Trying to predict the unpredictable: Variations in device-based daily monitored diagnostic parameters can predict malignant arrhythmic events in patients undergoing cardiac resynchronization therapy

Background: The aim of this study was to evaluate the value of device-based diagnostic parameters in predicting ventricular arrhythmias in cardiac resynchronization therapy (CRT) recipients. Methods: Ninety-six CRT-D patients participating in TRUST CRT Trial were analyzed. The inclusion criteria were: heart failure in NYHA ≥ 3 class, QRS ≥ 120 ms, LVEF £ 35% and significant mechanical dyssynchrony. Patients were divided into those with (n = 31, 92 arrhyth­mias) and without (n = 65) appropriate ICD interventions within follow-up of 12.03 ± 6.7 months. Daily monitored device-based parameters: heart rate (HR), thoracic impedance (TI), HR variability and physical activity were analyzed in 4 time windows: within 10, 7, 3 days and 1 day before appropriate ICD interventions. Results: A consistent pattern of changes in three monitored factors was observed prior to ar­rhythmia: 1) a gradual increase of day HR (from 103.43% of reference within 10-day window to 105.55% one day before, all p < 0.05 vs. reference); 2) variations in night HR (104.75% in 3 days, 107.65% one day before, all p < 0.05) and 3) TI decrease (from 97.8% in 10 days to 96.81% one day before, all p < 0.05). The combination of three parameters had better pre­dictive value, which improved further after exclusion of patients with atrial fibrillation (AF). The predictive model combining HR and TI together with LVEF and NT-proBNP was more prognostic than the model involving LVEF and NT-proBNP alone (difference in AUC 0.05, 95% CI 0.0005–0.09, p = 0.04). Conclusions: Daily device-monitored parameters show significant variations prior to ven­tricular arrhythmia. Combination of multiple parameters improves arrhythmia predictive performance by its additive value to baseline risk factors, while presence of AF diminishes it.

Assessment of right ventriclar function by tissue Doppler in relation to plasma NT-proBNP concentration in patients with dilated cardiomyopathy

Background: Impairment of right ventricular function is a common finding in patients with dilated cardiomyopathy (DCM). The aim of the study was to assess the function of the right ventricle by tissue Doppler imaging (TDI) in relation to NT-proBNP concentration in patients with DCM. Methods: 29 patients with DCM were studied. Group I (n = 21) constituted of subjects with a NT-proBNP concentration > 500 pg/ml and group II (n = 8) constituted of patients with NT-proBNP < 500 pg/ml. In all patients the TDI parameters for the free-wall of the right ventricle were analysed: velocity of myocardium (VEL), strain (&#949;) and strain rate (SR). Results: There were no significant differences between the two groups with respect to clinical characteristics, parameters of global and regional left ventricular systolic function or between indicators of global right ventricular function. In group I the maximal values of e in the apical and medial segments of the right ventricular free wall were significantly lower than in group II (-17 &#177; 10 vs. -29 &#177; 7%; p = 0.0168 and -13 &#177; 6 vs. -25 &#177; 5%; p = 0.0023 respectively). Moreover, in group I the maximal SR in the apical and medial segments of the right ventricular free wall were significantly lower than in group II (1.56 &#177; 0.6 &#949;-1 vs. -1.071 &#177; 0.5 &#949;-1; p = 0.0358 and -0.99 &#177; 0.38 &#949;-1 vs. -1.55 &#177; 0.37 &#949;-1; p = 0.0044 respectively). Conclusions: Impairment of right ventricular function is most visible in the apical and medial segments. The maximal values of e and SR for the right ventricle free wall are lower in patients with DCM and NT-proBNP > 500 pg/ml. (Cardiol J 2007; 14: 167-173

Long-term outcomes of cardiac resynchronization therapy are worse in patients who require atrioventricular junction ablation for atrial fibrillation than in those with sinus rhythm

