group A and 53.2 ± 6.4% in the control group (p = 0.00002). In paired comparisons between groups, Group B did better than the control group in terms of both ST-segment reduction (p = 0.0001) and peak troponin I (p = 0.004), whereas Group A differences from the control group did not achieve statistical significance (p = 0.054 and p = 0.062, respectively).ConclusionsThese findings demonstrate a cardioprotective effect of RIPC and morphine during primary percutaneous coronary intervention for the prevention of reperfusion injury. This is in agreement with observations that the beneficial effect of RIPC is inhibited by the opioid receptor blocker naloxone

The prognostic role of late gadolinium enhancement on cardiac magnetic resonance in patients with nonischemic cardiomyopathy and reduced ejection fraction, implanted with cardioverter defibrillators for primary prevention. A systematic review and meta-analysis

Background Previous studies suggest that late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) is associated with arrhythmic events in patients with nonischemic cardiomyopathy (NICM), while others have questioned the role of left ventricular ejection fraction (LVEF) as a sole predictor of future events. Objectives To evaluate the role of LGE on CMR in identifying patients with NICM and reduced LVEF for whom a benefit from defibrillator implantation for primary prevention is not anticipated, thus they are mainly exposed to potential risks. Methods Major electronic databases were searched for studies reporting the incidence of appropriate device therapy (ADT), sudden cardiac death (SCD), and cardiac death based on the presence of LGE on CMR, among patients with NICM and reduced LVEF, implanted with a cardioverter defibrillator for primary prevention. Results Eleven studies (1652 patients, 947 with LGE) were included in the final analysis. LGE presence was strongly associated with ADT (logOR: 1.95, 95%CI: 1.21-2.69) and cardiac death (logOR: 0.91, 95%CI: 0.14-1.68), but not with SCD (logOR: 0.26, 95%CI: -1.09-1.6). Diagnostic accuracy analysis demonstrated that contrast enhancement is a sensitive marker of future ADT and cardiac death (93%, 95%CI: 85.8-96.7%; 82.9%, 95%CI: 70.6-90.7%; respectively), with moderate specificity ( 44%, 95%CI: 27.2-62.6%; 37.7%, 95%CI: 23.4-54.6%; respectively). Conclusion LGE is a highly sensitive predictor of ADT and cardiac death in NICM patients implanted with a defibrillator for primary prevention. However, due to moderate specificity, derivation of a cutoff with adequate predictive values and probably a multifactorial approach are needed to improve discrimination of patients who will not benefit from ICDs

Effect of Postablation Statin Treatment on Arrhythmia Recurrence in Patients With Paroxysmal Atrial Fibrillation

Background: Statins have been proposed as a means to prevent postablation atrial fibrillation (AF) recurrences, mainly on the basis of their pleiotropic effects. The objective of this subanalysis of a prospectively randomized controlled study population of patients undergoing radiofrequency ablation for paroxysmal AF was to test the hypothesis that statin treatment is associated with longer time to recurrence. Methods and Results: This is a subanalysis over an extended follow-up period of a prospective randomized study (ClinicalTrials.gov Identifier NCT01791699). Among 291 patients, 2 propensity score-matched subgroups of patients who received or did not receive statins after pulmonary vein isolation were created. In the unmatched cohort, there was no difference in the rate of recurrence between statin-treated and not treated patients, with a 1-year recurrence estimate of 19% and 23%, respectively (Gehan statistic 0.59, P = 0.443). In the propensity-matched cohort (N = 166, 83 per group), recurrence-free survival did not differ significantly between groups (839 days, 95% confidence interval 755-922 days, in the no statin group vs. 904 days, 95% confidence interval 826-983 in the statin group; P = 0.301). The 1-year recurrence rate estimate was 30% in the no statin group versus 27% in the statin group (Gehan statistic 0.56, P = 0.455). Conclusion: Statin treatment does not seem to affect AF recurrence in following radiofrequency ablation for paroxysmal AF, over a follow-up time of about 2.5 years

Colchicine for prevention of atrial fibrillation recurrence after pulmonary vein isolation: Mid-term efficacy and effect on quality of life

BACKGROUND Our group previously showed that colchicine treatment is associated with decreased early recurrence rate after ablation for atrial fibrillation (AF). OBJECTIVE The purpose of this study was to test the mid-term efficacy of colchicine in reducing AF recurrences after a single procedure of pulmonary vein isolation in patients with paroxysmal AF. Assessment of quality-of-life (QOL) changes was a secondary objective. METHODS Patients with paroxysmal AF who were scheduled for ablation were randomized to a 3-month course of colchicine 0.5 mg twice daily or placebo and were followed for a median of 15 months (with a 3-month blanking period). QOL was assessed with a general-purpose health-related QOL tool (26-item World Health Organization QOL questionnaire) at baseline and after 3 and 12 months. RESULTS Two hundred twenty-three randomized patients underwent ablation, and 206 patients were available for analysis (144 male, age 62.2 +/- 5.8 years). AF recurrence rate in the colchicine group was 31.1% (32/103) vs 49.5% (51/103) in the control group (P = .010), translated in a relative risk reduction of 37% (odds ratio 0.46, 95% confidence interval 0.26-0.81). The number needed to treat was 6 (95% confidence interval 3.2-19.8). Physical domain QOL scores at 12 months were 63.6 +/- 13.8 in the colchicine group and 52.5 +/- 18.1 in controls, whereas psychological domain scores were 56.1 +/- 13.7 vs 44.7 +/- 17.3, respectively (P < .001, for both). CONCLUSION Colchicine treatment after pulmonary vein isolation for paroxysmal AF is associated with lower AF recurrence rates after a single procedure. This reduction is accompanied by corresponding improvements in physical and psychological health-related QOL scores

Permanent pacemaker implantation in octogenarians with unexplained syncope and positive electrophysiologic testing

BACKGROUND Syncope is a common problem in the elderly, and a permanent pacemaker is a therapeutic option when a bradycardic etiology is revealed. However, the benefit of pacing when no association of symptoms to bradycardia has been shown is not dear, especially in the elderly. OBJECTIVE The aim of this study was to evaluate the effect of pacing on syncope-free mortality in patients aged 80 years or older with unexplained syncope and “positive” invasive electrophysiologic testing (EPT). METHODS This was an observational study. A positive EPT for the purposes of this study was defined by at least 1 of the following: a corrected sinus node recovery time of >525 ms, a basic HV interval of >55 ms, detection of infra-Hisian block, or appearance of second-degree atrioventricular block on atrial decremental pacing at a paced cycle length of >400 ms. RESULTS Among the 2435 screened patients, 228 eligible patients were identified, 145 of whom were implanted with a pacemaker. Kaplan-Meier analysis determined that time to event (syncope or death) was 50.1 months (95% confidence interval 45.4-54.8 months) with a pacemaker vs 37.8 months (95% confidence interval 31.3-44.4 months) without a pacemaker (log-rank test, P =.001). The 4-year time-dependent estimate of the rate of syncope was 12% vs 44% (P <.001) and that of any-cause death was 41% vs 56% (P =.023), respectively. The multivariable odds ratio was 0.25 (95% confidence interval 0.15-0.40) after adjustment for potential confounders. CONCLUSION In patients with unexplained syncope and signs of sinus node dysfunction or impaired atrioventricular conduction on invasive EPT, pacemaker implantation was independently associated with longer syncope-free survival. Significant differences were also shown in the individual components of the primary outcome measure (syncope and death from any cause). (C) 2017 Heart Rhythm Society. All rights reserved