[Device therapy in chronic heart failure: a case of hypertrophic cardiomyopathy treated with cardiac contractility modulation therapy]

: Cardiac contractility modulation (CCM) currently represents an innovative therapeutic strategy to improve quality of life and reduce hospitalizations in patients with chronic heart failure with reduced ejection fraction. In contemporary practice, a substantial proportion of patients with heart failure unfortunately remains symptomatic despite guideline-recommended pharmacological therapy and implantation of cardiac resynchronization therapy (CRT) devices. Such patients represent possible candidates for the use of CCM therapy with the goal of improving symptoms, ventricular function and, ultimately, prognosis. In this case report, we describe, for the first time, the use of CCM therapy in a patient with non-obstructive hypertrophic cardiomyopathy and symptomatic chronic heart failure despite optimal medical therapy and CRT

Right atrial function and prognosis in idiopathic pulmonary arterial hypertension

Aim: To determine whether right atrial (RA) function has prognostic value in patients with idiopathic pulmonary arterial hypertension (PAH).Methods and results: Overall, 104 patients (70 female, mean age 58 +/- 13 years) with idiopathic PAH underwent standard Doppler echocardiography and strain and strain rate (SR) analysis before right heart catheterization. At a mean follow-up of 22 +/- 7 months, 30 patients (29%) had clinical worsening. On Cox multivariable proportional-hazards regression analysis, RA reservoir function measured as peak longitudinal SR (hazard ratio [HR] 0.5; P < 0.0001), RA area (HR 1.2; P < 0.01), right ventricular (RV) SR (HR 0.6; P < 0.0001), cardiac index (HR 0.79; P < 0.01), and mixed venous oxygen saturation (HR 0.82; P < 0.01) were found to be independent correlates of cardiac events. A RA SR reservoir cut-off value of <1.2 s(-1) and a RV SR cut-off value of <1 s(-1) well identified patients at higher risk of clinical worsening (sensitivity 85.5%; specificity 90.4%; test accuracy 88.8%). In particular, event rates and mean survival time free of clinical worsening were: 6.1% and 23.5 +/- 2.2 months in patients with normal RA and RV SR; 45% and 20.9 +/- 5.5 months in patients with impaired RA and normal RV SR; 56.2% and 17.7 +/- 6.6 months in patients with normal RA and impaired RV SR; and 87.5% and 12.9 +/- 7.6 months in patients with impairment of both RA and RV SR.Conclusion: Our data suggest that RA function has prognostic value in idiopathic PAH, where a poorer RA function, as explored by strain and SR analysis, is associated with a worse outcome. (C) 2017 Elsevier B.V. All rights reserved

A simple echocardiographic score for the diagnosis of pulmonary vascular disease in heart failure

Aims A simple echocardiographic score was designed for diagnosing precapillary vs postcapillary pulmonary hypertension and for discriminating between isolated postcapillary pulmonary hypertension (Ipc-PH) and combined precapillary and postcapillary pulmonary hypertension (Cpc-PH). Methods The score comprised 7 points (2 for E/e0 ratio-1.2, 1 for a right-to-left heart chamber dimension ratio >1 and 1 for the right ventricle forming the heart apex) and was applied to 230 consecutive patients referred for evaluation of pulmonary hypertension. Results Precapillary pulmonary hypertension and postcapillary pulmonary hypertension were diagnosed in 160 and 70 patients, respectively. In the latter, Ipc-PH was found in 51 and Cpc-PH in 19. The echo score was higher in precapillary vs postcapillary pulmonary hypertension patients (4.2 ± 1.7 vs 1.6 ± 1.7, P < 0.001) and in patients with Cpc-PH vs Ipc-PH (2.7 ± 2.1 vs 1.2 ± 1.3, P = 0.001). The sensitivity and specificity of the echo score at least 2 for precapillary pulmonary hypertension were 99 and 54%, respectively (area under the curve 0.85). In patients with postcapillary pulmonary hypertension, the sensitivity and specificity of the echo score at least 2 for Cpc-PH were 63 and 82% (area under the curve 0.73). Conclusion A simple echocardiographic score helps in the differential diagnosis between precapillary and postcapillary pulmonary hypertension, and between Ipc-PH and Cpc-PH.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Clinical Relevance of Fluid Challenge in Patients Evaluated for Pulmonary Hypertension

