Possible predicative role of electrical risk score on transcatheter aortic valve replacement outcomes in older patients. preliminary data

Background:Transcatheter aortic valve replacement (TAVR) is an effective procedure capable to change the natural history of the degenerative aortic valve stenosis. Despite the TAVR, the patients with advanced valve disease and severe myocardial damage (low flow, gradient and ejection fraction)show high mortality level. Aim of this study was toevaluate the predicative power of a noninvasive and inexpensive test obtained by means of a simple standard 12-leads electrocardiogram,known as the Electrical Risk Score (ERS). Methods: ERS was composed by seven simple ECG markers: heart rate (>75 bpm); QRS duration (>110 ms), left ventricular hypertrophy (Sokolow-Lyon criteria), delayed QRS transition zone (≥ V4), frontal QRS-T angle (>90°), long QTBazett (>450 ms for men and >460 in women) or JTBazett(330 ms for men and > 340 ms for women);long T peak to T end interval (Tp-e)( >89 ms). An ERS ≥ 4was considered high risk for all-cause or cardiovascular mortality.We calculated retrospectively the pre-procedure ERS in 40 TAVR patients after one year of follow-up. Results: In the follow up the all-cause and cardiovascular mortality were respectively 25% and 15%.None of survivors reported ERS ≥ 4,moreover, the ERS was the strongest predictor of all-cause (odd ratio 3.73, 95% CI: 1.44-9.66, p<0.05) or cardiovascular (odd ratio 3.95, 95% CI: 1.09-14.27, p<0.05) mortality.ROC curves showed that ERS had the widest significant sensitivity-specificity area under the curve (auc) predicting all-cause (auc: 0.855, p<0.05) or cardiovascular mortality (auc: 0.908, p<0.05). Conclusions:In this pivotal study, ERS resulted an useful tool to stratify the risk of mortality in one-year follow-up TAVR patients. Obviously, it is necessary to confirm these data in large prospective studies

Arrhythmic risk in elderly patients candidates to transcatheter aortic valve replacement. predicative role of repolarization temporal dispersion

Degenerative aortic valve stenosis (AS) is associated to ventricular arrhythmias and sudden cardiac death, as well as mental stress in specific patients. In such a context, substrate, autonomic imbalance as well as repolarization dispersion abnormalities play an undoubted role. Aim of the study was to evaluate the increase of premature ventricular contractions (PVC) and complex ventricular arrhythmias during mental stress in elderly patients candidate to the transcatheter aortic valve replacement (TAVR). In eighty-one elderly patients with AS we calculated several short-period RRand QT-derived variables at rest, during controlled breathing and during mild mental stress, the latter being represented by a mini-mental state evaluation (MMSE). All the myocardial repolarization dispersion markers worsened during mental stress (p &lt; 0.05). Furthermore, during MMSE, low frequency component of the RR variability increased significantly both as absolute power (LFRR) and normalized units (LFRRNU) (p &lt; 0.05) as well as the low-high frequency ratio (LFRR/HFRR) (p &lt; 0.05). Eventually, twenty-four (30%) and twelve (15%) patients increased significantly PVC and, respectively, complex ventricular arrhythmias during the MMSE administration. At multivariate logistic regression analysis, the standard deviation of QTend (QTesd), obtained at rest, was predictive of increased PVC (odd ratio: 1.54, 95% CI 1.14–2.08; p = 0.005) and complex ventricular arrhythmias (odd ratio: 2.31, 95% CI 1.40–3.83; p = 0.001) during MMSE. The QTesd showed the widest sensitive-specificity area under the curve for the increase of PVC (AUC: 0.699, 95% CI: 0.576–0.822, p &lt; 0.05) and complex ventricular arrhythmias (AUC: 0.801, 95% CI: 0.648–0.954, p &lt; 0.05). In elderly with AS ventricular arrhythmias worsened during a simple cognitive assessment, this events being a possible further burden on the outcome of TAVR. QTesd might be useful to identify those patients with the highest risk of ventricular arrhythmias. Whether the TAVR could led to a QTesd reduction and, hence, to a reductionof thearrhythmicburdenin thissettingofpatients isworthytobe investigated

Electrocardiographic and other noninvasive hemodynamic markers in decompensated CHF patients

cutely decompensated chronic heart failure (adCHF) is among the most important causes of in-hospital mortality. R-wave peak time (RpT) or delayed intrinsicoid deflection was proposed as a risk marker of sudden cardiac death and heart failure decompensation. Authors want to verify if QR interval or RpT, obtained from 12-lead standard ECG and during 5-min ECG recordings (II lead), could be useful to identify adCHF. At hospital admission, patients underwent 5-min ECG recordings, obtaining mean and standard deviation (SD) of the following ECG intervals: QR, QRS, QT, JT, and T peak–T end (Te). The RpT from a standard ECG was calculated. Patients were grouped by the age-stratified Januzzi NT-proBNP cut-off. A total of 140 patients with suspected adCHF were enrolled: 87 (mean age 83 ± 10, M/F 38/49) with and 53 (mean age: 83 ± 9, M/F: 23/30) without adCHF. V5-, V6- (p &lt; 0.05) RpT, and QRSD, QRSSD, QTSD, JTSD, and TeSD p &lt; 0.001 were significantly higher in the adCHF group. Multivariable logistic regression analysis demonstrated that the mean of QT (p &lt; 0.05) and Te (p &lt; 0.05) were the most reliable markers of in-hospital mortality. V6 RpT was directly related to NT-proBNP (r: 0.26, p &lt; 0.001) and inversely related to a left ventricular ejection fraction (r: 0.38, p &lt; 0.001). The intrinsicoid deflection time (obtained from V5-6 and QRSD) could be used as a possible marker of adCHF

Peak oxygen uptake in heart failure. Look behind the number!

