Left bundle branch block and the evolving role of QRS morphology in selection of patients for cardiac resynchronization

BACKGROUND

The clinical significance of left bundle branch block (LBBB) has recently expanded with the discovery of a strong association with better outcomes in patients receiving cardiac resynchronization therapy.

METHODS

Several milestones have contributed to the current understanding on the role of LBBB in clinical practice.

RESULT

Sunao Tawara described the arrangement of components of what he called the cardiac conduction system from the atrioventricular node to the terminal Purkinje fibers that connect to the working myocardium, and his hypotheses on how it functions remain current. Mauricio Rosenbaum and colleagues developed the bifascicular model of the left-sided conduction system that explains the characteristic electrocardiographic changes associated with propagation disturbances in its components. Andrés Ricardo Pérez-Riera and others have disputed the bifascicular model as oversimplified and have emphasized the role of the left septal fascicle. Marcelo Elizari and colleagues have explained the importance of masquerading bundle branch block. Elena Sgarbossa and colleagues developed a scheme to recognize ST elevation myocardial infarction in patients with left bundle branch block which remains current after more than 20 years. Enrique Cabrera and others identified electrocardiographic signs of remote myocardial infarction.

CONCLUSION

Substantial progress has been made in the understanding of LBBB, yet its role in clinical practice continues to evolve and important gaps remain to which research should be directed.

Ivabradine: Evidence and current role in cardiovascular diseases and other emerging indications

Increased heart rate (HR) is associated with deleterious effects on several disease conditions. Chronic heart failure (CHF) is one of the cardiovascular diseases with recurrent hospitalization burden and an ongoing drain on health-care expenditure. Despite advancement in medicine, management of CHF remains a challenge to health-care providers. Ivabradine selectively and specifically inhibits the pacemaker I(f) ionic current which reduces the cardiac pacemaker activity. The main effect of ivabradine therapy is the substantial lowering of HR. It does not influence intracardiac conduction, contractility, or ventricular repolarization. As shown in numerous clinical studies, ivabradine improves clinical outcomes and quality of life and reduces the risk of death from heart failure (HF) or other cardiovascular causes. Recently updated HF guidelines recommend ivabradine as a class II indication for reduction of HF hospitalizations. Based on the principle of benefits of reduced HR, the ivabradine in patients with ischemic heart disease, sepsis, and multiple organ dysfunction syndrome has also been studied. It can also be a useful agent for HR reduction in patients with contraindications to use beta-blockers or those who cannot tolerate them. In this review, we provide an overview of efficacy and safety of ivabradine and its combination with currently recommended pharmacological therapy in different conditions.

Real-world experience comparing two common left atrial appendage closure devices

Background

The interventional left atrial appendage closure (LAAC) is a guideline-conform alternative to oral anticoagulation (OAC) in non-valvular atrial fibrillation patients with OAC ineligibility. It was aimed to directly compare two contemporary devices in a real-world patient population.

Methods

LAAC was conducted in two centres between 2010 and 2014 as well as between 2014 and 2017, respectively, in a standard fashion based on the specific manufacturer’s recommendations. Baseline characteristics, procedural data and event rates during intra-hospital and 6 months follow-up were registered in a retrospective approach, and analysed in device-related groups.

Results

A total of 189 patients presented for LAAC device implantation. Baseline characteristics were mostly evenly distributed. In 148 patients, a Watchman™ device (Boston Scientific, Natick, MA, USA) was successfully implanted, an Amplatzer™ Amulet™ (St. Jude Medical, St. Paul, MN, USA) in 34 patients (96.1 and 97.1%, respectively; p = 1.00). Major access site bleedings were more frequent in the Amplatzer™ Amulet™ group (8.9 versus 1.4%; p = 0.046). No intra-hospital thromboembolic event was present. During 6 months follow-up, peri-device leaks > 5 mm and thromboembolic events were uncommon (each p = n.s.).

Conclusions

While procedural success was equally high with both contemporary devices, complications during follow-up were rare, and evenly distributed.

Doppler echocardiography for assessment of systemic vascular resistances in cardiogenic shock patients

OBJECTIVE

Impaired vascular tone plays an important role in cardiogenic shock. Doppler echocardiography provides a non-invasive estimation of systemic vascular resistance. The aim of the present study was to compare Doppler echocardiography with the transpulmonary thermodilution method for the assessment of systemic vascular resistance in patients with cardiogenic shock.

METHODS

This prospective monocentric comparison study was conducted in a single cardiology intensive care unit (Hopital Nord, Marseille, France). We assessed the systemic vascular resistance index by both echocardiography and transpulmonary thermodilution in 28 patients admitted for cardiogenic shock, on admission and after the introduction of an inotrope or vasopressor treatment.

RESULTS

A total of 35 paired echocardiographic and transpulmonary thermodilution estimations of the systemic vascular resistance index were compared. Echocardiography values ranged from 1309 to 3526 dynes.s.m²/cm⁵ and transpulmonary thermodilution values ranged from 1320 to 3901 dynes.s.m²/cm⁵. A statistically significant correlation was found between echocardiography and transpulmonary thermodilution (r=0.86, 95% confidence interval (CI) 0.74, 0.93; P<0.0001). The intraclass correlation coefficient was 0.84 (95% CI 0.72, 0.92). The mean bias was -111.95 dynes.s.m²/cm⁵ (95% CI -230.06, 6.16). Limits of agreement were -785.86, 561.96.

