Body composition in heart failure and the impact of cardiac resynchronisation therapy: a proof-of-concept study

Aims

Body composition (BC) is known to alter in heart failure. Cardiac resynchronisation therapy (CRT) improves left ventricular geometry but the impact on BC is unknown. Our aim was to evaluate BC in these patients before and after CRT implantation.

Methods

Prospective proof-of-concept pilot study of heart failure patients undergoing CRT between September 2014 and December 2015. Assessments performed pre-CRT and post-CRT (6 weeks and 6 months) were: BC parameters (using air-displacement plethysmography), New York Heart Failure classification for assessing symptom severity, echocardiography to assess left ventricular geometry, electrocardiography, Minnesota Heart Failure Questionnaire and N-terminal probrain natriuretic peptide (NT-pro-BNP). Repeated measures analysis of variance was performed to assess relative change over time and potential correlations.

Results

Twenty-five patients were recruited; mean-age (±SD) was 73.4±10.0 years, 23 males, 18 CRT defibrillators (remainder CRT pacemakers), 16 had ischaemic aetiology, 6 diabetics, 17 with left bundle-branch morphology on ECG and 10 had atrial fibrillation. Significant inverse correlations were observed in the first 6 weeks following CRT between fat mass and left ventricular end-diastolic volume (r=−0.69, p<0.01) and NT-pro-BNP and fat mass (r=0.41, p=0.05). No significant differences were noted over 6 months. There was an observed trend towards reduced fat mass in the first 6 weeks post-CRT implant driven by non-responders. There was no significant difference between responders and non-responders in BC over 6 months.

Conclusion

This is the first study to observe interplay between BC and cardiac geometry/function following CRT; a trend in overall fat mass reduction was noted following CRT and merits further study.

Chest radiographs of cardiac devices (Part 1): Cardiovascular implantable electronic devices, cardiac valve prostheses and Amplatzer occluder devices

Several new innovative cardiac devices have been created over the last few decades. Chest radiographs (CXRs) are the most common imaging investigations undertaken because of their value in evaluating the cardiorespiratory system. It is important for the interpreting radiologist to not only identify these iatrogenic objects but also to assess for their accurate placement, as well as for any complications related to their placement, which may be seen either on the immediate post-procedural CXR or on a follow-up CXR.

Update in Cardiac Pacing

Initial efforts to artificially stimulate the heart were borne out of a necessity to prevent catastrophic bradycardic events. The initial pacemaker systems were large, bulky external devices. However, advancements in technology allowed for the development of internally powered, fully implantable devices. Further advancements resulted in more complex, programmable devices, but the overall systems have remained largely unchanged for more than 50 years. The most recent advancements in the field have represented fundamental paradigm shifts in both pacemaker design and the approach to cardiac pacing. These efforts have focused on reducing and eliminating hardware to reduce the risk of complications and to focus on improving cardiac efficiency to improve clinical outcomes. In this article, the authors explore these advances including leadless pacemaker systems, permanent His bundle pacing and advances in the field of cardiac resynchronisation therapy.

Cardiac Resynchronisation Therapy and Cellular Bioenergetics: Effects Beyond Chamber Mechanics

Cardiac resynchronisation therapy is a cornerstone in the treatment of advanced dyssynchronous heart failure. However, despite its widespread clinical application, precise mechanisms through which it exerts its beneficial effects remain elusive. Several studies have pointed to a metabolic component suggesting that, both in concert with alterations in chamber mechanics and independently of them, resynchronisation reverses detrimental changes to cellular metabolism, increasing energy efficiency and metabolic reserve. These actions could partially account for the existence of responders that improve functionally but not echocardiographically. This article will attempt to summarise key components of cardiomyocyte metabolism in health and heart failure, with a focus on the dyssynchronous variant. Both chamber mechanics-related and -unrelated pathways of resynchronisation effects on bioenergetics – stemming from the ultramicroscopic level – and a possible common underlying mechanism relating mechanosensing to metabolism through the cytoskeleton will be presented. Improved insights regarding the cellular and molecular effects of resynchronisation on bioenergetics will promote our understanding of non-response, optimal device programming and lead to better patient care.