An impaired peak oxygen uptake (V̇O2peak) during a maximal cardiopulmonary exercise test (CPET) has been shown extensively to correlate with a poor prognosis in heart failure (HF) patients. Even, the abovementioned relationship remains effective irrespective of the left ventricular ejection fraction (LVEF), a most recent study by Sato showing an unaltered V̇O2peak prognostic power also in the early defined HF with mid-range ejection fraction class (HFmrEF). The advantage of adopting V̇O2peak to evaluate and, possibly, to manage clinically this setting of patients is linked to its composite character which enables it to account for most of the mechanisms underlying the HF pathophysiology. In fact, as per the well-known Fick Law, V̇O2 represents arithmetically the resulting number of the product between cardiac output (CO = stroke volume*heart rate) and artero-venous O2 difference (ΔavO2). Thus, a reduced V̇O2peak, as a single variable, mirrors variably a reduced LVEF and/or a concomitant chronotropic incompetence as well as a huge number of conditions able to impact negatively on the O2 transport and deliver

Short-term RR-interval power spectral analys as a tool to stratify the risk of sudden deah in various cardiovascular condition

Recently short-term power spectral analysis of heart rate variability (HRV) has been used also to stratify the risk of sudden death in subjects with chronic heart failure (CHF). Short-term spectral analysis of RR variability in normotensive healthy subjects shows two distinct components of HRV: high-frequency power (HF), which synchronizes with breathing and therefore reflects vagal modulation of the sinus node, and low-frequency power (LF) oscillating around 0.1 Hz influenced also, though not solely, by sympathetic modulation of the sinus node. Among factors that strongly influence autonomic control of the sinus node and HRV are aging, hypertension and CHF. CHF, markedly reduces both spectral components of HRV and the paradoxical LF reduction is a risk factor for sudden death. It is reasonable that, in a next future, LF could become a useful tool to identify more precisely subjects at high risk of sudden death in various cardiovascular conditionsRecently short-term power spectral analysis of heart rate variability (HRV) has been used also to stratify the risk of sudden death in subjects with chronic heart failure (CHF). Short-term spectral analysis of RR variability in normotensive healthy subjects shows two distinct components of HRV: high-frequency power (HF), which synchronizes with breathing and therefore reflects vagal modulation of the sinus node, and low-frequency power (LF) oscillating around 0.1 Hz influenced also, though not solely, by sympathetic modulation of the sinus node. Among factors that strongly influence autonomic control of the sinus node and HRV are aging, hypertension and CHF. CHF, markedly reduces both spectral components of HRV and the paradoxical LF reduction is a risk factor for sudden death. It is reasonable that, in a next future, LF could become a useful tool to identify more precisely subjects at high risk of sudden death in various cardiovascular condition

Cardiopulmonary exercise test in hypertrophic cardiomyopathy

Understanding the functional limitation in hypertrophic cardiomyopathy, the most common inherited heart disease, is challenging. In addition to the occurrence of disease-related complications, several factors are potential determinants of exercise limitation, including left ventricular hypertrophy, myocardial fiber disarray, left ventricular outflow tract obstruction, microvascular ischemia, and interstitial fibrosis. Furthermore, drugs commonly used in the daily management of these patients may interfere with exercise capacity, especially those with a negative chronotropic effect. Cardiopulmonary exercise testing can safely and objectively evaluate the functional capacity of these patients and help the physician in understanding the mechanisms that underlie this limitation. Features that reduce exercise capacity may predict progression to heart failure in these patients and even the risk of sudden cardiac death

Cardiopulmonary exercise testing in heart failure: from ugly duckling to swan

[No abstract available

Cardiopulmonary exercise testing: An increasingly important step in managing hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy, the most common genetic heart disease, inherited with an autosomal dominant pattern, incomplete penetrance and variable expressivity, is characterized by markedly heterogeneous morphologic and clinical spectra […]. In such a context, as it is yet worldwide recognized in heart failure with reduced ejection fraction (HFrEF) […], the cardiopulmonary exercise test (CPET) is becoming an essential tool in the contemporary HCM clinical management […]. Indeed, also in this setting of patients, a well-reasoned CPET assessment might be extremely useful to evaluate objectively the true functional capacity […] as well as to better understand mechanisms underlying the exercise impairment [..]. Properly the latter aspect represents one of the most challenging field in the HCM scenario where, besides the disease-related complications, a number of factors have been advocated as possibly implied […], including left ventricular (LV) hypertrophy with myocardial fiber disarray and interstitial fibrosis, LV outflow tract obstruction, microvascular ischemia, chronotropic incompetence, peripheral muscle changes and, in nearly 5% of cases, even LV systolic dysfunction (progression to the “end-stage” phase) (Figure 1). Contextually, growing evidences suggest a possible role of the CPET variables also in stratifying the HCM risk of adverse cardiac events both in terms of sudden cardiac death (SCD) as well as of HF development […], the latter gaining even more in significance in the last decades due to the improvements in pharmacological and no-pharmacological HCM management