CRT in Patients with Heart Failure: Time Course of Perfusion and Wall Motion Changes

In patients treated with CRT no data relative to the relationship between regional wall motion and perfusion and reverse remodelling of the left ventricle at short and medium term followup were available. To this aim, 36 heart failure patients were studied by G-SPECT before (T0), within 2 months (T1) and 6 months (T2) after CRT. A clinical followup was completed for 36 months. In 30/36 patients there was an improvement of NYHA Class at T1 that persisted at T2. G-SPECT showed significant improvement of perfusion at T1 in 92% of patients without further changes at T2. A reduction of LV volumes, an increase of EF and an improvement of regional wall motion and thickening were observed at T1 versus baseline, with only minor changes at T2. Moreover, baseline extension of perfusion defects was scarcely correlated with improvement after CRT. Finally, end diastolic volume, perfusion defect and diabetes mellitus were independent predictors of survival. The main effects of CRT on regional myocardial perfusion and wall motion are obtained within 2 months. Volume overload modulates recovery of ventricular function independently of reperfusion and, with extension of perfusion abnormalities and diabetes were independent predictors of survival during followup

Double Trouble Percutaneous Disobstruction of 2 Pulmonary Veins Following Catheter Ablation for Atrial Fibrillation

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Adrenomedullin plasma levels as predictors of left ventricular reverse remodelling in patients treated with cardiac resynchronization therapy

Purpose: Adrenomedullin (ADM), a potent natriuretic and vasorelaxing peptide, has been isolated from human pheochromocytoma cells and from cardiovascular tissue. Increase in ADM plasma levels in congestive heart failure (CHF) patients (pts) is due to many cardiac and systemic factors and in particular to the greater plasma volume and to the activation of sympathetic nervous system. Aim of this study was to assess the role of plasma ADM levels in CHF pts treated by cardiac resynchronization therapy (CRT). Methods: 42 pts, mean age 70 years, 27 males, NYHA Class III-IV CHF underwent CRT. Cause of CHF were idiopathic dilated cardiomyopathy in 27 pts, post ischemic in 15; all pts were in sinus rhythm and with complete left bundle branch block (QRS duration 138?8 msec). A complete echoDoppler exam, blood samples for brain natriuretic peptide (BNP) and ADM were obtained within 2 days before implantation. Results: At 18?6 months follow-up, >1 NYHA Class improvement was observed in 31/42 pts. However, a >10% reduction in end-systolic dimensions (ESD): -18.2?2.3% was reported in 16 pts (Group I); in the remaining 26 pts ESD change was almost negligible: -1.5?3.2% (Group II). The two groups were comparable for age, sex, cause of LV dysfunction, ongoing therapy, QRS duration at baseline, pre implantation ESD (60.6?1.8 vs 59.9?1.9 mm - Group I vs II), LVEF% (24.3?1.2 vs 25.4?1.3%) and BNP (545?80 vs 494?89 pg/ml). Significantly higher pre implantation ADM levels were present in Group I than in Group II (25.8?2.4 pmol/l vs. 17.1?1.6, p = 0.005). Conclusions: Significantly higher ADM levels indicate a subgroup of pts in whom significant reverse remodelling can be observed after CRT. Since AM is also produced in cardiac myocytes, lower ADM values before CRT could suggest the presence of more severe myocardial damage which may impair LV reverse remodelling even in the setting of clinically successful resynchronization

Circulating adrenomedullin levels and Doppler-derived dP/dt in idopathic cardiomyopathy

Chronic heart failure (CHF) is characterized both by ventricular and vascular remodeling. Osteopontin (OP) is an extracellular matrix protein,that might have a role as a marker of ventricular remodelling, its expression being increased in myocardial tissue of CHF patients from biopsies. Adrenomedullin (AM), a potent vasodilator peptide secreted by endothelial cells, and endothelin (ET), a substance with long-acting vasocostrictor action, might express the paracrine vasomotor response to CHF progression

Livelli plasmatici di adrenomedullina come indicatori di prognosi dopo terapia di resincronizzazione cardiaca

The cardiac resynchronization therapy (CRT), based on correction of electro-mechanical dyssynchrony by biventricular pacing in patientswith severe chronicHF unresponsive to optimalmedical treatment and left ventricular conduction disturbances, has been developed. The determination of plasma adrenomedullin (ADM) levels before implantation could provide important additional information to reduce the high percentage (30%) of patients not responding to treatment despite the use of increasingly sophisticatedmethods for selecting candidates. The case described illustrates the importance of basal ADM plasma levels in predicting the clinical and functional improvement after treatment with CRT

Reverse left ventricular remodeling is more likely in non ischemic cardiomyopathy patients upgraded to biventricular stimulation after chronic right ventricular pacing

<p>Abstract</p> <p>Background</p> <p>Chronic right ventricular (RV) apical pacing may lead to left ventricular (LV) dyssynchrony and LV dysfunction. In heart failure due to RV pacing, upgrading to biventricular stimulation (CRT) can improve NYHA Class and LV function. A proportion of patients do not respond to upgrading. Aim was to assess whether etiology of LV dysfunction accounts for responses to CRT in RV-paced patients.</p> <p>Methods</p> <p>Sixty-two patients treated by CRT, under RV pacing from 50.2 ± 5.4 months, were studied. Cause of LV dysfunction was non-ischemic (NIC) in 28 and ischemic cardiomyopathy (IC) in 34 patients. Clinical and conventional echocardiographic parameters were available within 1 month before RV pacing, within 1 month before CRT and at 12 ± 2 months of follow-up (FU).</p> <p>Results</p> <p>Decreased LVEF (from 37.0 ± 8.8 to 25.6 ± 6.1%, p <0.001), increased LV end-systolic dimensions (LVESD) (from 48.1 ± 8.6 to 55.2 ± 7.9 mm, p <0.001) and worsened NYHA Class (from 1.9 ± 1.1 to 3.2 ± .6, p < 0.005) were found before CRT, compared to pre RV-pacing. After CRT, 44/62 patients showed a ≥ 1 NYHA Class improvement; >10% decrease in LVESD was observed in 24 patients: 5 with IC, 19 with NIC (p < .0.001). The association between cause of LV dysfunction with >10% decrease in LVESD remained highly significant (p < 0.001) adjusting for pre-CRT QRS duration, NYHA Class, LVEF, LVESD, treatment or RV pacing duration.</p> <p>Conclusions</p> <p>CRT improves functional class even after long-lasting pacing. Reverse remodeling is evident in a small population, more likely with NIC.</p