Background: The aim of the study was to assess the impact of atrial fibrillation (AF) with and without the need for atrioventricular junction (AVJ) ablation on outcomes in patients undergoing cardiac resynchronization therapy (CRT).Methods: A single center cohort of 200 consecutive CRT patients was divided into three groups: 1) AF with CRT pacing &lt; 95% in which AVJ ablation was performed (AF-ABL, n = 40; 20%), 2) AF without the need for AVJ ablation (AF-non ABL, n = 40; 20%), 3) sinus rhythm (SR, n = 120; 60%). All patients were assessed before CRT implantation and at 6-month follow-up. Positive clinical response to CRT was considered alive status without the need for heart transplantation and improvement ≥ 1 NYHA after 6 months. The comparative analysis among all study groups with respect to response-rate and long-term survival was performed.Results: The 6-month response-rate in both AF-ABL and AF-nonABL was significantly lower than in SR (52.5 and 50 vs.77.5%, respectively; both p &lt; 0.017), though there were no differences in baseline characteristics among study groups apart from higher baseline NT-proBNP levels in AF-ABL. However, after adjustment for this confounder, and despite optimal CRT pacing burden in study groups, the remote all-cause mortality during median follow-up of 36.1 months was significantly higher in AF-ABL than in SR (adjusted HR = 2.57, 95% CI 1.09–6.02, p = 0.03). What is more, no difference in long-term survival between SR and AF-nonABL was observed.Conclusions: Despite the improvement of CRT pacing burden and thus response-rate up to the level of AF subjects without the need for ablation, the long-term survival of AF patients requiring AVJ ablation remains still worse than in SR

Atrial fibrillation in cardiac resynchronization recipients with and without prior arrhythmic history. How much of arrhythmia is too much?

Background: The aim of the study was to assess long-term incidence of atrial fibrillation (AF) in cardiac resynchronization (CRT) recipients with and without prior arrhythmic history, factors predisposing to arrhythmia, as well as to evaluate the prognostic power of cumulative arrhythmia burden, duration of the longest episode and the number of episodes. Methods: Device-collected data on AF episodes during 24 months in 96 participants of a randomized CRT-trial were analyzed (15% in NYHA class IV, sinus rhythm, median left ventricular ejection fraction 24% and QRS 169 ms). Blindly adjudicated major adverse car­diac events (MACE) and any-cause death were censoring variables. Results: Two-year incidence of AF was 70%, including 66% of patients without previous AF history. No baseline characteristics distinguished those who developed new onset AF. Percent of time spent in AF, but not number of episodes predicted mortality (adjusted hazard ratio [HR] 1.05 ± 95% confidence interval CI 1.01–1.10) and MACE incidence (HR 1.03 ± 1.01–1.07; p = 0.03). Duration of the longest episode also predicted mortality (HR 1.06 ± 1.01–1.12; both p = 0.03). Prognostic impact of AF load was marked only in patients with slower ventricular response (&lt; 98/min), but was independent from CHADS2 scores, pacing burden, or prior atrioventricular nodal ablation. Conclusions: Seven out of 10 CRT-patients had AF within 2 years, including two-thirds of subjects without arrhythmic history. No baseline features distinguished those who developed new onset AF. Arrhythmia burden and duration of the longest episode, but not number of episodes influenced outcomes in CRT-patients, irrespectively from pacing burden or prior atrioventricular node ablation.

Ocena prawej komory za pomocą tkankowej echokardiografii doplerowskiej a stężenie NT-proBNP w surowicy u chorych na kardiomiopatię rozstrzeniową

Wstęp: W przebiegu kardiomiopatii rozstrzeniowej (DCM) często dochodzi do upośledzenia funkcji prawej komory. Celem niniejszej pracy była ocena czynności prawej komory z użyciem tkankowej echokardiografii doplerowskiej (TDI) oraz analiza związku między stężeniem N-końcowego mózgowego peptydu natriuretycznego (NT-proBNP) w surowicy krwi a parametrami mechanicznymi prawej komory u chorych na DCM. Metody: Badaniem objęto 29 osób z DCM. W zależności od stężenia NT-proBNP chorych podzielono na grupę I (n = 21), ze stężeniem NT-proBNP powyżej 500 pg/ml, i grupę II (n = 8) ze stężeniem NT-proBNP poniżej 500 pg/ml. Porównywano parametry uzyskane w trakcie badania za pomocą TDI: prędkości miokardium (VEL), odkształcenie ( e) i tempo odkształcania (SR) dla wolnej ściany prawej komory. Wyniki: Analizowane grupy nie różniły się charakterystyką kliniczną, parametrami globalnej i regionalnej funkcji skurczowej lewej komory, a także globalnymi wskaźnikami czynności prawej komory. W grupie I stwierdzono statystycznie znamiennie niższe warto&#339;ci maksymalnego e w segmencie koniuszkowym (-17 &#177; 10% vs. -29 &#177; 7%; p = 0,0168) i środkowym (-13 &#177; 6% vs. -25 &#177; 5%; p = 0,0023) wolnej ściany prawej komory. Ponadto w grupie I stwierdzono istotnie niższe wartości maksymalnego SR w segmencie koniuszkowym (-1,56 &#177; 0,6 s-1 vs. -1,071 &#177; 0,5 s-1; p = 0,0358) i środkowym (-0,99 &#177; 0,38 s-1 vs. -1,55 &#177; 0,37 s-1; p = 0,0044) wolnej ściany prawej komory. Wnioski: Zaburzenia funkcji prawej komory są najwyraźniej zaznaczone w segmencie środkowym i koniuszkowym. Wartości maksymalnego e i SR dla wolnej ściany prawej komory są niższe u chorych na DCM ze stężeniem NT-proBNP powyżej 500 pg/ml w porównaniu z pacjentami z DCM i NT-proBNP poniżej 500 pg/ml. (Folia Cardiologica Excerpta 2007; 2: 194-200