CONCLUSIONS

Doppler echocardiography constitutes an accurate non-invasive alternative to transpulmonary thermodilution to provide an estimation of systemic vascular resistance in patients with cardiogenic shock.

Chronic heart failure management and remote haemodynamic monitoring

Heart failure (HF) has a large societal and economic burden and is expected to increase in magnitude and complexity over the ensuing years. A number of telemonitoring strategies exploring remote monitoring and management of clinical signs and symptoms of congestion in HF have had equivocal results. Early studies of remote haemodynamic monitoring showed promise, but issues with device integrity and implantation-associated adverse events hindered progress. Nonetheless, these early studies established that haemodynamic congestion precedes clinical congestion by several weeks and that remote monitoring of intracardiac pressures may be a viable and practical management strategy. Recently, the safety and efficacy of remote pulmonary artery pressure-guided HF management was established in a prospective, single-blind trial where randomisation to active pressure-guided HF management reduced future HF hospitalisations. Subsequent commercial use studies reinforced the utility of this technology and post hoc analyses suggest that tight haemodynamic management of patients with HF may be an additional pillar of therapy alongside established guideline-directed medical and device therapy. Currently, there is active exploration into utilisation of this technology and management paradigm for the timing of implantation of durable left ventricular assist devices (LVAD) and even optimisation of LVAD therapy. Several ongoing clinical trials will help clarify the extent and utility of this strategy along the spectrum of patient with HF from individuals with chronic, stable HF to those with more advanced disease requiring heart replacement therapy.

Patient survival and therapeutic outcome in the UK bridge to transplant left ventricular assist device population

Objective

To study the survival and patient outcome in a population of UK patients supported by an implantable left ventricular assist device (LVAD) as a bridge to heart transplantation.

Methods

Data on all adult patients (n=342) who received a HeartMate II or HVAD as a first long-term LVAD between January 2007 and 31 December 2013 were extracted from the UK Ventricular Assist Device (VAD) Database in November 2015. Outcomes analysed include survival on a LVAD, time to urgent listing, heart transplantation and complications including those needing a pump exchange.

Results

112 patients were supported with the Thoratec HeartMate II and 230 were supported with the HeartWare HVAD. Median duration of support was 534 days. During the study period, 81 patients required moving to the UK urgent waiting list for heart transplantation. Of the 342 patients, 85 (24.8%) received a heart transplant, this included 63 on the urgent list. Thirty-day survival was 88.9%, while overall patient survival at 3 years from LVAD implant was 49.6%. 156 patients (46%) died during LVAD support; the most common cause of death on a VAD was a cerebrovascular accident. There was no significant difference between the two devices used in any outcome.

Conclusions

In a population of patients with advanced heart failure, who have a very poor prognosis, support with an implantable LVAD allowed a quarter to receive a heart transplant in a 3-year period. Overall survival of the cohort was about 50%. With improvement in technology and in post-LVAD management, it is likely that outcomes will improve further.

Clinical impact of mineralocorticoid receptor antagonists treatment after acute coronary syndrome in the real world: A propensity score matching analysis

BACKGROUND

Recent studies suggest that the benefit of mineralocorticoid receptor antagonists in the acute coronary syndrome setting is controversial. The aim of this study was to examine the current long-term prognostic benefit of mineralocorticoid receptor antagonists in patients with acute coronary syndrome.

MATERIAL AND METHODS

We conducted a retrospective cohort study of 8318 consecutive acute coronary syndrome patients. Baseline patient characteristics were examined and a follow-up period was established for registry of death, major cardiovascular adverse events and heart failure re-hospitalization. We performed a propensity-matching analysis to draw up two groups of patients paired according to whether or not they had been treated with mineralocorticoid receptor antagonists. The prognostic value of mineralocorticoid receptor antagonists to predict events during follow-up was analysed using Cox regression.

RESULTS

Among the study participants, only 524 patients (6.3%) were discharged on mineralocorticoid receptor antagonists. Patients on mineralocorticoid receptor antagonists had a different clinical and pharmacological profile. These differences disappeared after the propensity score analysis. The median follow-up was 40.7 months. After the propensity score analysis, the cardiovascular mortality and heart failure readmission rates were similar between patients who were discharged on mineralocorticoid receptor antagonists and those whose not. The use of mineralocorticoid receptor antagonists was only associated with a reduction in major cardiovascular adverse events (hazard ratio=0.83, 95% confidence interval 0.69-0.97, p=0.001).

CONCLUSIONS

Our results do not corroborate the long-term benefit of mineralocorticoid receptor antagonists to improve survival after acute coronary syndrome in a large cohort of patients with heart failure or reduced left ventricular ejection fraction and diabetes. Their prescription was associated with a significantly lower incidence of major cardiovascular adverse events during the long-term follow-up without effect on heart failure development.

Moderate Aortic Stenosis and Reduced Left Ventricular Ejection Fraction: Current Evidence and Challenges Ahead

Moderate aortic stenosis (AS) and reduced left ventricular ejection fraction (LVEF) constitute a clinical entity that has been proposed as a therapeutic target for transcatheter aortic valve replacement (TAVR). It is defined by a mean trans-aortic gradient between 20 and 40 mmHg and an aortic valve area between 1.0 and 1.5 cm² in patients with LVEF < 50%. Retrospective data suggests a prevalence of 0.8% among patients referred for echocardiographic assessment. These patients are younger and show a higher frequency of previous myocardial infarction than those with severe AS randomized to TAVR in recent trials. In two retrospective studies including patients with moderate AS and reduced LVEF, a one-year mortality rate of 9 and 32% was reported, the latter in patients treated with medical therapy only during follow-up. Echocardiographic diagnosis of moderate AS poses challenges as current guidelines are directed to determine severe AS, and different presentations of moderate and mild AS have been generally neglected. Thus, the nomenclature would need to be revised and a description of possible scenarios is provided in this review. Dobutamine stress echocardiography and computed tomography are promising complementary tools. Likewise, a standardized clinical pathway is needed, in which a high level of suspicion and a low threshold for referral to a heart valve center is warranted. The Transcatheter Aortic Valve Replacement to UNload the Left ventricle in patients with Advanced heart failure (TAVR UNLOAD) trial (NCT02661451) is exploring whether TAVR would improve outcomes in patients receiving optimal heart failure therapy.