Implantable Cardiac Electronic Devices in the Elderly Population

The use of cardiac implantable electronic devices in the management of patients with heart rhythm conditions is well established. As the population ages, the use of cardiac implantable electronic devices in the elderly is likely to increase. This review provides a summary of the indications, implantation considerations and pragmatic advice on how to approach the use of these devices in this group of patients.

Adverse Consequences of Right Ventricular Apical Pacing and Novel Strategies to Optimize Left Ventricular Systolic and Diastolic Function

Several studies have focused on the deleterious consequences of Right Ventricular Apical (RVA) pacing on Left Ventricular (LV) function, mediated by pacing-induced ventricular dyssyn-chrony. Therapeutic strategies to reduce the detrimental consequences of RVA pacing have been pro-posed, that includes upgrading of RVA pacing to Cardiac Resynchronization Therapy (CRT), alterna-tive Right Ventricular (RV) pacing sites, minimal ventricular pacing strategies, as well as atrial-based pacing. In developing countries, single chamber RV pacing still constitutes a majority of cases of permanent pacing, and assessment of the optimal RV pacing site is of paramount importance. In chronically-paced patients, it is crucial to maintain as close and normal LV physiological function as possible, by minimizing ventricular dyssynchrony, reducing the chances for heart failure and other complications to develop. This review provides an analysis of the deleterious immediate and long-term consequences of RVA pacing, and the most recent available evidence regarding improvements in pacing options and strategies to optimize LV diastolic and systolic function. Furthermore, the place of advanced echocardiography in the identification of patients with pacing-induced LV dysfunction, the potential role of a new predictor of LV dysfunction in RV-paced subjects, and the long- term out-comes of patients with RV septal pacing will be explored

Outcomes of patients with heart failure after primary prevention ICD unit generator replacement

OBJECTIVE

Data describing outcomes after implantable cardioverter-defibrillator (ICD) unit generator replacement in patients with heart failure (HF) with primary prevention devices are limited.

METHOD

Data on patients with HF who underwent primary prevention ICD/cardiac resynchronisation therapy-defibrillator (CRT-D) implantation from 2007 until mid-2015 who subsequently received unit generator replacement were analysed. Outcomes assessed were mortality, appropriate ICD therapy and shock, and procedural complications.

RESULTS

61 of 385 patients with HF with primary prevention ICD/CRT-D undergoing unit generator replacement were identified. Follow-up period was 1.8±1.5 years after replacement. 43 (70.5%) patients had not received prior appropriate ICD therapy prior to unit replacement. The cumulative risks of appropriate ICD therapy at 1, 3 and 5 years after unit replacement in those without prior ICD therapy were 0%, 6.2% and 50% compared with 6.2%, 59.8% and 86.6%, respectively (p=0.005) in those with prior ICD therapies. No predictive factors associated with appropriate ICD therapy after replacement could be identified. 41 (32.8%) patients no longer met guideline indications at the time of unit replacement but risks of subsequent appropriate ICD interventions were not different compared with those who continued to meet primary prevention ICD indications.The 5-year mortality risk after unit replacement was 18.4% and there were high procedural complication rates (9.8%).

CONCLUSION

No predictive marker successfully stratified patients no longer needing ICD support prospectively. Finding such a marker is important in decision-making about device replacement particularly given the concerns about the complication rates. These factors should be considered at the time of ICD unit replacement.

Contractility surrogates derived from three-dimensional lead motion analysis and prediction of acute haemodynamic response to CRT

Background

Patient-specific left ventricular (LV) lead optimisation strategies with immediate feedback on cardiac resynchronisation therapy (CRT) effectiveness are needed. The purpose of this study was to compare contractility surrogates derived from biventricular lead motion analysis to the peak positive time derivative of LV pressure (dP/dt_max) in patients undergoing CRT implantation.