Prognostic impact of cardiac resynchronization therapy guided by phase analysis: a CZT study

Aims To evaluate whether phase analysis imaging may predict treatment response and long-term prognosis after cardiac resynchronization therapy (CRT). Methods and results Sixty-nine patients underwent myocardial perfusion imaging followed by CRT. Patients with ischaemic heart disease and non-ischaemic cardiomyopathy (NICM) were identified. Left ventricular (LV) mechanical dyssynchrony (LVMD) was assessed at phase analysis and the region of the latest mechanical activation was identified. LV pacing lead position was considered ‘concordant’ when located in the region of the latest mechanical activation, and ‘discordant’ otherwise. The ‘6 months post-CRT’/‘baseline’ ratio of LV ejection fraction was computed as a measure of CRT response. LVMD was revealed in 47/69 patients, 27 of whom (57%) had a concordant LV lead implantation. Only concordant pacing was associated with LV functional improvement (ejection fraction ratio: 1.28 ± 0.25 vs. 1.11 ± 0.32 in discordant stimulation, P = 0.028). However, this relationship persisted only in patients with NICM (P &lt; 0.001), while it disappeared in those with ischaemic heart disease (P = NS). Twenty-eight events occurred during 30 ± 21 months follow-up. While discordant LV lead location was the major predictor of unfavourable prognosis (hazard ratio 3.29, 95% confidence interval 1.25–8.72; P = 0.016), this relationship was confirmed only in patients with NICM. Conclusions Phase analysis of myocardial perfusion imaging may guide CRT implantation, identifying patients who would most likely benefit from this procedure

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In patients treated with CRT no data relative to the relationship between regional wall motion and perfusion and reverse remodelling of the left ventricle at short and medium term followup were available. To this aim, 36 heart failure patients were studied by G-SPECT before (T0), within 2 months (T1) and 6 months (T2) after CRT. A clinical followup was completed for 36 months. In 30/36 patients there was an improvement of NYHA Class at T1 that persisted at T2. G-SPECT showed significant improvement of perfusion at T1 in 92% of patients without further changes at T2. A reduction of LV volumes, an increase of EF and an improvement of regional wall motion and thickening were observed at T1 versus baseline, with only minor changes at T2. Moreover, baseline extension of perfusion defects was scarcely correlated with improvement after CRT. Finally, end diastolic volume, perfusion defect and diabetes mellitus were independent predictors of survival. The main effects of CRT on regional myocardial perfusion and wall motion are obtained within 2 months. Volume overload modulates recovery of ventricular function independently of reperfusion and, with extension of perfusion abnormalities and diabetes were independent predictors of survival during followup

The role of stress myocardial perfusion to predict left ventricular reverse remodeling in patients with ischemic cardiomyopathy treated by resynchronisation therapy

Purpose: Cardiac resynchronization therapy (CRT) improves quality of life and left ventricular (LV) function in patients (pts) with heart failure; however, improvement in LV function is known to be less evident in ischemic (IC) rather than in non ischemic cardiomyopathy. Assessment of baseline perfusion defects has been used for the prediction of response to CRT in IC; little is known on the effects of myocardial ischemia at the time of implantation on LV reverse remodeling at follow up (FU) in pts treated by CRT. Methods: Fortysix IC pts treated by CRT were studied. All were in NYHA Class III, LVEF ,35%, left bundle branch block with a QRS duration of 154+8 msec, under optimal medical therapy for ischemia and heart failure and no indications to percutaneous or surgical revascularization. Pts underwent conventional echocardiography and stress/ rest myocardial scintigraphy - effort in 28, i.v. dipyridamole in 18 - within 3 weeks before CRT. Among scintigraphic variables, summed rest (SRS), summed stress (SSS) and summed difference score (SDS) were quantitatively analyzed. Results: Pts were divided according to the extension of ischemic area detected by myocardial scintigraphy: Group I (n 32): pts in whom SDS was &#8804;4, Group II (n 14): pts with SDS .4. No differences were observed between Group I and II in NYHA Class, baseline LVEF, site of previous myocardial infarction, myocardial perfusion score (SRS: 12.4+1.2 vs 10.5+1.6) and pre-CRT echocardiographic end systolic dimensions (ESD): 56.2+1.2 vs 56.3+1.6 mm. At 12+1 month FU, clinical improvement (&#8805;1 NYHA Class reduction) was found in 29/46 pts, 23 in G I pts and 6 in G II pts (p=.05); however, a significant reduction in echocardiographic ESD was seen in G I pts, while no significant changes in ESD could be reported in G II (-9.1+1.2%, vs 20.9+1.1%, p ? 0.01). In the total population, no relation (r ? 0.12) existed between baseline perfusion and changes in ESD at FU. Conclusions: Extension of ischemia evaluated by stress myocardial scintigraphy provides more reliable information than baseline perfusion on LV reverse remodeling in IC pts with no revascularization options treated by CRT