Fragmented QRS as a predictor of in-hospital life-threatening arrhythmic complications in ST-elevation myocardial infarction patients

BACKGROUND

Fragmented QRS (fQRS) complex is an electrocardiographic pattern that reflects the inhomogeneity of ventricular depolarization. The aims of this study were to determine the prognostic significance of fQRS for predicting in-hospital life-threatening arrhythmic complications in ST-elevation myocardial infarction (STEMI) patients, and to identify the most appropriate duration of cardiac rhythm monitoring in STEMI patients with fQRS.

METHODS

Patients diagnosed with and treated for STEMI at Siriraj Hospital (Bangkok, Thailand) during 2009-2012 were enrolled. Patients were divided according to fQRS status (having or not having fQRS) at hospital admission. The primary outcome was in-hospital life-threatening arrhythmic events, including sustained ventricular tachycardia and ventricular fibrillation. Time to last life-threatening arrhythmic event from hospital admission was recorded.

RESULTS

Of the 452 patients that were included, 96 patients (21.2%) had fQRS. There were significantly more life-threatening arrhythmic events in the fQRS group than in the non-fQRS group (22.9% vs. 4.5%, respectively; p < 0.001). Median (IQR) time to last life-threatening arrhythmic event from hospital admission was significantly longer in fQRS than in non-fQRS (6.58 hr [3.08-39.34] vs. 2.59 hr [1.75-5.75], respectively; p = 0.047). Multivariate analysis identified fQRS as an independent predictor of in-hospital life-threatening arrhythmic events (OR: 4.162, 95% CI: 1.669-10.384; p = 0.002).

CONCLUSIONS

The presence of fQRS complex on admission ECG was found to be an independent predictor of in-hospital life-threatening arrhythmic events in STEMI patients. Since the time to last life-threatening arrhythmic event from admission was longer in fQRS than in non-fQRS, cardiac rhythm monitoring longer than 24-48 hr may be needed in patients with fQRS.

ECMO and Short-term Support for Cardiogenic Shock in Heart Failure

PURPOSE OF REVIEW

This review aims to discuss the role of ECMO in the treatment of cardiogenic shock in heart failure.

RECENT FINDINGS

Trials done previously have shown that IABP does not improve survival in cardiogenic shock compared to medical treatment, and that neither Impella 2.5 nor TandemHeart improves survival compared to IABP. The "IMPRESS in severe shock" trial compared Impella CP with IABP and found no difference in survival. A meta-analysis of cohort studies comparing ECMO with IABP showed 33% improved 30-day survival with ECMO (risk difference 33%; 95% CI 14-52%; p = 0.0008; NNT 3). ECMO is indicated in medically refractory cardiogenic shock. ECMO can be considered in cardiogenic shock patients with estimated mortality of more than 50%. ECMO is probably the MCS of choice in cardiogenic shock with; biventricular failure, respiratory failure, life-threatening arrhythmias and cardiac arrest.

Risk factors for stroke and choice of oral anticoagulant in atrial fibrillation

PURPOSE

To investigate risk factors for stroke in patients initiating oral anticoagulants for atrial fibrillation in Norway and their association with receiving DOACs versus warfarin.

METHODS

From nationwide registries, we identified naïve users initiating treatment with warfarin, dabigatran, rivaroxaban, or apixaban for atrial fibrillation from 2010 to 2015 in Norway. We studied temporal changes in the CHA₂DS₂-VASc score and its component risk factors. We used multiple logistic regressions to identify CHA₂DS₂-VASc risk factors associated with receiving DOACs versus warfarin in 2015.

RESULTS

From 2010 to 2015, the yearly number of new oral anticoagulant users increased from 7588 to 13,344. All new users initiated warfarin in 2010, while 86% initiated a DOAC in 2015. The mean CHA₂DS₂-VASc score decreased from 3.2 (SD 1.7) to 3.1 (SD 1.6) in the same period. Vascular disease (0.56 [0.49-0.63]), congestive heart failure (OR 0.65 [95% CI 0.58-0.72]), and diabetes (0.83 [0.73-0.95]) decreased the odds of receiving DOACs instead of warfarin, and ischemic stroke/transient ischemic attack/arterial thromboembolism (1.31 [1.12-1.54]), age 65-74 (1.23 [1.06-1.43]), and female sex (1.22 [1.10-1.36]) increased it. Age ≥ 75 (reference age < 65) and hypertension had no impact.

CONCLUSIONS

The uptake of DOACs was rapid and spurred an increase in new users of oral anticoagulants for atrial fibrillation from 2010 to 2015 in Norway. The mean CHA₂DS₂-VASc score did not change substantially during this period. Vascular disease, heart failure, and diabetes were associated with initiation of warfarin, and previous stroke, age 65-74 and female sex with initiation of DOACs.

