Longer right to left ventricular activation delay at cardiac resynchronization therapy implantation is associated with improved clinical outcome in left bundle branch block patients.

AIMS: Data on longer right to left ventricular activation delay (RV-LV AD) predicting clinical outcome after cardiac resynchronization therapy (CRT) by left bundle branch block (LBBB) are limited. We aimed to evaluate the impact of RV-LV AD on N-terminal pro-B-type natriuretic peptide (NT-proBNP), ejection fraction (EF), and clinical outcome in patients implanted with CRT, stratified by LBBB at baseline. METHODS AND RESULTS: Heart failure (HF) patients undergoing CRT implantation with EF /= 120 ms were evaluated based on their RV-LV AD at implantation. Baseline and 6-month clinical parameters, EF, and NT-proBNP values were assessed. The primary endpoint was HF or death, the secondary endpoint was all-cause mortality. A total of 125 patients with CRT were studied, 62% had LBBB. During the median follow-up of 2.2 years, 44 (35%) patients had HF/death, 36 (29%) patients died. Patients with RV-LV AD >/= 86 ms (lower quartile) had significantly lower risk of HF/death [hazard ratio (HR): 0.44; 95% confidence interval (95% CI): 0.23-0.82; P = 0.001] and all-cause mortality (HR: 0.48; 95% CI: 0.23-1.00; P = 0.05), compared with those with RV-LV AD /= 86 ms and LBBB showed the greatest improvement in EF (28-36%; P<0.001), NT-proBNP (2771-1216 ng/mL; P < 0.001), and they had better HF-free survival (HR: 0.23, 95% CI: 0.11-0.49, P < 0.001) and overall survival (HR: 0.35, 95% CI: 0.16-0.75; P = 0.007). There was no difference in outcome by RV-LV AD in non-LBBB patients. CONCLUSION: Left bundle branch block patients with longer RV-LV activation delay at CRT implantation had greater improvement in NT-proBNP, EF, and significantly better clinical outcome

Effect of cardiac resynchronization therapy with implantable cardioverter defibrillator versus cardiac resynchronization therapy with pacemaker on mortality in heart failure patients: results of a high-volume, single-centre experience.

AIMS: There are limited and contradictory data on the effects of CRT with implantable cardioverter defibrillator (CRT-D) on mortality as compared with CRT with pacemaker (CRT-P). METHODS AND RESULTS: We evaluated the long-term outcome of patients implanted with a CRT-D or CRT-P device in our high-volume single-centre experience. Data on all-cause mortality were derived from clinic visits and the Hungarian National Healthcare Fund Death Registry. Kaplan-Meier survival analyses and multivariate Cox regression models were used to evaluate all-cause mortality in patients with CRT-D vs. CRT-P, stratified by the aetiology of cardiomyopathy. From 2000 to 2011, 1122 CRT devices, 693 CRT-P (LVEF 28.2 +/- 7.4%) and 429 CRT-D (LVEF 27.6 +/- 6.4%), were implanted at our centre. During the median follow-up of 28 months, 379 patients died from any cause, 250 patients (36%) with an implanted CRT-P and 129 patients (30%) with an implanted CRT-D. There was no evidence of mortality benefit in patients implanted with a CRT-D compared with a CRT-P in the total cohort [hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.73-1.32, P = 0.884]. In patients with ischaemic cardiomyopathy, CRT-D treatment was associated with a significant 30% risk reduction in all-cause mortality compared with an implanted CRT-P (HR 0.70, 95% CI 0.51-0.97, P = 0.03). In non-ischaemic patients, there was no mortality benefit of CRT-D over CRT-P (HR 0.98, 95% CI 0.73-1.32, P = 0.894, interaction P-value = 0.15). CONCLUSIONS: In heart failure patients with ischaemic cardiomyopathy, CRT-D was associated with a mortality benefit compared with CRT-P, but no benefit of CRT-D over CRT-P in mortality was observed in non-ischaemic cardiomyopathy

Szubklinikus pitvarfibrilláció és antikoaguláns kezelés : Mit tudunk 2022-ben? = Subclinical atrial fibrillation and anticoagulant therapy: What we know in 2022?

Jelen áttekintő közlemény a beültethető kardiológiai eszközökkel detektált szubklinikus pitvarfibrilláció (SCAF) ese- tében szóba jövő antikoaguláns kezelés kockázat-haszon viszonyára fókuszál. Mai tudásunk szerint az 5-6 percet meghaladó SCAF-epizódokat követően kell számolnunk a stroke kockázatának fokozódásával. Bár az abszolút koc- kázat alacsonyabb a manifeszt, klinikai pitvarfibrillációban (AF) megfigyelthez képest, a rizikó fokozatosan emelkedik, arányosan a SCAF-események hosszával/gyakoriságával. A pitvari ritmuszavarok és a stroke-események időbeli ösz- szefüggése ugyanakkor nem mindig konzekvens, amely alapján a SCAF/AF kardiovaszkuláris kockázati markernek és nem mindig a stroke közvetlen okának tekinthető. Több tanulmány is készült a SCAF, illetve ismeretlen eredetű stroke esetén alkalmazott intenzív monitorozás és antikoaguláns kezelési stratégiák vizsgálatára, amelyek eredményei több ponton ellentmondásosak. A rendelkezésre álló adatok és az aktuális ajánlások tükrében a trombembóliás rizikó és a SCAF-események hosszának/gyakoriságának individuális és dinamikus mérlegelése alapján kell döntenünk az antiko- aguláció bevezetéséről ezen betegek esetében. | This review focuses on the risk-benefit ratio of anticoagulant therapy in subclinical atrial fibrillation (SCAF) detected by implantable cardiac electronic devices. To the best of our knowledge, we have to count on the increase of stroke risk after the detection of SCAF episodes lasting ≥5-6 minutes. Although the absolute risk is lower compared to that one observed in clinical atrial fibrillation (AF), the risk increases gradually with SCAF burden. The temporal relationship be- tween atrial arrhythmias and stroke events is not always consistent, suggesting that SCAF/AF is also a risk marker and not always the direct cause of stroke. Several studies have been conducted in SCAF and/or stroke of unknown origin to investigate the role of intensive monitoring and anticoagulant treatment strategies, reporting contradictory results at more endpoints. Based on the available evidence and current recommendations, the decision to introduce anticoagu- lation in these patients should be based on an individual and dynamic evaluation of the thromboembolic risk and the length/frequency of SCAF events