Cardiac Resynchronization Therapy in Patients with Mild Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

# The Author(s) 2011. This article is published with open access at Springerlink.com Objective This review aims at updating the results of cardiac resynchronization therapy (CRT) in mild heart failure patients, and investigating whether CRT can prevent or reverse heart failure progression in an earlier stage. Methods Randomized controlled trials of CRT in patients with New York Heart Association (NYHA) Class I or II heart failure were identified. The effects of CRT on worsening heart failure hospitalization, all-cause mortality, and overall adverse events were meta-analyzed, and the effects of CRT on left ventricular (LV) were systematically reviewed and meta-analyzed. Results Eight studies were identified with a total of 4,302 patients. CRT was associated with a substantial improvement in LVend-systolic volume (WMD −39, 95%CI −41.56 to −36.45). CRT also had a marked effect in reducing new hospitalizations for worsening heart failure by 31 % (RR 0.69, 95%CI 0.60 to 0.79). In addition, CRTsignificantly decreased all-cause mortality by 21 % (RR 0.79, 95%CI 0.67 to 0.93). However, complications in patients with CRT increased by 74 % (RR 1.74, 95%CI 1.44 to 2.11). Conclusions This meta-analysis suggests that CRT could improve the prognosis in patients with mild heart failure and ventricular dyssynchrony, but these improvements are accompanied by more adverse events. Since most patients in the included trials had received ICD therapy, our analysis suggests that CRT could offer an additional benefit. Key words Heart failure. Cardiac resynchronization therapy. Meta-analysi

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry

Background: Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. Methods: From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. Results: Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions: An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients

Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry

Background: Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. Methods: We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. Results: A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p <.001. Over 24 months, impaired renal function was associated with significantly greater incidence of the primary composite outcome and all secondary outcomes. Multivariable Cox regression analysis demonstrated an inverse relationship between eGFR and the primary outcome (HR 1.07 [95% CI, 1.01–1.14] per 10 ml/min/1.73 m2 decrease), that was most notable in patients with eGFR <30 ml/min/1.73 m2 (HR 2.21 [95% CI, 1.23–3.99] compared to eGFR ≥90 ml/min/1.73 m2). Conclusion: A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry

Background: Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients\u2019 clinical phenotypes and analyse the differential clinical course. Methods: We performed a hierarchical cluster analysis based on Ward\u2019s Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry. Results: A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients\u2019 prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P <.001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27\u20133.62; HR 3.42, 95%CI 2.72\u20134.31; HR 2.79, 95%CI 2.32\u20133.35), and Cluster 1 (HR 1.88, 95%CI 1.48\u20132.38; HR 2.50, 95%CI 1.98\u20133.15; HR 2.09, 95%CI 1.74\u20132.51) reported a higher risk for the three outcomes respectively. Conclusions: In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes

Facteurs prédictifs de fibrillation auriculaire précoce après ablation de Flutter atrial commun pur par radiofréquence (une étude prospective unicentrique)