Effect of statins on toll-like receptors: a new insight to pleiotropic effects

The toll-like receptors (TLRs) are a class of transmembrane-spanning receptors that are sentinels of both innate and adaptive immunity. Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) are the most commonly prescribed therapeutic agents for treating hypercholesterolemia globally. However, statin therapy appears to have pleiotropic effects including attenuation of chronic low-grade inflammation and modulation of TLR activity. Statins through abolition of TLR4 expression and regulation of the TLR4/Myd88/NF-κB signaling pathway may slow the progression of atherosclerosis and other inflammatory diseases. In this review, we have focused on the impact and mechanism of action of statins on cardiovascular and non-cardiovascular diseases.

Differences in Heart Rate Response and Recovery After 6-Minute Walk Test Between Patients With Atrial Fibrillation and in Sinus Rhythm

Long-term heart rate (HR) control is a management strategy for patients with chronic atrial fibrillation (AF). Nevertheless, the optimal target HR of AF patients is debatable. Our aim was to study HR at rest, during, and after a 6-minute walk test (6MWT) in AF patients, compared with controls with sinus rhythm (SR). Consecutive matched patients with AF (n = 186) or SR (n = 172) were recruited, and 6MWT was performed. HRs at rest, during 6MWT, and recovery periods were recorded. All subjects were divided into 5 subgroups (<80 beats/min, 80 to 89 beats/min, 90 to 99 beats/min, 100 to 109 beats/min, and ≥110 beats/min) according to the HR at rest. No statistical difference was observed in baseline HR at rest, between AF and SR groups (p = 0.30). The exercise HR increase percentage was significantly higher in overall AF patients compared with those in SR (40 ± 15% vs 14 ± 7%, p <0.001). Even with similar mean baseline HRs at rest, the 5 AF subgroups all showed significantly higher mean exercise HR, maximal exercise HR, and maximal exercise HR increase percentage compared with their respective SR subgroups, especially the subgroups with HR at rest >90 beats/min. Unlike the SR patients, the 4 AF subgroups with HR >80 beats/min at the fifth minute after 6MWT did not recover to at rest levels. In conclusion, HR increased excessively during 6MWT and HR recovery was delayed after 6MWT in AF patients, especially when HR at rest is >90 beats/min. The optimal initial HR at rest for AF patients should perhaps be <90 beats/min.

Status of the Epicardial Coronary Arteries in Non-ST Elevation Acute Coronary Syndrome in Patients with Mechanical Prosthetic Heart Valves (from the TROIA-ACS Trial)

Coronary thromboembolism (CE) is a rare cause of prosthetic valve derived complications. This study investigates the diagnosis and treatment strategies for non-ST elevation acute coronary syndrome (NSTEACS) in patients with prosthetic heart valves. Forty-eight NSTEACS patients with prosthetic heart valves (mitral:27; aortic:14; mitral+aortic:7) were included in this study. All patients underwent transthoracic and transesophageal echocardiographic examination and coronary angiography. Normal coronary angiographic findings, or visible trombus in one of the coronary arteries, international normalized ratio <2, concomitant prosthetic valve thrombosis (PVT) and absence of multivessel atherosclerotic disease favored CE rather than atherothrombosis. Thrombolytic therapy (TT) with low-dose slow-infusion of tissue type plasminogen activator was used in patients with suspected CE and/or PVT. Coronary angiography demonstrated normal coronary arteries in 26 patients, CE in 16 patients and coronary atherosclerosis in 6 patients. Transesophageal echocardiography revealed obstructive PVT in 9 and nonobstructive PVT in 28 patients whereas 11 patients had normally functioning prostheses. TT was administered to 24 patients with PVT and/or CE. In these patients, TT was successful in 19 patients, partially successful in 4 patients and failed in 1 patient. In conclusion, NSTEACS in patients with prosthetic heart valves is more likely to be associated with PVT derived CE rather than atherosclerosis. TT with low-dose slow infusion of type plasminogen activator has proved its efficacy and safety in patients with CE and/or PVT.

Relation of Echocardiographic Markers of Left Atrial Fibrosis to Atrial Fibrillation Burden

In patients with atrial fibrillation (AF), left atrial (LA) fibrosis is a major determinant of the progression to, and burden of AF. LA reservoir strain and total atrial conduction time (PA-TDI) reflect LA fibrotic content. We aimed to investigate the relation between LA reservoir strain and PA-TDI in AF patients and control subjects. Six-hundred two patients (mean age 56 years, 53% men) with first episode of AF and 342 controls (mean age 64 years, 71% men) without structural heart disease underwent echocardiography. LA volumes, PA-TDI, LA reservoir strain, and left ventricular global longitudinal strain (GLS) were compared. Compared with controls, patients with paroxysmal AF and patients with persistent AF had longer PA-TDI (128 ± 25 millisecond, 140 ± 31 millisecond, and 154 ± 33 millisecond, respectively; p <0.001) and a progressive decline in LA reservoir strain (36.9 ± 11.6%, 29.8 ± 13.4%, 24.2 ± 12.3%, respectively; p <0.001). LA reservoir strain was negatively correlated with PA-TDI (r = -0.43, p <0.001). On multivariate analyses, LA reservoir strain, diabetes mellitus, and burden of AF were independent correlates of PA-TDI (R² = 0.23, p <0.001); whereas only PA-TDI was an independent correlate of LA reservoir strain (R² = 0.43, p <0.001); controlling for age, hypertension, coronary artery disease, body mass index, severity of mitral regurgitation, left ventricular global longitudinal strain, and LA volume. In conclusion, PA-TDI and LA reservoir strain are negatively correlated in all subjects, irrespective of the presence or burden of AF. Patients with persistent AF have longer PA-TDI and impaired LA reservoir strain compared with paroxysmal AF and controls, suggesting increasing burden of fibrosis and LA structural remodeling in the progression of AF.

