Contemporary management of Patent Foramen Ovale: A multinational survey on cardiologists' perspective

Objectives. The purpose of our survey is to analyze the clinical approach used by interventional and imaging cardiologists to diagnose, treat, and follow-up patients with PFO-related left circulation thromboembolism in different parts of the world with particular emphasis on adherence to current guidelines. Background. Firm guidelines do not cover many aspects of PFO-related patient care. Consequently, very disparate approaches exist among clinicians in the real-world. Methods. A 24-item electronic questionnaire was sent directly to experienced cardiology specialists practicing at consultant/attending positions directly involved in PFO closure management in the United States, United Kingdom, Gulf countries, and other countries. There were no unanswered questions. Responses were recorded between October 2019 and July 2020. Results. Seventy-one responses were obtained: 31 from the UK, 19 from the US, 16 from Gulf countries, 2 from Poland, and 1 response from Australia, Italy, and Switzerland. The overall response rate was 76%. Significant differences between regions were noted in the duration of ECG monitoring during the diagnostic process, PFO closure for left circulation thromboembolism other than stroke/transient ischemic attack, and intraoperative use of intracardiac echocardiography. A similar pattern was noted in the lack of routine screening for thrombophilia and the use of the long-term single antiplatelet therapy. Conclusions. The study shows a vast spectrum of opinions on the optimal approach to PFO closure with significant differences between the US, UK, and Gulf countries. The results stress the need for systematic, high-quality data on the diagnostic work-up and follow-up strategies to inform the standardized approach

Left ventricular non-compaction: clinical features and cardiovascular magnetic resonance imaging

Background: It is apparent that despite lack of family history, patients with the morphological characteristics of left ventricular non-compaction develop arrhythmias, thrombo-embolism and left ventricular dysfunction. METHODS: Forty two patients, aged 48.7 +/- 2.3 yrs (mean +/- SEM) underwent cardiovascular magnetic resonance (CMR) for the quantification of left ventricular volumes and extent of non-compacted (NC) myocardium. The latter was quantified using planimetry on the two-chamber long axis LV view (NC area). The patients included those referred specifically for CMR to investigate suspected cardiomyopathy, and as such is represents a selected group of patients. RESULTS: At presentation, 50% had dyspnoea, 19% chest pain, 14% palpitations and 5% stroke. Pulmonary embolism had occurred in 7% and brachial artery embolism in 2%. The ECG was abnormal in 81% and atrial fibrillation occurred in 29%. Transthoracic echocardiograms showed features of NC in only 10%. On CMR, patients who presented with dyspnoea had greater left ventricular volumes (both p < 0.0001) and a lower left ventricular ejection fraction (LVEF) (p < 0.0001) than age-matched, healthy controls. In patients without dyspnoea (n = 21), NC area correlated positively with end-diastolic volume (r = 0.52, p = 0.0184) and end-systolic volume (r = 0.56, p = 0.0095), and negatively with EF (r = -0.72, p = 0.0001). CONCLUSION: Left ventricular non-compaction is associated with dysrrhythmias, thromboembolic events, chest pain and LV dysfunction. The inverse correlation between NC area and EF suggests that NC contributes to left ventricular dysfunction

Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance

Abstract Background Myocardial scarring at the LV pacing site leads to incomplete resynchronization and a suboptimal symptomatic response to CRT. We sought to determine whether the use of late gadolinium cardiovascular magnetic resonance (LGE-CMR) to guide left ventricular (LV) lead deployment influences the long-term outcome of cardiac resynchronization therapy (CRT). Methods 559 patients with heart failure (age 70.4 ± 10.7 yrs [mean ± SD]) due to ischemic or non-ischemic cardiomyopathy underwent CRT. Implantations were either guided (+CMR) or not guided (-CMR) by LGE-CMR prior to implantation. Fluoroscopy and LGE-CMR were used to localize the LV lead tip and and myocardial scarring retrospectively. Clinical events were assessed in three groups: +CMR and pacing scar (+CMR+S); CMR and not pacing scar (+CMR-S), and; LV pacing not guided by CMR (-CMR). Results Over a maximum follow-up of 9.1 yrs, +CMR+S had the highest risk of cardiovascular death (HR: 6.34), cardiovascular death or hospitalizations for heart failure (HR: 5.57) and death from any cause or hospitalizations for major adverse cardiovascular events (HR: 4.74) (all P Conclusions Compared with a conventional implantation approach, the use of LGE-CMR to guide LV lead deployment away from scarred myocardium results in a better clinical outcome after CRT. Pacing scarred myocardium was associated with the worst outcome, in terms of both pump failure and sudden cardiac death.</p