Background Fluid challenge may help in the differential diagnosis between pre- and postcapillary pulmonary hypertension (PH). However, the test is still in need of standardization and better defined clinical relevance. Methods Two hundred twelve patients referred for PH underwent a right-sided heart catheterization with measurements before and after rapid infusion of 7 mL/kg of saline. PH was defined as mean pulmonary artery pressure ≥ 25 mm Hg, and postcapillary PH was defined as pulmonary artery wedge pressure (PAWP) > 15 mm Hg. An increase in PAWP ≥ 18 mm Hg was considered diagnostic for postcapillary PH. At baseline, 66 patients received a diagnosis of no PH; 22, of postcapillary PH; and 124, of precapillary PH (mostly pulmonary arterial hypertension). Results After fluid challenge, five of 66 patients with no PH (8%) and eight of 124 with precapillary PH (6%) had the diagnosis reclassified as postcapillary PH. Fluid challenge was associated with an increase in PAWP by 7 ± 2 mm Hg in postcapillary PH and 3 ± 1 mm Hg in both precapillary PH and no-PH groups. Between-group differences were significant, but there was overlap. There were no adverse events related to fluid challenge. Prediction bands calculated from quadratic fits of the PAWP responses in pooled control subjects with no PH and patients with precapillary PH helped confirm 18 mm Hg as the cutoff for diagnosing postcapillary PH. Conclusions Fluid challenge with 7 mL/kg saline increases PAWP, more in postcapillary than in precapillary PH or in control subjects with no PH. A cutoff value of 18 mm Hg allows reclassification of 6% to 8% of patients with precapillary PH or normal hemodynamic characteristics at baseline.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Cardiac involvement in undifferentiated connective tissue disease at risk for systemic sclerosis (otherwise referred to as very early-early systemic sclerosis): a TDI study