[Noninvasive mapping for catheter ablation of arrhythmias using the CardioInsight™ ECG vest]

BACKGROUND

CardioInsight™ is a noninvasive three-dimensional mapping system technology which offers a unique method for arrhythmia characterization and localization. With a 252-lead ECG vest on the patient's torso and a noncontrast CT scan, epicardial potentials are detected and by means of reconstruction algorithms activation and phase maps are created, offering a deeper understanding of localization and mechanisms of arrhythmias including atrial fibrillation without the need for an endocardial catheter.

MATERIALS AND METHODS

The system has proven to be accurate and applicable in the clinical setting of accessory pathways, premature ventricular contractions (PVC), atrial tachycardias and atrial fibrillation. Beat-to-beat analysis offers detection and thus a therapeutic approach for arrhythmias which occur only paroxysmally such as supraventricular extrasystoles, atrial bursts or PVCs. Another advantage is the simultaneous display of various heart chambers such as the left and right atrium. However, major multicenter prospective randomized data are still lacking.

CONCLUSION

If in the future noninvasive mapping could be achieved with MRI and if the technology was compatible with invasive mapping systems so that catheter positioning and noninvasive maps can be merged, the authors believe that this would represent a new dimension of mapping technology and ablation strategy of arrhythmias.

Aspirin Plus Clopidogrel vs Aspirin Alone for Preventing Cardiovascular Events Among Patients at High Risk for Cardiovascular Events

CLINICAL QUESTION

Among patients at high risk for or with established cardiovascular disease (ie, history of peripheral artery disease, stroke, or coronary artery disease without a coronary stent), is the addition of clopidogrel to aspirin associated with lower risk of mortality and cardiovascular events compared with aspirin alone?

BOTTOM LINE

Clopidogrel plus aspirin is associated with a reduced risk for myocardial infarction and ischemic stroke and an increased risk for major bleeding compared with aspirin alone among patients at high risk for or with an established cardiovascular disease but without a coronary stent. However, combined therapy is not associated with lower mortality.

Age- and sex-dependent changes in sympathetic activity of the left ventricular apex assessed by 18F-DOPA PET imaging

BACKGROUND

Sexual dimorphism in cardiac sympathetic outflow has recently gained attention in the context of Takotsubo cardiomyopathy. Previous studies suggest that there are sex- and age-dependent differences in peripheral autonomic control, however, data on cardiac-specific sympathetic activation in aged women and men are lacking.

METHODS AND RESULTS

Regional quantitative analysis of cardiac fluorine-18 (18F)- Dihydroxyphenylalanine (DOPA) uptake was retrospectively performed in 133 patients (69 females, mean age 52.4±17.7 years) referred for assessment of neuroendocrine tumours (NET) by Positron-Emission-Tomography. Cardiac 18F-DOPA uptake was significantly higher in women as compared to men (1.33±0.21 vs. 1.18±0.24, p<0.001). This sex-difference was most pronounced in the apical region of the left ventricle (LV, 1.30±0.24 in women vs. 1.13±0.25 in men, p<0.001) and in individuals >55 years of age (1.39±0.25 in women vs. 1.09±0.24 in men, p<0.001). Women showed a prominent increase in myocardial 18F-DOPA uptake with age with the strongest increase seen in the LV apical region (r = 0.34, p = 0.004). Accordingly, sex and age were selected as significant predictors of LV apical 18F-DOPA uptake in a stepwise linear regression model. No age-dependent changes of cardiac 18F-DOPA uptake were observed in men or in the right ventricular region.

CONCLUSION

Our study suggests that aging is related to sex-specific changes in regional cardiac sympathetic activity. Future studies will have to assess whether the increase in LV apical 18F-DOPA uptake with age in women is of pathogenic relevance for the higher susceptibility of postmenopausal women to conditions associated with increased sympathetic activity.

Relationship between Serum Osteocalcin and Carotid Atherosclerosis in Middle-Aged Men in China: A Cross-Sectional Study

BACKGROUND AND PURPOSE

Numerous investigations found that there exists a close relationship between serum osteocalcin and incurrence of atherosclerosis, but studies investigating the effect of serum osteocalcin on carotid atherosclerosis are very limited. Our study is aimed at investigating the role of osteocalcin in carotid atherosclerosis in middle-aged men in China.

METHODS

A total of 335 male middle-aged participants (40-60, 52.4 ± 3.87 years averagely) were enrolled from the institute. The carotid intima-media thicknesses (CIMT) of each subject were measured. All subjects were included either in the carotid atherosclerosis (AS) group or the control group according to the CAS diagnosis criteria. Serum osteocalcin and other markers of each patient were assessed following standard laboratory tests protocol.

RESULTS

135 subjects were included in AS group, and 199 subjects were included in control group. The average osteocalcin level in AS group was 18.71 ± 6.20 ng/ml and was significantly different from that in control group, which was 20.38 ± 7.19 ng/ml (p=0.039). Logistic regression analysis revealed that OCN (standardized β=-0.024, p=0.013) and FINS (standardized β=-0.065, p=0.010) were independently and inversely associated with the carotid atherosclerosis, while FPG (standardized β=0.538, p=0.006) was independently and positively associated with the carotid atherosclerosis.