Methods

Twenty-seven patients underwent CRT implantation with continuous haemodynamic monitoring. The right ventricular (RV) lead was placed in apex and a quadripolar LV lead was placed laterally. Biplane fluoroscopy cine films facilitated construction of three-dimensional RV–LV interlead distance waveforms at baseline and under biventricular pacing (BIVP) from which the following contractility surrogates were derived; fractional shortening (FS), time to peak systolic contraction and peak shortening of the interlead distance (negative slope). Acute haemodynamic CRT response was defined as LV ∆dP/dt_max ≥ 10 %.

Results

We observed a mean increase in dP/dt_max under BIVP (899±205 mm Hg/s vs 777±180 mm Hg/s, p<0.001). Based on ΔdP/dt_max, 18 patients were classified as acute CRT responders and nine as non-responders (23.3%±10.6% vs 1.9±5.3%, p<0.001). The baseline RV–LV interlead distance was associated with echocardiographic LV dimensions (end diastole: R=0.61, p=0.001 and end systole: R=0.54, p=0.004). However, none of the contractility surrogates could discriminate between the acute CRT responders and non-responders (ΔFS: −2.5±2.6% vs − 2.0±3.1%, p=0.50; Δtime to peak systolic contraction: −9.7±18.1% vs −10.8±15.1%, p=0.43 and Δpeak negative slope: −8.7±45.9% vs 12.5±54.8 %, p=0.09).

Conclusion

The baseline RV–LV interlead distance was associated with echocardiographic LV dimensions. In CRT recipients, contractility surrogates derived from the RV–LV interlead distance waveform could not discriminate between acute haemodynamic responders and non-responders.

Protocol-driven remote monitoring of cardiac resynchronization therapy as part of a heart failure disease management strategy

BACKGROUND

Cardiac resynchronisation therapy (CRT) is an established treatment for heart failure (HF) with reduced ejection fraction. CRT devices are equipped with remote monitoring functions, which are pivotal in the detection of device problems, but may also facilitate disease management. The aim of this study was to provide a comprehensive overview of the clinical interventions taken based on remote monitoring.

METHODS

This is a single centre observational study of consecutive CRT patients (n = 192) participating in protocol-driven remote follow-up. Incoming technical- and disease-related alerts were analysed together with subsequently triggered interventions.

RESULTS

During 34 ± 13 months of follow-up, 1372 alert-containing notifications were received (2.53 per patient-year of follow-up), comprising 1696 unique alerts (3.12 per patient-year of follow-up). In 60%, notifications resulted in a phone contact. Technical alerts constituted 8% of incoming alerts (0.23 per patient-year of follow-up). Rhythm (1.43 per patient-year of follow-up) and bioimpedance alerts (0.98 per patient-year of follow-up) were the most frequent disease-related alerts. Notifications included a rhythm alert in 39%, which triggered referral to the emergency room (4%), outpatient cardiology clinic (36%) or general practitioner (7%), or resulted in medication changes (13%). Sole bioimpedance notifications resulted in a telephone contact in 91%, which triggered outpatient evaluation in 8% versus medication changes in 10%. Clinical outcome was excellent with 97% 1-year survival.

CONCLUSIONS

Remote CRT follow-up resulted in 0.23 technical- versus 2.64 disease-related alerts annually. Rhythm and bioimpedance notifications constituted the majority of incoming notifications which triggered an actual intervention in 22% and 15% of cases, respectively.

Coronary sinus ostial atresia with persistent left superior caval vein in a patient with congenitally corrected transposition of the great arteries

We present a case of a 57-year-old man with congenitally corrected transposition of great vessels who was found to have coronary ostial atresia with cranial flow through left superior vena cava on CT with contrast injection in coronary tributaries. As such, he was ineligible for cardiac resynchronization therapy.

