Effectiveness of cardiac resynchronization therapy in heart failure patients with valvular heart disease: comparison with patients affected by ischaemic heart disease or dilated cardiomyopathy. The InSync/InSync ICD Italian Registry

AimsTo analyse the effectiveness of cardiac resynchronization therapy (CRT) in patients with valvular heart disease (a subset not specifically investigated in randomized controlled trials) in comparison with ischaemic heart disease or dilated cardiomyopathy patients.Methods and resultsPatients enrolled in a national registry were evaluated during a median follow-up of 16 months after CRT implant. Patients with valvular heart disease treated with CRT (n = 108) in comparison with ischaemic heart disease (n = 737) and dilated cardiomyopathy (n = 635) patients presented: (i) a higher prevalence of chronic atrial fibrillation, with atrioventricular node ablation performed in around half of the cases; (ii) a similar clinical and echocardiographic profile at baseline; (iii) a similar improvement of LVEF and a similar reduction in ventricular volumes at 6-12 months; (iv) a favourable clinical response at 12 months with an improvement of the clinical composite score similar to that occurring in patients with dilated cardiomyopathy and more pronounced than that observed in patients with ischaemic heart disease; (v) a long-term outcome, in term of freedom from death or heart transplantation, similar to patients affected by ischaemic heart disease and basically more severe than that of patients affected by dilated cardiomyopathy.ConclusionIn 'real world' clinical practice, CRT appears to be effective also in patients with valvular heart disease. However, in this group of patients the outcome after CRT does not precisely overlap any of the two other groups of patients, for which much more data are currently available

Cardiac resynchronization and implantable cardioverter defibrillator therapy: Preliminary results from the InSync Implantable Cardioverter Defibrillator Italian Registry

The aim of this study was to evaluate ventricular arrhythmias occurring in recipients of the InSync ICD for the primary and secondary prevention of sudden death. The InSync ICD was implanted in 142 patients (128 men; mean age 65 +/- 10 years) with heart failure (mean NYHA functional Class 3.0 +/- 0.7) and wide QRS (mean 159 +/- 33 ms). The underlying etiology was ischemic in 55%, idiopathic in 33%, and valvular or hypertensive cardiomyopathy in 12% of patients. The numbers of arrhythmic episodes/100 patient-months was computed with their 95% CI, assuming a Poisson distribution. Implants were performed in 48 (34%) patients who did not have an ACC/AHA guidelines Class I indication for ICD therapy. A total of 104 patients were compliant for follow-up visits. During a 9-month median (range 0.1-24) follow-up of 104 compliant patients, 19 experienced a total of 94 ventricular arrhythmias, all successfully interrupted or selfterminated, with a median number of two separate episodes, corresponding to a rate of 10 episodes/100 person-month (95% CI 8-12). A rate of 12 episodes/100 person-months (95% CI 10-15) was measured in the subgroup of patients with ACC/AHA class I indications, versus two episodes/100 person-months (95% CI 1-5) in the remainder of the population. Among 12 deaths, 9 were due to heart failure, 1 to a noncardiovascular cause, and 2 to unknown causes. The implantation of ICD in heart failure patients has been prominently extended to primary prevention. Patients without standard ICD indications experienced life-threatening arrhythmic events. The impact of ICD combined with cardiac resynchronization therapy on arrhythmic profile, mortality, and costs in this subgroup of patients need to be more precisely studied, with a particular focus on the various types of underlying heart disease

The last three millions of unequal spring thaws

Evidence from various climate proxies provides us with increasingly reliable proof that only in the past 10 millennia were natural systems more or less as we see them at the present (without considering human impact). Prior to 10,000 years ago, natural systems repeatedly changed under the influence of an unstable climate. This is particularly true over the last one million years. During these times, terrestrial environments were populated by a diversity of large animals that did not survive either the last dramatic climate change or the increasing power of humans. The volume of continental ice covering the land and its impact on the planet’s physiography∗ and vegetation have varied consistently. We can try to imagine extreme conditions: the very cold springtimes of the full glacials∗, and the warm springtimes of the rapid deglaciation phases, with enormous volumes of water feeding terrifying rivers. Most of this story is frozen in the ice cover of Greenland and Antarctica, the deep layers of which have been reached by human coring activities only over the past half century. Shorter cores have been drilled in high-altitude ice caps (e.g., in the Andes) that provide insight into other parts of the planet. The interpretation of the signals locked into the ice cores led to the reconstruction of climatic curves covering approximately the past 800 millennia. In addition, long sediment cores have been recovered from thousands of lakes across the globe and yielded data useful to estimate climatic trends based on pollen* records. In the past one to three million years, the continents and oceans were in roughly their present-day locations. Environmental factors, including tectonics (mountain uplift or closure of ocean gateways), interacted with the overall long-term oscillation in atmospheric carbon-dioxide concentration, which, in turn, influenced vegetation cover and ecosystem composition. Well-established glacial-interglacial∗ cycles impacted biotic dispersal∗ events at mid-to-high latitudes and determined the geographical restriction and expansion of tropical and subtropical (warm-temperate) biomes around the globe. This book chapter constitutes an imaginary field trip, presenting the reader with exemplary records of environments, plants, large mammals, and hominins impacted by cooling and warming phases, glaciations, changes in rainfall patterns, and sea level culminating in the world of today