Multimodality imaging to guide cardiac interventional procedures

In recent years, a number of new cardiac interventional procedures have been introduced. Catheter ablation procedures for atrial fibrillation (AF) have been refined and are now considered a good treatment option in patients with drug-refractory AF. In cardiac pacing, cardiac resynchronization therapy (CRT) is now standard of care for patients with drug-refractory heart failure. At the same time, CRT may also be beneficial in patients with heart failure after long-term right ventricular (RV) apical pacing. Finally, new percutaneous procedures for valvular heart disease have been introduced for patients that are deemed inoperable. At the same time, various imaging modalities have been further developed and important advances have been made in the integration of different imaging modalities. The aim of the present thesis was to explore the role of multimodality imaging in cardiac interventional procedures. In Part I, the integration of different imaging modalities during catheter ablation procedures for AF was studied. In addition, the effects of these procedures on left atrial and left ventricular (LV) size and function were investigated. Part II studied the effects of RV apical pacing on LV dyssynchrony and mechanics, and the effect of upgrade to CRT. Finally, in Part III the role of imaging in new percutaneous procedures for valvular heart disease was explored.UBL - phd migration 201

The ever-changing field of mechanical circulatory support: new challenges at the advent of the 'single device era'

Cardiolog

Fusion cardiac resynchronization therapy in an left ventricular assist device patient from two devices and crossing leads: a case report

Background Cardiac implanted electronic devices (CIED) have significantly improved the survival and quality of life in heart failure patients. Although implantable cardioverter-defibrillators (ICD) and cardiac resynchronization therapy (CRT) have a major role in patients with moderate to severe heart failure symptoms, the role of these devices in patients with a left ventricular assist device (LVAD) is not yet well defined. The burden of CIED-related procedures in patients with an LVAD is high. The price of lead malfunctions and pocket complications requires creative approaches to tackle CIED-related issues in this patient population.Case summary Here, we describe the clinical course of a 67-year-old ventricular pacing dependent LVAD patient with an ICD indication based on recurrent monomorphic ventricular tachycardias and a CRT indication due to previous deterioration of (right-sided) heart failure in the absence of biventricular pacing. We were confronted with impending right ventricular lead failure and bilateral venous access problems due to chronic subclavian vein occlusion in a patient with a total of five transvenous leads, therapeutic anticoagulation, and pronounced thoracic collaterals. We sought for a creative solution to be able to deliver effective biventricular fusion pacing with the existing leads from two contralateral pulse generators resulting in biventricular fusion pacing. This provided the solution to deliver effective CRT.Discussion This case illustrates the complexity of care and CIED-related decision-making in pacing dependent LVAD patients, in particularly those with an ICD and CRT indication.Cardiolog

Prognostic value of natriuretic peptides for all-cause mortality, right ventricular failure, major adverse events, and myocardial recovery in advanced heart failure patients receiving a left ventricular assist device: a systematic review

Aims: Major adverse event (MAE) rates during left ventricular assist device (LVAD) therapy in advanced heart failure (HF) patients are high, and impair quality of life and survival. Prediction and risk stratification of MAEs in order to improve patient selection and thereby outcome during LVAD therapy is therefore warranted. Circulating natriuretic peptides (NPs) are strong predictors of MAEs and mortality in chronic HF patients. However, whether NPs can identify patients who are at risk of MAEs and mortality or tend toward myocardial recovery after LVAD implantation is unclear. The aim of this systematic review is to analyze the prognostic value of circulating NP levels before LVAD implantation for all-cause mortality, MAEs and myocardial recovery after LVAD implantation.Methods and Results: Electronic databases were searched for studies analyzing circulating NP in adults with advanced HF before LVAD implantation in relation to mortality, MAEs, or myocardial recovery after LVAD implantation. Twenty-four studies published between 2008 and 2021 were included. Follow-up duration ranged from 48 hours to 5 years. Study sample size ranged from 14 to 15,138 patients. Natriuretic peptide levels were not predictive of all-cause mortality. However, NPs were predictive of right ventricular failure (RVF) and MAEs such as ventricular arrhythmias, moderate or severe aortic regurgitation, and all-cause rehospitalization. No relation between NPs and myocardial recovery was found.Conclusion: This systematic review found that NP levels before LVAD implantation are not predictive of all-cause mortality after LVAD implantation. Thus, NP levels may be of limited value in patient selection for LVAD therapy. However, NPs help in risk stratification of MAEs and may be used to identify patients who are at risk for RVF, ventricular arrhythmias, moderate or severe aortic regurgitation, and all-cause rehospitalization after LVAD implantation.Cardiolog

Right ventricular dysfunction affects survival after surgical left ventricular restoration

Cardiolog

Guidance on the management of left ventricular assist device (LVAD) supported patients for the non-LVAD specialist healthcare provider: executive summary

The accepted use of left ventricular assist device (LVAD) technology as a good alternative for the treatment of patients with advanced heart failure together with the improved survival of patients on the device and the scarcity of donor hearts has significantly increased the population of LVAD supported patients. Device-related, and patient-device interaction complications impose a significant burden on the medical system exceeding the capacity of LVAD implanting centres. The probability of an LVAD supported patient presenting with medical emergency to a local ambulance team, emergency department medical team and internal or surgical wards in a non-LVAD implanting centre is increasing. The purpose of this paper is to supply the immediate tools needed by the non-LVAD specialized physician - ambulance clinicians, emergency ward physicians, general cardiologists, and internists - to comply with the medical needs of this fast-growing population of LVAD supported patients. The different issues discussed will follow the patient's pathway from the ambulance to the emergency department, and from the emergency department to the internal or surgical wards and eventually back to the general practitioner.Cardiolog

Multimodality imaging to guide cardiac interventional procedures

In recent years, a number of new cardiac interventional procedures have been introduced. Catheter ablation procedures for atrial fibrillation (AF) have been refined and are now considered a good treatment option in patients with drug-refractory AF. In cardiac pacing, cardiac resynchronization therapy (CRT) is now standard of care for patients with drug-refractory heart failure. At the same time, CRT may also be beneficial in patients with heart failure after long-term right ventricular (RV) apical pacing. Finally, new percutaneous procedures for valvular heart disease have been introduced for patients that are deemed inoperable. At the same time, various imaging modalities have been further developed and important advances have been made in the integration of different imaging modalities. The aim of the present thesis was to explore the role of multimodality imaging in cardiac interventional procedures. In Part I, the integration of different imaging modalities during catheter ablation procedures for AF was studied. In addition, the effects of these procedures on left atrial and left ventricular (LV) size and function were investigated. Part II studied the effects of RV apical pacing on LV dyssynchrony and mechanics, and the effect of upgrade to CRT. Finally, in Part III the role of imaging in new percutaneous procedures for valvular heart disease was explored