Effects of cardiac resynchronization therapy in patients unselected for mechanical dyssynchrony

BACKGROUND Observational echocardiographic studies have suggested that pre-implant dyssynchrony is required for a response to cardiac resynchronization therapy. Some clinical guidelines on CRT have adopted dyssynchrony as a requirement prior to CRT. AIMS To assess the effects of CRT in patients with heart failure who are unselected for mechanical dyssynchrony. METHODS 248 consecutive patients with heart failure (sinus rhythm, NYHA class III [n=171, 89%]) or IV (n=77, 31%; LVEFor=120 ms) underwent a clinical assessment, including NYHA class, 6-min walking distance and quality of life (Minnesota Living with Heart Failure questionnaire) before and after CRT. Clinical event variables included mortality and hospitalizations for major cardiovascular events and for heart failure. RESULTS At follow-up, NYHA class was reduced from 3.25+/-0.56 to 2.06+/-0.84 (mean+/-SD, por=1 NYHA classes or>or=25% in 6-min walking distance, was 81% (202/248 patients). Over a follow-up period of up to 7.4 years (median 720 days), the annualized total and cardiovascular mortality rates were 11.7% and 9.89%, respectively. CONCLUSIONS In patients undergoing CRT, the improvements in functional capacity and quality of life as well as the event rates expected from landmark trials are achievable by selecting patients on the basis of NYHA class, LVEF and QRS duration alone. The added value of echocardiographic measures of dyssynchrony remains questionable

Fluoroscopic left ventricular lead position and the long-term clinical outcome of cardiac resynchronization therapy.

BACKGROUND To determine the effects of left ventricular (LV) lead tip position on the long-term outcome of cardiac resynchronization therapy (CRT). SETTING Cardiac device therapy center. PATIENTS Five hundred and fifty-six patients (age 70.4 ± 10.7 years [mean ± standard deviation]). INTERVENTIONS CRT-pacing or CRT-defibrillation device implantation. MAIN OUTCOME MEASURES Cardiovascular mortality and events over a maximum follow-up period of 9.1 years. RESULTS Hazard ratios (HRs [95% 785]797) for cardiovascular mortality, adjusted for age, gender, QRS duration, heart failure etiology, New York Heart Association class, and presence of diabetes and atrial fibrillation, were derived for LV lead tip positions in terms of veins, circumferential, and longitudinal positions with respect to the LV chamber. For vein position, these were 1.07 (0.74-1.56) for anterolateral vein position and 1.24 (0.79-1.95) for the middle cardiac vein, compared with a posterolateral vein. For circumferential lead tip position, HRs were 1.56 (0.73-3.34) for anterolateral and 1.57 (0.76-3.25) for lateral, compared with posterior positions. For longitudinal lead tip positions, HRs were 1.02 (0.72-1.46) for basal and 1.21 (0.68-2.17) for apical, compared with mid-ventricular positions. The risk of meeting the composite endpoints of cardiovascular death or hospitalizations for heart failure and death from any cause or hospitalizations for major adverse cardiovascular events was similar among the various LV lead tip positions. CONCLUSIONS The position of the LV lead over the LV free wall, assessed by fluoroscopy, has no influence over the long-term outcome of CRT

Long-term effects of cardiac resynchronization therapy in octogenarians: a comparative study with a younger population.