Significant mitral regurgitation as a predictor of long-term prognosis in patients receiving cardiac resynchronisation therapy

BACKGROUND

Cardiac resynchronisation therapy (CRT) has been shown to reduce functional mitral regurgitation, although the relationship between significant mitral regurgitation (SMR) and the clinical prognosis of CRT remains uncertain.

AIM

We sought to investigate the association of baseline SMR with long-term outcomes in patients undergoing CRT.

METHODS

A total of 296 consecutive patients undergoing CRT were enrolled. SMR was quantified by colour Doppler in all patients at baseline and defined as level ≥ 3 on the severity scale. The primary endpoints included all-cause death, heart failure hospitalisation (HFH), and heart transplantation, and the secondary endpoints were response to CRT and New York Heart Association (NYHA) class III or IV six months after CRT implantation.

RESULTS

The mean age was 59 ± 11 years, and 202 (68.2%) patients were male. Among all patients, 124 (41.9%) presented with baseline SMR. Over a mean follow-up of 4.17 ± 3.16 years, there were 53 (17.9%) cases of all-cause death, 41 (13.8%) cases of HFH, and four (1.4%) cases of heart transplantation. SMR was positively associated with primary endpoint events (hazard ratio [HR] 1.602, 95% confidence interval [CI] 1.083-2.371, p = 0.019), HFH (HR 3.567, 95% CI 1.763-7.219, p < 0.001) and NYHA class III or IV (HR 2.101, 95% CI 1.313-3.363, p = 0.002). After adjusting for multiple factors, we found that SMR (HR 1.785, 95% CI 1.091-2.920, p = 0.021), ischaemic heart disease (HR 1.628, 95% CI 1.062-2.494, p = 0.025), and the lack of use of spironolactone (HR 2.044, 95% CI 1.040-4.017, p = 0.038) were independent predictors of primary endpoints, and SMR remained an independent predictor of HFH (HR 4.622, 95% CI 1.955-10.923, p < 0.001).

CONCLUSIONS

Significant mitral regurgitation before CRT implantation was strongly associated with long-term poor progno-sis. SMR was positively associated with HFH rather than all-cause death and CRT response.

Are changes in heart rate, observed during dobutamine stress echocardiography, associated with a response to cardiac resynchronisation therapy in patients with severe heart failure? Results of a multicentre ViaCRT study

BACKGROUND

According to current European Society of Cardiology guidelines for the diagnosis and treatment of heart failure (HF), cardiac resynchronisation therapy (CRT) is indicated in patients suffering from HF with reduced ejection fraction (EF) with significantly widened QRS complexes. The presence of vital myocardium proven by dobutamine stress echocardiography (DSE) is considered as a good prognostic factor for responsiveness to this treatment. Chronotropic incompetence is, on the other hand, a known factor of unfavourable outcome in HF.

AIM

The aim of this study was to analyse the relationship between heart rate (HR) response during DSE and resultant changes in echocardiographic parameters determined prior to CRT and six weeks post-implantation of the CRT system.

METHODS

The study included 72 men and 25 women with chronic HF and markedly deteriorated left ventricular (LV) sys-tolic function (EF < 35%). Low-dose DSE was performed prior to the CRT system implantation. Baseline echocardiographic parameters determined before CRT were compared to those measured six weeks after implantation.

RESULTS

Implantation of the CRT system resulted in an improvement of LV systolic function. DSE showed a significant in-crease in HR, by 16.3 bpm on average. Patients with the least prominent increase in HR during DSE (< 7 bpm) presented with significantly greater end-diastolic LV dimension and volume, as well as with significantly lower EF than the subjects with the most evident increase in HR (> 24 bpm). Improvement in EF at six weeks was associated with lower baseline HR and its greater absolute and relative increase during DSE. Greater absolute increase in HR during DSE was also associated with more prominent decrease in systolic/diastolic LV volumes.

CONCLUSIONS

Patients with better chronotropic response during DSE show significant improvement in LV parameters determined by echocardiography within six weeks of CRT. Chronotropic response to pharmacologic stress test may serve as a predictive factor in patients qualified for CRT.