Undifferentiated connective tissue disease at risk for systemic sclerosis (UCTD-risk-SSc), otherwise referred to as very early-early SSc, is a condition characterized by Raynaud's phenomenon with serum SSc marker autoantibodies and/or typical capillaroscopic findings and unsatisfying classification criteria for the disease. The aim of the present study was to assess the prevalence of right (RV) or left ventricular (LV) systolic and/or diastolic dysfunction by standard echocardiography and tissue Doppler imaging (TDI). Thirty patients with UCTD-risk-SSc (28 female, mean age 47 ± 13 years, range 21-70) and 30 age- and sex-matched controls underwent cardiac assessment by standard echocardiography and TDI. UCTD-risk-SSc patients and controls did not show any difference at standard echocardiography. Despite results falling within the respective normal ranges, TDI pointed out a mild impairment of LV and RV diastolic (E m 15 ± 4 vs. 19 ± 5, p = 0.0004; E/E m 6.1 ± 1.7 vs. 4.8 ± 1.2, p = 0.001; E t 14 ± 3 vs. 16 ± 2, p = 0.02; E t/A t 0.9 ± 0.4 vs. 1.3 ± 0.3, p = 0.002; E/E t 3.5 ± 1.2 vs. 4.2 ± 0.9, p = 0.02) and systolic function (S m 13 ± 3 vs. 15 ± 2 cm/s, p < 0.0003; S t 14 ± 2 vs. 16 ± 3 cm/s, p < 0.0001) and increased estimated pulmonary artery wedge pressure (9 ± 2 vs. 8 ± 1, p = 0.001) in UCTD-risk-SSc patients as compared to controls. Notably, a statistically significant difference also emerged in the prevalence of TDI detected E'/A't, (71% of UCTD-risk-SSc patients vs. 19% of controls; p < 0.0001). Our study shows that UCTD-risk-SSc patients show a previously unrecognized, mild biventricular systolic and diastolic dysfunction as compared to controls. The pathophysiologic meaning as well the predictive value of developing overt SSc await to be elucidated.Undifferentiated connective tissue disease at risk for systemic sclerosis (UCTD-risk-SSc), otherwise referred to as very early-early SSc, is a condition characterized by Raynaud's phenomenon with serum SSc marker autoantibodies and/or typical capillaroscopic findings and unsatisfying classification criteria for the disease. The aim of the present study was to assess the prevalence of right (RV) or left ventricular (LV) systolic and/or diastolic dysfunction by standard echocardiography and tissue Doppler imaging (TDI). Thirty patients with UCTD-risk-SSc (28 female, mean age 47 +/- 13 years, range 21-70) and 30 age- and sex-matched controls underwent cardiac assessment by standard echocardiography and TDI. UCTD-risk-SSc patients and controls did not show any difference at standard echocardiography. Despite results falling within the respective normal ranges, TDI pointed out a mild impairment of LV and RV diastolic (E-m 15 +/- 4 vs. 19 +/- 5, p = 0.0004; E/E-m 6.1 +/- 1.7 vs. 4.8 +/- 1.2, p = 0.001; E (t) 14 +/- 3 vs. 16 +/- 2, p = 0.02; E-t/A(t) 0.9 +/- 0.4 vs. 1.3 +/- 0.3, p = 0.002; E/E-t 3.5 +/- 1.2 vs. 4.2 +/- 0.9, p = 0.02) and systolic function (S-m 13 +/- 3 vs. 15 +/- 2 cm/s, p < 0.0003; S-t 14 +/- 2 vs. 16 +/- 3 cm/s, p < 0.0001) and increased estimated pulmonary artery wedge pressure (9 +/- 2 vs. 8 +/- 1, p = 0.001) in UCTD-risk-SSc patients as compared to controls. Notably, a statistically significant difference also emerged in the prevalence of TDI detected E'/A'(t), (71% of UCTD-risk-SSc patients vs. 19% of controls; p < 0.0001). Our study shows that UCTD-risk-SSc patients show a previously unrecognized, mild biventricular systolic and diastolic dysfunction as compared to controls. The pathophysiologic meaning as well the predictive value of developing overt SSc await to be elucidated

A mobile app for improving the compliance with remote management of patients with cardiac implantable devices: a multicenter evaluation in clinical practice

Background: The remote device management (RM) is recommended for patients with cardiac implantable electronic devices (CIEDs). RM underutilization is frequently driven by the lack of correct system activation. The MyLATITUDE Patient App (Boston Scientific) has been developed to encourage patient compliance with RM by providing information on communicator setup, troubleshooting, and connection status of the communicator. Methods: At 14 centers, patients with CIEDs were invited to download and install the App on a mobile device. After 3 months, patients were asked to complete an ad hoc questionnaire to evaluate their experience. Results: The App was proposed to 242 consecutive patients: 81 before RM activation, and 161 during follow-up. The App was successfully installed by 177 (73%) patients. The time required for activation of the communicator and the need for additional support were similar between patients who followed the indications provided by the App and those who underwent standard in-clinic training. During follow-up, notifications of lack of connection were received by 20 (11%) patients and missed transmission by 22 (12%). The median time from notification to resolution was 2 days. After 3 months, 175 (99%) communicators of the 177 patients who installed the App were in "Monitored" status versus 113 (94%) of 120 patients without the App installed (p=0.033). The use of the app made 84% of patients feel reassured. Conclusions: The App was well accepted by CIED patients and offered support for communicator management and installation. Its use enabled patients to remain connected with greater continuity during follow-up

Implantable defibrillator-detected heart failure status predicts atrial fibrillation occurrence