CONCLUSION

Our study suggests that OCN is independently related to carotid atherosclerosis in middle-aged male individuals.

Cost Saving Potential of an Early Detection of Atrial Fibrillation in Patients after ICD Implantation

Atrial fibrillation (AF) is a relevant comorbidity in recipients of implantable cardioverter-defibrillators (ICD). Latest generation single-chamber ICD allow the additional sensing of atrial tachyarrhythmias and, therefore, contribute to the early detection and treatment of AF, potentially preventing AF-related stroke. The present study aimed to measure the impact on patient-related costs of this new ICD compared to conventional ICD. A Markov model was developed to simulate the long-term incidence of stroke in patients treated with a single-chamber ICD with or without atrial sensing capabilities. The median annual cost per patient and its difference, the number of strokes avoided, and the cost per stroke avoided were estimated. During a 9-year horizon, the costs for the ICD and stroke treatment were €570 per patient-year for an ICD with atrial sensing capabilities and €491 per patient-year for a conventional ICD. Per 1,000 patients, 4.6 strokes per year are assumed to be avoided by the new device. Higher CHA2DS2-VASc scores are associated with higher numbers of avoided strokes and larger potential for cost savings. Apart from clinical advantages, the use of ICD with atrial sensing capabilities may reduce the incidence of stroke and, in high-risk patients, may also contribute to reduce overall health care costs.

Obstacles to mineralocorticoid receptor antagonists in a community-based heart failure population

AIM

Previous studies and national assessments indicate an undertreatment of mineralocorticoid receptor antagonists (MRA) in heart failure with reduced ejection fraction (HFrEF). This study aimed to investigate why MRA is not used to full extent.

METHODS

A complete community-based heart failure population was studied. Several variables were collected, and medical records were scrutinized to identify reasons for not prescribing MRA.

RESULTS

Of 2029 patients, 812 had EF ≤40%. Five hundred and fifty-three patients (68%) tried MRA at some point but 184 of these (33%) discontinued therapy. There were 259 patients that never tried MRA with 177 with a listed explanation or contraindication. Eighty-two patients, 10% of the total HFrEF population, had no clear contraindications. They were older and had less HF hospitalizations compared to patients on MRA (P < 0.05) and 32% did not have any follow-up at the cardiology clinic. Contraindications to MRA were renal dysfunction (93 patients), hypotension (28 patients), and hyperkalemia (25 patients). Only six patients had hyperkalemia without renal dysfunction. Of the patients with renal dysfunction, 66 (72%) had eGFR >30 mL/min.

CONCLUSIONS

The reasons why MRA are underutilized were mainly because of contraindications. However, the data suggest that physicians are overly cautious about moderately reduced kidney function. There seems to be a 10%-18% avoidable undertreatment with MRA, especially for elderly patients that are admitted to the hospital for other reasons than heart failure. This suggests that patients with heart failure would benefit from routine follow-up at a cardiology clinic.

Internal quality control status for BNP and NT-proBNP in China from 2014 to 2017

BACKGROUND

This study aimed to investigate and analyze the status of internal quality control (IQC) for BNP and NT-proBNP from 2014 to 2017, so as to have an integral understanding of quality performance of measurement in clinical laboratories in China.

METHODS

The 4-year IQC information for BNP and NT-proBNP of participant laboratories were collected through EQA reporting system. Percentages of laboratories meeting different quality requirements (pass rates) for current coefficient of variations (CVs) were calculated afterwards. Further analysis for current CVs and pass rates among different years and measurement systems were conducted. Finally, we analyzed and summarized IQC practice and its changes in 4 years.

RESULTS

The current CVs for BNP and NT-proBNP have decreased significantly from 2014 to 2017, and pass rates both presented significant increasing trends. NT-proBNP had higher pass rates than BNP regardless of 1/3TEa or 1/4TEa specification was used. The main measurement systems for two analytes were different. For NT-proBNP, current CVs of Roche has decreased significantly among 4 years and were significantly lower than Radiometer and BioMérieux in 2015. Current CVs of Abbott also had decreasing tendency for BNP. Analysis of IQC practice indicated that control rules and IQC frequency had made great progress in 4 years.

CONCLUSION

The imprecision performance of measurement of BNP and NT-proBNP has improved with decreasing of current CVs and increasing of pass rates in 4 years. However, it still needs continual improvement. Clinical laboratories in China should take active actions to promote performance of BNP and NT-proBNP measurement.

Continuity and utilization of health and community care in elderly patients with heart failure before and after hospitalization

BACKGROUND

The period after hospitalization due to deteriorated heart failure (HF) is characterized as a time of high generalized risk. The transition from hospital to home is often problematic due to insufficient coordination of care, leading to a fragmentation of care rather than a seamless continuum of care. The aim was to describe health and community care utilization prior to and 30 days after hospitalization, and the continuity of care in patients hospitalized due to de novo or deteriorated HF from the patients' perspective and from a medical chart review.

METHODS

This was a cross-sectional study with consecutive inclusion of patients hospitalized at a county hospital in Sweden due to deteriorated HF during 2014. Data were collected by structured telephone interviews and medical chart review and analyzed with the Spearman's rank correlation coefficient and Chi square. A P value of 0.05 was considered significant.