Overview of implantable cardioverter defibrillator and cardiac resynchronisation therapy in heart failure management

Clinical trials have established the benefits of implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy (CRT) in the treatment of heart failure patients. As adjuncts to guideline-directed medical therapy, ICDs confer mortality benefits from sudden cardiac arrest, while CRT reduces mortality, hospitalisation rates and improves functional capacity. This review discusses the use of ICDs and CRT devices in heart failure management, outlining the evidence supporting their use, indications and contraindications.

Long-term complications, reoperations and survival following cardioverter-defibrillator implant

OBJECTIVE

Implantable cardioverter-defibrillators (ICDs) reduce risk of death in select populations, but are also associated with harms. We aimed to characterise long-term complications and reoperation rate.

METHODS

We assessed the rate, cumulative incidence and predictors of long-term reoperation and survival using a prospective, multicentre registry serving British Columbia in Canada, a universal single payer healthcare system with 4.5 million residents. 3410 patients (mean 63.3 years, 81.7% male) with new primary (n=1854) or secondary prevention (n=1556) ICD implant from 2003 to 2012 were followed for a median of 34 months (single chamber n=1069, dual chamber n=1905, biventricular n=436). Independent predictors of adverse outcomes were defined using Cox regression models.

RESULTS

The overall reoperation rate was 12.0% per patient-year, and less for single vs dual vs biventricular ICDs (9.1% vs 12.5% vs 17.8% per patient-year, respectively). The Kaplan-Meier complication estimates (excluding generator end of life) at 1, 3 and 5 years were respectively: single chamber 10.2%, 16.2% and 21.6%; dual 11.7%, 19.1% and 27.4% and biventricular 15.9%, 22.2% and 24.7%. Cardiac resynchronisation therapy had the highest rate of early lead complications, but lower long-term need for upgrade. Device complexity, age and atrial fibrillation were key determinants of complications. Overall mortality at 1, 3 and 5 years was 5.4%, 17.4% and 32.7%, respectively. In younger patients, observed 5-year survival approached the expected survival in the general population (relative survival ratio=0.96 (0.90-0.98)). With increasing age, observed survival steadily declined relative to expected.

CONCLUSIONS

In a prospective registry capturing all procedures, complication and reoperation rates following de novo ICD implantation were high. Shared decision making must carefully consider these factors.

Chronic heart failure part 2: treatment and management

Chronic heart failure is a common and complex clinical syndrome that results from impaired cardiac relaxation or contraction. There have been considerable advances in the management of chronic heart failure; however, the mortality rate remains high. Patients with chronic heart failure may experience multiple debilitating symptoms, such as fatigue, pain, and peripheral oedema. However, breathlessness may be considered the most debilitating symptom. The management of chronic heart failure aims to improve the patient's quality of life by reducing symptoms and supporting the patient to manage their condition. Treatment of patients with chronic heart failure may involve a combination of pharmacological therapy, device implantation and cardiac rehabilitation. This is the second of two articles on chronic heart failure. Part 1 discussed the pathophysiology of chronic heart failure, its causes, assessment, signs and symptoms. Part 2 outlines the treatment and management of patients with the condition, including pharmacological strategies, device implantation, lifestyle modification, cardiac rehabilitation and palliative care.

Highlights of the 2016 European Society of Cardiology Guidelines on Heart Failure

The European Society of Cardiology guidelines for the diagnosis and treatment of heart failure (HF) was updated in 2016. In this article, highlights of the updates made based on new findings and practical recommendations are presented. The 2016 guidelines include definitions and criteria for diagnosing the different types of HF. In addition, a newly developed algorithm is proposed for treating particularly symptomatic HF with reduced ejection fraction, including the use of the angiotensin-converting enzyme inhibitors, beta-blockers, mineralocorticoid receptor antagonists and the angiotensin receptor neprilysin inhibitor sacubitril/valsartan. Further evidence is required for some aspects of the diagnosis and treatment of HF, but these guidelines will prove useful for decision making in this setting.