Novel Echocardiographic Biomarkers in the Management of Atrial Fibrillation

Purpose of Review: Atrial fibrillation (AF) is the most common arrhythmia in adults. The number of patients with AF is anticipated to increase annually, mainly due to the aging population alongside improved arrhythmia detection. AF is associated with a significantly elevated risk of hospitalization, stroke, thromboembolism, heart failure, and all-cause mortality. Echocardiography is one of the key components of routine assessment and management of AF. Therefore, the aim of this review is to briefly summarize current knowledge on “novel” echocardiographic parameters that may be of value in the management of AF patients. Recent Findings: Novel echocardiographic biomarkers and their clinical application related to the management of AF have been taken into consideration. Both standard parameters such as atrial size and volume but also novels like atrial strain and tissue Doppler techniques have been analyzed. Summary: A number of novel echocardiographic parameters have been proven to enable early detection of left atrial dysfunction along with increased diagnosis accuracy. This concerns particularly experienced echocardiographers. Hence, these techniques might improve the prediction of stroke and thromboembolic events among AF patients and need to be further developed and disseminated. Nonetheless, even the standard imaging parameters could be of significant value and should not be discontinued in everyday clinical practice. © 2019, The Author(s)

Echokardiograficzna kwalifikacja i ocena odpowiedzi na terapię resychronizującą wśród pacjentów z przewlekłą niewydolnością serca. Metaloproteinaza macierzy zewnątrzkomórkowej&#8722;9 &#8212; subanaliza