RESULTS

A total of 121 patients were included in the study, mean age 82.5 (±6.8) and 49% were women. Half of the patients had not visited any health care facility during the month prior to the index hospital admission, and 79% of the patients visited the emergency room (ER) without a referral. Among these elderly patients, a total of 40% received assistance at home prior to hospitalization and 52% after discharge. A total of 86% received written discharge information, one third felt insecure after hospitalization and lacked knowledge of which health care provider to consult with and contact in the event of deterioration or complications. Health care utilization increased significantly after hospitalization.

CONCLUSION

Most patients had not visited any health care facility within 30 days before hospitalization. Health care utilization increased significantly after hospitalization. Flaws in the continuity of care were found; even though most patients received written information at discharge, one third of the patients lacked knowledge about which health care provider to contact in the event of deterioration and felt insecure at home after discharge.

Catheter ablation for treatment of patients with atrial fibrillation and heart failure: a meta-analysis of randomized controlled trials

Background

There is a little evidence for the effects of catheter ablation (CA) on hard endpoints in patients with atrial fibrillation (AF) and heart failure (HF).

Methods

PubMed, Embase and Cochrane Library were searched for randomized controlled trials (RCTs) enrolling patients with AF and HF who were assigned to CA, rate control or medical rhythm control groups. This meta-analysis was performed by using random-effect models.

Results

Seven RCTs enrolling 856 participants were included in this meta-analysis. CA reduced the risks of all-cause mortality (risk ratio [RR] 0.52, 95% CI 0.35 to 0.76), HF readmission (RR 0.58, 95% CI 0.46 to 0.66) and the composite of all-cause mortality and HF readmission (RR 0.55, 95% CI 0.47 to 0.66) when compared with control. But there was no significant difference in cerebrovascular accident (RR 0.56, 95% CI 0.23 to 1.36) between two groups. Compared with control, CA was associated with improvement in left ventricular ejection fraction (mean difference [MD] 7.57, 95% CI 3.72 to 11.41), left ventricular end systolic volume (MD -14.51, 95% CI -26.84 to − 2.07), and left ventricular end diastolic volume (MD -3.78, 95% CI -18.51 to 10.96). Patients undergoing CA exhibited increased peak oxygen consumption (MD 3.16, 95% CI 1.09 to 5.23), longer 6-min walk test distance (MD 26.67, 95% CI 12.07 to 41.27), and reduced Minnesota Living with Heart Failure Questionnaire scores (MD -9.49, 95% CI -14.64 to − 4.34) than those in control group. Compared with control, CA was associated with improved New York Heart Association class (MD -0.74, 95% CI -0.83 to − 0.64) and lower B-type natriuretic peptide levels (MD -105.96, 95% CI -230.56 to 19.64).

Conclusions

CA was associated with improved survival, morphologic changes, functional capacity and quality of life relative to control. CA should be considered in patients with AF and HF.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0904-3) contains supplementary material, which is available to authorized users.

A Multiple Biomarker Approach in Patients with Cardiac Sarcoidosis

Sarcoidosis is a systemic granulomatous disease including heart (cardiac sarcoidosis, CS). It has recently been reported that isolated CS, which presenting primarily cardiac symptoms without clinical evidence of sarcoid involvement in other organs. Diagnostic and prognostic biomarkers of CS, especially in isolated CS, have not yet been established.We studied plasma levels of angiotensin-converting enzyme (ACE), soluble interleukin-2 receptor (sIL-2R), B-type natriuretic peptide (BNP) and cardiac troponin I (cTnI) in consecutive 172 patients with diagnosed sarcoidosis. We compared these markers between non-cardiac sarcoidosis (non-CS, n = 123, 71.5%) and CS patients (n = 49, 28.5%), including non-isolated CS (n = 30, 17.4%) and isolated CS (n = 19, 11.1%). ROC analysis revealed that BNP identified CS with AUC of 0.85 (P < 0.01) in sarcoidosis patients. In addition, ACE and sIL-2R levels were significantly higher in non-isolated CS than in isolated CS (P < 0.05). Furthermore, in the Cox proportional hazard analysis, cTnI, but not ACE, IL2R or BNP, was a predictor of fatal arrhythmia in sarcoidosis patients (HR 2.418, P = 0.003).Higher ACE and sIL2-R are associated with systemic lesions, whereas BNP is a useful marker for detecting cardiac involvement in sarcoidosis patients. cTnI is a predictor of fatal arrhythmia in CS patients. A multiple biomarker approach supports comprehensive management of sarcoidosis.

Validation of the MB-LATER score for prediction of late recurrence after catheter-ablation of atrial fibrillation

BACKGROUND

Reliable identification of atrial fibrillation (AF) patients more likely to be AF-free long-term post-single catheter ablation (CA) would facilitate appropriate risk communication to patients. We validated the recently proposed MB-LATER score for prediction of late recurrences of AF (LRAF) post-CA.

METHODS

Patients who underwent CA for symptomatic AF refractory to ≥1 antiarrhythmic drugs at the Johns Hopkins Hospital, Baltimore, between March 2003 and December 2015, for whom ≥1-year post-CA follow-up data were available, were enrolled.

RESULTS

Of 226 patients (median age 58.5 years [IQR: 52.0-65.0], 163 males [72.1%], 142 [62.8%] with paroxysmal AF), LRAF occurred in 133 patients (58.8%) during a median 2-year follow-up (IQR: 1.1-4.1). The mean MB-LATER score was significantly higher in patients with versus those without LRAF (2.4 ± 1.2 vs. 1.9 ± 1.3, p = 0.002) and showed modest but significant predictive ability for LRAF (AUC: 0.62 [95% CI: 0.54-0.69], p = 0.003). A score cut-off value of >2 showed the best predictive ability for LRAF (70.4% [61.5-77.9]), with modest sensitivity (42.9% [34.3-51.7]) and specificity (74.2% [64.1-82.7]). Kaplan-Meyer survival free from AF was significantly better for patients with a MB-LATER score of ≤2 than for those with a score of >2 (log-rank p = 0.005).