Key Lessons from the ELECTRa Registry in the Modern Era of Transvenous Lead Extraction

The implantation rate of cardiac electronic devices has grown over the past decades. The number of treated patients has increased in parallel with the complexity of the patient population treated, being older, frailer, having more complex devices (in particular, cardiac resynchronisation therapy) and presenting with a greater comorbidity burden. As a consequence, there is a rising number of related implanted system complications, including malfunction and infection. Thus, the demand for transvenous lead extraction (TLE) has also substantially increased. To identify the indication to TLE by various operators and centres, techniques used to perform TLE, and the safety and efficacy of the current clinical practice of TLE, a large prospective registry has been started in Europe - the European Lead Extraction Controlled (ELECTRa) Registry. The key findings of the ELECTRa Registry are discussed in the present review and placed in the context of previous knowledge. The ELECTRa Registry confirms that the TLE procedure is a safe and effective treatment, with an acceptable risk-benefit ratio that is comparable with other well-known cardiological invasive procedures. Of course, TLE is accompanied by potential life-threatening complications; the vast majority of these can be managed by an experienced multidisciplinary team. Multiple factors predict complications, including patient/lead profile, centre experience and procedure volumes, which may suggest caution when accepting a patient for TLE.

Is There a Future for Remote Cardiac Implantable Electronic Device Management?

In the era of communication technology, remote monitoring has been a paradigm shift in the way patients with cardiac implantable electronic devices are managed. It has been endorsed by scientific societies and is being increasingly adopted in the clinical setting. Despite the various advantages associated with this strategy, data on improved clinical outcome are still sparse. The recently published study on the remote management of heart failure using implanted devices and formalised follow-up procedures, which turned out to be negative, has cast doubt on whether remote monitoring should still be used. This article provides a critical appraisal of the study, and discusses the issue of remote data management.

The Prognostic Role of Tissue Characterisation using Cardiovascular Magnetic Resonance in Heart Failure

Despite significant advances in heart failure diagnostics and therapy, the prognosis remains poor, with one in three dying within a year of hospital admission. This is at least in part due to the difficulties in risk stratification and personalisation of therapy. The use of left ventricular systolic function as the main arbiter for entrance into clinical trials for drugs and advanced therapy, such as implantable defibrillators, grossly simplifies the complex heterogeneous nature of the syndrome. Cardiovascular magnetic resonance offers a wealth of data to aid in diagnosis and prognostication. The advent of novel cardiovascular magnetic resonance mapping techniques allows us to glimpse some of the pathophysiological mechanisms underpinning heart failure. We review the growing prognostic evidence base using these techniques.

Gender-related differences in coronary venous anatomy: a potential basis for various response to cardiac resynchronisation therapy

BACKGROUND AND AIM

We hypothesised that small differences in the anatomy of the coronary venous tree might be one of the factors responsible for the differences in the response for cardiac resynchronisation depending on a patient's gender.

METHODS

Cardiac computed tomography scans with retrospective gating were performed on 315 subjects (aged 58.3 ± 11.6 years; 117 women) according to the clinical criteria. The standard protocol for coronary arteries was used during scanning. Additional reconstructions that were focused on the coronary veins during post processing were used to analyse the data. Gender-related anatomical variants were identified.

RESULTS

The average of 3.6 ± 1.4 veins per case were visualised. The posterolateral vein was visualised more frequently in men than in women (p < 0.05). Eight variants were identified as being more frequent - they were found in 237 out of 315 cases (75.24%). Those variants occurred in 95 (81.19%) of the women and in 142 (71.72%) of the men, p = 0.080. Six variants occurred more frequently in women; however, the differences were not significant.

CONCLUSIONS

In women a more frequent presence of favourable coronary vein variants in the target area for cardiac resynchronisation can be seen. Anatomical findings may help to explain why women more frequently respond to cardiac resyn-chronisation therapy compared to men.