Background: The concept of cardiac resynchronisation therapy (CRT) is based on biventricular pacing in symptomatic, chronic heart failure (HF) patients with systolic left ventricular (LV) dysfunction and QRS &#8805; 120 ms. The response to CRT is determined by clinical and echocardiographic parameters. The change of biochemical status (e.g. natriuretic peptides or metalloproteinase levels) caused by CRT is not well explored. Aim: To analyse the clinical and haemodynamic changes caused by CRT in relation to patients&#8217; biochemical status and to assess factors determining a favourable response to CRT. Methods: Fifty patients with chronic systolic HF (NYHA IV: two patients), wide QRS complex (160 &#177; 31 ms) and reduced LV ejection fraction (26 &#177; 5.8%) under optimal pharmacotherapy, who underwent CRT, were enrolled. Data on NT-proBNP and C-reactive protein serum levels, as well as standard echocardiography with tissue Doppler measurements, were collected before CRT and after six months of pacing. The levels of matrix metalloproteinase-9 (MMP-9) were assessed in a subgroup of 18 patients. Patients were regarded as responders if LV end-systolic volume decreased by 10% compared to baseline. Results: Thirty five (70%) patients responded favourably to CRT. Cardiac resynchronisation therapy resulted in an improvement of max. ventilatory oxygen uptake (12.9 &#177; 3.8 vs 16.6 &#177; 4.7 mL/kg/min; p < 0.05), a of NT-proBNP decrease (2,579 &#177; 2,598 vs 1,339 &#177; 1,088 pg/mL, p < 0.05), and decrease of atrio-, inter- and intra-LV dyssynchrony. A greater baseline dyssynchrony was observed in responders. A decrease of MMP-9 level following CRT was observed in 12 (67%) patients. Significant MMP-9 decrease was observed only in the subgroup of ischaemic HF patients (26,100 &#177; 7,624 pg/mL vs 23,360 &#177; 6,258 pg/mL; p = = 0.03). In patients with MMP-9 decrease during CRT, a lower C-reactive protein concentration at baseline was observed (2.12 &#177; 1.6 vs 4.7 &#177; 4.1 mg/L). The reduction in LV end-diastolic diameter correlated with the changes in MMP-9 level (r = = 51; p = 0.03). Baseline left atrial end-diastolic diameter measured in parasternal long-axis view &#163; 46 mm had a sensitivity of 83% and a specificity of 67% in predicting MMP-9 decrease (AUC 0.83; 95% CI 0.59&#8211;0.96). Conclusions: The CRT induces favourable myocardial remodelling, resulting in NT-proBNP level decrease, improvement of regional and global biventricular function, and MMP-9 level reduction, in ischaemic HF patients. The changes of MMP-9 level may be predicted by baseline left atrial end-diastolic diameter and correlate with LV end-diastolic diameter change during CRT. Kardiol Pol 2011; 69, 10: 1043&#8211;1051Wstęp: Terapia resynchronizująca (CRT) jest oparta na koncepcji synchronicznej stymulacji prawej i lewej komory (LV) u pacjentów z zaawansowaną przewlekłą niewydolnością w przebiegu dysfunkcji skurczowej LV i poszerzonym zespołem QRS &#8805; 120 ms. Korzystna odpowiedź na CRT jest definiowana za pomocą klinicznych i echokardiograficznych kryteriów. Zmiany stanu pacjenta na poziomie biochemicznym (peptydy natriuretyczne, metaloproteinazy macierzy zewnątrzkomórkowej) wymagają przeprowadzenia dalszych badań. Cel: Celem pracy była analiza klinicznych, hemodynamicznych i biochemicznych zmian pod wpływem CRT oraz znalezienie czynników determinujących korzystną odpowiedź na CRT. Metody: Do badania włączono 50 pacjentów ze skurczową niewydolnością serca (NYHA IV &#8212; 2 pacjentów), poszerzonym zespołem QRS (160 &#177; 31 ms) i obniżoną frakcją wyrzutową LV (26 &#177; 5,8%), optymalnie leczonych farmakologicznie, u których zastosowano CRT. Analizie poddano dane echokardiograficzne (z włączeniem doplera tkankowego) i biochemiczne (NT-proBNP i CRP) zebrane przed terapią i po 6 miesiącach CRT. Stężenie metaloproteinazy macierzy zewnątrzkomórkowej- 9 (MMP-9) oceniono w podgrupie 18 pacjentów. Korzystną odpowiedź na CRT definiowano jako spadek objętości końcowoskurczowej LV o 10% w porównaniu z wartością wyjściową. Wyniki: Na CRT korzystnie odpowiedziało 35 (70%) pacjentów. Pod koniec obserwacji zarejestrowano poprawę maksymalnego zużycia tlenu w teście spiroergometrcznym (VO2 , z 12,9 &#177; 3,8 do 16,6 &#177; 4,7 ml/kg/min; p < 0,05), zmniejszenie stężenia NT-proBNP (z 2579 &#177; 2598 do 1339 &#177; 1088 pg/ml; p < 0.05) oraz redukcję dyssynchronii między-, przedsionkowo- i śródkomorowej. Przed CRT większą dyssynchronię zaobserwowano w grupie korzystnej odpowiedzi na CRT. Obniżenie stężenia MMP-9 zanotowano u 12 (67%) pacjentów, w tym istotne statystycznie wśród osób z niedokrwienną etiologią niewydolności serca (26 100 &#177; 7624 pg/ml v. 23 360 &#177; 6258 pg/ml; p = 0,03). W grupie pacjentów z redukcją MMP-9 stwierdzono niższe wyjściowe stężenie CRP (2,12 &#177; 1,6 v. 4,7 &#177; 4,1 mg/l). Zmniejszenie wymiaru końcoworozkurczowego LV korelowało ze zmianami MMP-9 (r = 51; p = 0,03). Wymiar lewego przedsionka przed CRT mierzony w przymostkowej osi długiej &#163; 46 mm z 83-procentową czułością i 67-procentową swoistością przewidywał spadek stężenia MMP-9 (AUC 0,83; 95% CI 0,59&#8211;0,96). Wnioski: Terapia resynchronizująca powoduje korzystną przebudowę mięśnia sercowego ze zmniejszeniem stężenia NT-proBNP, poprawę funkcji globalnej i regionalnej komór serca i redukcję stężenia MMP-9 wśród pacjentów z niedokrwienną niewydolnością serca. Zmiany stężenia MMP-9 podczas CRT dobrze korelują ze zmianami wymiaru końcoworozkurczowego LV i można je przewidywać, oceniając wyjściowy wymiar lewego przedsionka. Kardiol Pol 2011; 69, 10: 1043&#8211;105