Heart failure is a disease of octogenarians. The evidence base for cardiac resynchronization therapy (CRT) has emerged from trials of patients in their 60s. We compared the effectiveness of CRT in octogenerians with younger patients. Patients aged >or=80 years [n = 53, age 83.7 +/- 2.6 years (mean +/- SD)] and or= 120 ms) underwent CRT. A clinical assessment, including a 6-min walk test, and a quality of life assessment (Minnesota Living with Heart Failure questionnaire) were undertaken at baseline and after CRT. In octogenarians, CRT was associated with similar changes in NYHA class [-1.28 vs. -1.22, P or=1 NYHA classes or >or=25% 6-min walking distance) was observed in 80% of or=1 NYHA classes or >or=25% 6-min walking distance), a response was observed in 201 out of 277 (73%) patients <80 years and in 36 out of 53 (68%) octogenarians (P = NS). After a maximum follow-up of 7.6 years (median 634 days), no group differences emerged with respect to the composite endpoints of cardiovascular death or hospitalization for major cardiovascular events, the composite endpoint of cardiovascular death or heart failure hospitalization, cardiovascular mortality, or total mortality.Octogenarians derive similar benefits from CRT to younger patients

Pacing-Induced Increase in QT Dispersion Predicts Sudden Cardiac Death Following Cardiac Resynchronization Therapy

ObjectivesThis study was designed to determine whether cardiac resynchronization therapy (CRT) by means of biventricular pacing (BiVP) alters the QT interval (QTc) and QT dispersion (QTD), and whether such changes relate to the risk of developing major arrhythmic events (MAE).BackgroundProlonged QTcis associated with MAE. Left ventricular pacing and BiVP alter QTc.MethodsA total of 75 patients with drug-resistant heart failure (New York Heart Association functional class III/IV) and QRS duration ≥120 ms underwent CRT. The QTcand QTD were measured before and 48 days after BiVP.ResultsOver 807 days (range 93 to 1,543 days), 11 patients had a MAE. Compared to baseline, at 48 days after CRT, QTD increased in 47% of patients and QTcdecreased in 53%. The QTcat follow-up was higher in MAE patients compared with no-MAE patients (35.9 ± 14.2 ms vs. 0.52 ± 6.0 ms; p = 0.0323). Similar differential responses for QTD were observed (46.4 ± 13.5 ms in MAE vs. −5.1 ± 4.1 ms in no MAE, p < 0.0001). The MAE occurred in 29% of patients exhibiting an increase in QTD and in 3% of those exhibiting a decrease (p = 0.0017). In multiple regression analyses, change in QTD from baseline (ΔQTD) strongly predicted MAE, independent of ΔQTc, QRS duration, and left ventricular ejection fraction and end-diastolic volume (p < 0.001). Differences in survival curves were observed when patients were dichotomized according to whether QTD increased or decreased in relation to baseline values (p < 0.0001).ConclusionsThe MAE in patients with BiVP are related to pacing-induced increases in QTD. Measures of ventricular repolarization at the time of pacemaker implantation may guide selection of patients for combined CRT and defibrillator therapy

Multinational survey on management of patients with patent foramen ovale and left circulation thromboembolism

Background: The purpose of our survey was to capture the contemporary clinical practice of interventional and imaging cardiologists specialising in PFO management in different parts of the world with special emphasis on practice patterns in three core areas: patient screening, procedure and follow-up. Methods: An electronic questionnaire consisting of multiple-choice (single or multiple answers) or open-ended questions was sent in an email to suitable respondents identified by senior authors in their country/region of practice. All respondents were cardiology consultants directly involved in PFO closure procedures either as the operator, imaging specialist or in both roles. Responses were recorded between October 2019 and July 2020. There were no unanswered questions. Results: Seventy-one responses were obtained from different parts of the world: 31 from the United Kingdom, 19 from the United States, 16 from Gulf Countries, two from Poland and one response each from Australia, Italy and Switzerland. The overall response rate was 76%. Regional differences between the US, the UK and Gulf Countries are presented in Table. Conclusion: Based on the responses from the US, the UK and Gulf Countries, we show that there is no standard approach to patient selection, work-up and follow-up neither on international nor national/regional level. The results stress the need for systematic, high-quality data on diagnostic work-up and follow-up strategies to inform the standardised approach