Pacing and Defibrillators in Complex Congenital Heart Disease

Device therapy in the complex congenital heart disease (CHD) population is a challenging field. There is a myriad of devices available, but none designed specifically for the CHD patient group, and a scarcity of prospective studies to guide best practice. Baseline cardiac anatomy, prior surgical and interventional procedures, existing tachyarrhythmias and the requirement for future intervention all play a substantial role in decision making. For both pacing systems and implantable cardioverter defibrillators, numerous factors impact on the merits of system location (endovascular versus non-endovascular), lead positioning, device selection and device programming. For those with Fontan circulation and following the atrial switch procedure there are also very specific considerations regarding access and potential complications. This review discusses the published guidelines, device indications and the best available evidence for guidance of device implantation in the complex CHD population.

Retrospective application of Program to Access and Review Trending iNformation and Evaluate coRrelation to Symptoms in patients with Heart Failure criteria for the remote management of patients with cardiac resynchronisation therapy

Aim The Program to Access and Review Trending iNformation and Evaluate coRrelation to Symptoms in patients with Heart Failure (PARTNERS HF) trial elaborated a multiparametric model for prediction of acute decompensation in advanced heart failure patients, based on periodical in office data download from cardiac resynchronisation devices. In this study, we evaluated the ability of the PARTNERS HF criteria to detect initial decompensation in a population of moderate heart failure patients under remote monitoring. Methods We retrospectively applied the PARTNERS HF criteria to 1860 transmissions from 104 patients (median follow up 21 months; range 1-67 months), who were enrolled in our programme of telemedicine after cardiac resynchronisation therapy. We tested the ability of a score based on these criteria to predict any acute clinical decompensation occurring in the 15 days following a transmission. Results In 441 cases, acute heart failure was diagnosed after the index transmission. The area under the curve (AUC) of the score for the diagnosis of acute decompensation was 0.752 (confidence interval (CI) 95% 0.728-0.777). The best score cut-off was consistent with the results of PARTNERS HF: with a score ≥2, sensitivity was 75% and specificity 68%. The odds ratio for events was 6.24 (CI 95% 4.90-7.95; p < 0.001). Conclusions When retrospectively applied to remote monitoring transmissions and arranged in a score, PARTNERS HF criteria could identify HF patients who subsequently developed acute decompensation. These results warrant prospective studies applying PARTNERS HF criteria to remote monitoring.

Clinical utility of speckle-tracking echocardiography in cardiac resynchronisation therapy

Cardiac resynchronisation therapy (CRT) can profoundly improve outcome in selected patients with heart failure; however, response is difficult to predict and can be absent in up to one in three patients. There has been a substantial amount of interest in the echocardiographic assessment of left ventricular dyssynchrony, with the ultimate aim of reliably identifying patients who will respond to CRT. The measurement of myocardial deformation (strain) has conventionally been assessed using tissue Doppler imaging (TDI), which is limited by its angle dependence and ability to measure in a single plane. Two-dimensional speckle-tracking echocardiography is a technique that provides measurements of strain in three planes, by tracking patterns of ultrasound interference ('speckles') in the myocardial wall throughout the cardiac cycle. Since its initial use over 15 years ago, it has emerged as a tool that provides more robust, reproducible and sensitive markers of dyssynchrony than TDI. This article reviews the use of two-dimensional and three-dimensional speckle-tracking echocardiography in the assessment of dyssynchrony, including the identification of echocardiographic parameters that may hold predictive potential for the response to CRT. It also reviews the application of these techniques in guiding optimal LV lead placement pre-implant, with promising results in clinical improvement post-CRT.

Day by day telemetric care of patients treated with cardiac resynchronisation therapy: first Polish experience

BACKGROUND

Due to the recent rapid increase in the number of patients implanted with pacemakers, cardioverter-defibrillators (ICD), and cardiac resynchronisation therapy devices (CRT), conventional monitoring at specialist clinics is becoming increasingly difficult. The development of technology has enabled remote device monitoring with the use of teletransmission systems.