BACKGROUND In heart failure (HF) patients, atrial fibrillation (AF) is associated with a worse prognosis. Implantable cardioverter-defibrillator (ICD) diagnostics allow continuous monitoring of AF and are equipped with algorithms for HF moni-toring. OBJECTIVE We evaluated the association between the values of the multisensor HF HeartLogic index and the incidence of AF, and as-sessed the performance of the index in detecting follow-up periods of significantly increased AF risk. METHODS The HeartLogic feature was activated in 568 ICD pa-tients. Median follow-up was 25 months [25th-75th percentile (15-35)]. The HeartLogic algorithm calculates a daily HF index and identifies periods of IN-alert state on the basis of a configurable threshold. The endpoints were daily AF burden &gt;= 5 minutes, &gt;= 6 hours, and &gt;= 23 hours. RESULTS The HeartLogic index crossed the threshold value 1200 times. AF burden &gt;= 5 minutes/day was documented in 183 patients (32%), &gt;= 6 hours/day in 118 patients (21%), and &gt;= 23 hours/day in 89 patients (16%). The weekly time of IN-alert state was independently associated with AF burden &gt;= 5 minutes/day (hazard ratio [HR] 1.95; 95% confidence interval [CI] 1.22- 3.13; P 5 .005), &gt;= 6 hours/day (HR 2.66; 95% CI 1.60-4.44; P &lt;.001), and &gt;= 23 hours/day (HR 3.32; 95% CI 1.83-6.02; P &lt;.001), after correction for baseline confounders. Comparison of the episode rates in the IN-alert state with those in the OUT -of-alert state yielded HR ranging from 1.57 to 3.11 for AF burden from &gt;= 5 minutes to &gt;= 23 hours. CONCLUSIONS The HeartLogic alert state was independently asso-ciated with AF occurrence. The intervals of time defined by the algo-rithm as periods of increased risk of HF allow risk stratification of AF according to various thresholds of daily burden

Combination of an implantable defibrillator multi-sensor heart failure index and an apnea index for the prediction of atrial high-rate events

Aims Patients with atrial fibrillation frequently experience sleep disorder breathing, and both conditions are highly prevalent in presence of heart failure (HF). We explored the association between the combination of an HF and a sleep apnoea (SA) index and the incidence of atrial high-rate events (AHRE) in patients with implantable defibrillators (ICDs).Methods and results Data were prospectively collected from 411 consecutive HF patients with ICD. The IN-alert HF state was measured by the multi-sensor HeartLogic Index (&gt; 16), and the ICD-measured Respiratory Disturbance Index (RDI) was computed to identify severe SA. The endpoints were as follows: daily AHRE burden of &gt;= 5 min, &gt;= 6 h, and &gt;= 23 h. During a median follow-up of 26 months, the time IN-alert HF state was 13% of the total observation period. The RDI value was &gt;= 30 episodes/h (severe SA) during 58% of the observation period. An AHRE burden of &gt;= 5 min/day was documented in 139 (34%) patients, &gt;= 6 h/day in 89 (22%) patients, and &gt;= 23 h/day in 68 (17%) patients. The IN-alert HF state was independently associated with AHRE regardless of the daily burden threshold: hazard ratios from 2.17 for &gt;= 5 min/day to 3.43 for &gt;= 23 h/day (P &lt; 0.01). An RDI &gt;= 30 episodes/h was associated only with AHRE burden &gt;= 5 min/day [hazard ratio 1.55 (95% confidence interval: 1.11-2.16), P = 0.001]. The combination of IN-alert HF state and RDI &gt;= 30 episodes/h accounted for only 6% of the follow-up period and was associated with high rates of AHRE occurrence (from 28 events/100 patient-years for AHRE burden &gt;= 5 min/day to 22 events/100 patient-years for AHRE burden &gt;= 23 h/day).Conclusions In HF patients, the occurrence of AHRE is independently associated with the ICD-measured IN-alert HF state and RDI &gt;= 30 episodes/h. The coexistence of these two conditions occurs rarely but is associated with a very high rate of AHRE occurrence