La survenue d'acces de fibrillation auriculaire (FA) precoces (6=mois) après ablation de flutter auriculaire (FL) typique n'est pas rare et s'observe dans 20 à 25 % des cas. Les variables predictives de cette evolution chez les patients ayant beneficie d'une ablation pour FL et sans aucun antecedent de FA n'ont pas ete totalement etudiees. Objectifs : Le but de cette etude etait d'identifier les facteurs predictifs de FA precoce dans l'ensemble de la population apres ablation de FL par radiofrequence et plus particulièrement, dans le sous-groupe des patients n'ayant jamais eu d'antecedent de FA avant l'ablation. Methodes : Cette etude prospective incluait 96 patients (age 65+/-13 ans ; 18 femmes) sur une periode de 12 mois. Le FL typique etait traite par radiofrequence par le meme operateur, avec un catheter 8 mm. Vingt sept variables cliniques, electrophysiologiques et echographiques ont ete retenues, a priori, dans l'analyse : age, genre, type de FL (permanent ou paroxystique), duree des symptomes (mois), antecedents de FA pre-ablation, cardiopathie sous jacente, fraction d'ejection du ventricule gauche (FEVG), taille de l'oreillette gauche, dimension de l'isthme septal, dimension de l'isthme cavo-tricuspide, pression arterielle pulmonaire systolique à 30 mmHg, surface des oreillettes droite et gauche, bloc isthmique, nombre de tirs de radiofrequence, antiarythmique a la sortie, diametre telediastolique du ventricule gauche (VG), diametre telesystolique du VG, volume telediastolique du VG (VTDVG), volume telesystolique du VG (VTSVG), vitesse des ondes A et E, rapport E/A, temps de relaxation isovolumetrique, temps de deceleration de l'onde E, insuffisance mitrale, cycle du FL. Résultats : Sur 96 patients, 16 ont presente une FA precoce (soit 16.6 %) dans les 30+/-46 jours (1 - 171 jours) apres ablation. L'analyse univariee montre que le risque de survenue de FA precoce est associe avec les antecedents pre ablation de FA, la taille de l'oreillette gauche, la FEVG, le VTDVG, la vitesse de l'onde A, l'insuffisance mitrale (II+ à IV) et le cycle du FL. Les seuls facteurs predictifs de FA precoce par analyse multivariee, utilisant le modele de Cox, sont la FEVG et les antecedents de FA pre ablation. Le risque de fibrillation auriculaire chez les patients n'ayant aucun antecedent de FA etait de 8% (5/63), et l'analyse statistique montre que, dans ce sous groupe, la presence d'une insuffisance mitrale significative est le seul facteur predictif. Conclusion : Dans le sous-groupe de patients sans antecedent de fibrillation auriculaire, l'insuffisance mitrale est le seul facteur predictif de survenue de FA precoce avec une sensibilite de 80 %, une specificite de 78 % et une valeur predictive negative de 98 %. Cette etude suggere que la recherche d'une insuffisance mitrale par echocardiographie doppler devrait faire partie du bilan systematique des patients ayant beneficie d'une ablation de flutter auriculaire commun pur par radiofrequence. De plus, son existence serait a prendre en compte pour la prise en charge ulterieure, notamment l'anticoagulation et la prescription d'antiarythmiques.ST ETIENNE-BU Médecine (422182102) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

A single-centre experience concerning the safety of Sprint Fidelis defibrillator lead extraction at the time of pulse generator replacement or in case of evidence of lead failure

SummaryBackgroundThe reported failure rate of the Sprint Fidelis defibrillator lead (SFDL) has increased more than initially expected, with emerging evidence of accelerating fracture rates. Current consensus guidelines continue to discourage prophylactic lead extraction, citing major complication rates of 1.4–7.3%. Therefore, data relating to the risks of systematic SFDL extraction are lacking, with no methodical extraction protocol reported to date. Moreover, few statistical analyses have identified predictors of SFDL failure.ObjectivesThe aims of this single-centre study were: to examine the safety and feasibility of systematic SFDL extraction at the time of pulse generator replacement or in case of lead failure; and to identify predictors of SFDL failure.MethodsBetween January 2005 and October 2007, 218 consecutive patients underwent transvenous SFDL implantation in our centre.ResultsDuring a mean follow-up of 43±15months, SFDL extraction was performed in 49 patients (22.5%) for the following reasons: inappropriate shocks (n=21; 9.6%), systematic extraction at time of pulse generator extraction (n=23; 10.5%), high impedance (n=3; 1.4%), high SFDL threshold (n=1; 0.4%) and cardiac device-related infection (n=1; 0.4%). No severe complications occurred, although two minor complications were reported (lead dislodgments). SFDL fracture was observed in 25 patients (11.5%; 3.2%/year incidence). The only predictor associated with SFDL fracture was the number of leads (P=0.01).ConclusionIn our series, SFDL extraction at the time of pulse generator extraction or in case of evidence of lead failure was feasible and safe. Number of leads was identified as a new predictive factor for SFDL fracture