AIM

To assess the effectiveness of transmission and the possibility of using telemetric data for further clinical management of patients with heart failure (HF) treated with CRT-D.

METHODS

The analysis included 305 consecutive patients with chronic HF, New York Heart Association functional classes II-IV, treated with the use of CRT-D by Biotronik or Medtronic in the years 2006-2012. The patients received transmitters, enabling the remote monitoring of the implanted device from the patients' houses. Scheduled reports were automatically sent every month. The triggers for pre-specified emergency alert transmissions were as follows: ventricular tachycardia (VT) or ventricular fibrillation (VF) episodes, CRT-D intervention, ventricular extrasystoles > 110/h, any episode of atrial fibrillation (AF), atrial flutter (AFL) or supraventricular tachycardia, mean heart rate (HR) during, mean 24-h HR, CRT pacing < 95%, Elective Replacement Indicator, or End Of Service and device malfunction. The all-cause mortality of the study population has been assessed at the end of the follow-up period (mean of 20.5 months).

RESULTS

Devices manufactured by Biotronik were provided to 71% of the study population, while 29% received devices by Medtronic. In 97.3% of cases, the monitors were wireless, fully automatic, and capable of immediate data transmission whenever a pre-specified alert notification was fulfilled. The analysis of long-term outcomes revealed that all-cause mortality of the whole study population was 13%. The effectiveness of report transmission was 98%. During follow-up a total of 31,198 transmissions were received and analysed, which constituted, on average, 4.9 transmissions per patient per month. Among analyses, 30% were reports generated by scheduled remote follow-ups, and 70% were caused by unscheduled device alerts. Correct functioning of the system was confirmed; the quality of the received data was 100%. In 63.9% of patients, decisions based on the information obtained from telemonitoring reports were made to modify the therapy, refer the patients to cardiology or electrophysiology clinics, or hospitalise them urgently. The most common medical reaction was device reprogramming (46.8%). Pharmacotherapy was modified in 33.7% of patients: beta-blocker dose increase (25.9%), anticoagulant treatment inclusion (15.7%), amiodarone inclusion (1.9%), or digoxin inclusion (4.5%). The remaining medical responses were referring patients for atrioventricular junction ablation (8.1%), VT ablation (2.9%), or AF/AFl ablation (1.6%).

CONCLUSIONS

Remote monitoring of implantable devices is feasible, safe, and effective in supervising patients with CRT-D devices. Daily-based remote monitoring of a large population of HF patients allows continuous "triage" of high-risk patients and selection of individuals who require urgent intervention.

Outcomes in Women Undergoing Electrophysiological Procedures

The number of invasive electrophysiological procedures is steadily increasing in Western countries, as the age of the population increases and technologies advance. In recent years, gender-related differences in cardiac rhythm disorders have been increasingly appreciated, which can potentially have a great impact on the outcomes of invasive electrophysiological procedures. Among supraventricular arrhythmias, women have a higher incidence of atrioventricular nodal re-entrant tachycardia and a significantly lower incidence of atrioventricular re-entrant tachycardia compared with males, and present to ablation procedures later and after having failed more antiarrhythmic drugs. The results of catheter ablation of atrial fibrillation in women have been reported worse than in men. This finding is possibly due to a later referral of females to ablation procedures, who present older and with a higher incidence of long-standing persistent atrial fibrillation. With regard to cardiac device implantation procedures, a smaller survival benefit from prophylactic implantable cardioverter defibrillator (ICD) implantation has been shown in women, essentially due to gender-specific differences in the clinical course of patients with severe left ventricular dysfunction, with women dying predominantly from non-arrhythmic causes. On the other side, the clinical outcome of cardiac resynchronisation therapy seems to be more favourable in women, who experience a greater degree of reverse left ventricular remodelling and a striking decrease of heart failure events or mortality after biventricular pacing. This review will summarise the available evidence on gender-related differences in outcomes of invasive electrophysiological procedures.