CONCLUSION

In our study, the MB-LATER score showed a significant but modest predictive ability for LRAF post-AF ablation. Further prospective validation is needed to better define the potential role of the MB-LATER score in patient selection and treatment decision-making post-AF ablation.

Long-term monitoring to detect atrial fibrillation with the indwelling implantable cardiac monitors

An increasing number of detection tools are available and several detection strategies have been described to pursue the diagnosis of atrial fibrillation to prevent ischemic stroke. Monitoring tools include standard electrocardiography, snapshot single-lead recordings with professional or personal devices (e.g. smartphone-based), Holter monitor, external devices with long-term recording capabilities, and cardiac implantable electronic devices, including pacemakers, implantable cardioverter defibrillators and insertable cardiac monitors. Insertable cardiac monitors have shown high sensitivity and specificity for the detection of atrial fibrillation, allow up to three years of continuous monitoring, do not require cooperation of the patient, are well tolerated, have a short device-related time delay between detection of atrial fibrillation and notification to the physician, provide information on atrial fibrillation burden and are minimally invasive. On the other hand, insertable cardiac monitors require a considerable use of resources to process the recordings and have a significant initial cost. Studies conducted with insertable cardiac monitors on patients with prior stroke and on patients with risk factors for stroke but no prior cerebrovascular events or atrial fibrillation have consistently shown a measurable incidence of atrial fibrillation at follow-up. However, the effectiveness of oral anticoagulations in reducing the incidence of ischemic stroke in patients with atrial fibrillation lasting less than 24 h, though reasonable, is currently unproven. The future of atrial fibrillation detection tools and atrial fibrillation detection strategies will be influenced by ongoing studies exploring whether oral anticoagulations reduce the incidence of stroke in patients with atrial fibrillation burden lower than 24 h.

Alveolar Air and O2 Uptake During Exercise in Patients With Heart Failure

BACKGROUND

Peak exercise pulmonary oxygen uptake (V̇O₂) is a primary marker of prognosis in heart failure (HF). The pathophysiology of impaired peak V̇O₂ is unclear in patients. To what extent alveolar airway function affects V̇O₂ during cardiopulmonary exercise testing (CPET) has not been fully elucidated. This study aimed to describe how changes in alveolar ventilation (V̇_A), volume (V_A), and related parameters couple with exercise V̇O₂ in HF.

METHODS AND RESULTS

A total of 35 patients with HF (left ventricular ejection fraction 20 ± 6%, age 53 ± 7 y) participated in CPET with breath-to-breath measurements of ventilation and gas exchange. At rest, 20 W, and peak exercise, arterial CO₂ tension was measured via radial arterial catheterization and used in alveolar equations to derive V̇_A and V_A. Resting lung diffusion capacity for carbon monoxide (DL_CO) was assessed and indexed to V_A for each time point. Resting R² between V̇O₂ and V̇_A, V_A, DL_CO, and DL_CO/V_A was 0.68, 0.18, 0.20, and 0.07, respectively (all P < .05 except DL_CO/V_A). 20 W R² between V̇O₂ and V̇_A, V_A, DL_CO, and DL_CO/V_A was 0.64, 0.32, 0.07, and 0.18 (all P < .05 except DL_CO). Peak exercise R² between V̇O₂ and V̇_A, V_A, DL_CO, and DL_CO/V_A was 0.55, 0.31, 0.34, and 0.06 (all P < .05 except DL_CO/V_A).

CONCLUSIONS

These data suggest that alveolar airway function that is not exclusively related to effects caused by localized lung diffusivity affects exercise V̇O₂ in moderate-to-severe HF.

Antibodies aggravate the development of ischemic heart failure

Heart-specific antibodies have been widely associated with myocardial infarction (MI). However, it remains unclear whether autoantibodies mediate disease progression or are a byproduct of cardiac injury. To disambiguate the role of immunoglobulins in MI, we characterized the development of ischemic heart failure in agammaglobulinemic mice (AID^-/-μS^-/-). Although these animals can produce functional B cells, they cannot synthesize secretory IgM (μS^-/-) or perform Ig class switching (AID^-/-), leading to complete antibody deficiency. Agammaglobulinemia did not affect overall post-MI survival but resulted in a significant reduction in infarct size. Echocardiographic analyses showed that, compared with wild-type infarcted control mice, AID^-/-μS^-/- mice exhibited improved cardiac function and reduced remodeling on day 56 post-MI. These differences remained significant even after animals with matched infarct sizes were compared. Infarcted AID^-/-μS^-/- mice also showed reduced myocardial expression levels of transcripts known to promote adverse remodeling, such as matrix metalloproteinase-9, collagen type I a1, collagen type III a1, and IL-6. An unbiased screening of the heart reactivity potential in the plasma of wild-type MI animals revealed the presence of antibodies that target the myocardial scar and collagenase-sensitive epitopes. Moreover, we found that IgG accumulated within the scar tissues of infarcted mice and remained in close proximity with cells expressing Fcγ receptors (CD16/32), suggesting the existence of an in situ IgG-Fcγ receptor axis. Collectively, our study results confirm that antibodies contribute to ischemic heart failure progression and provide novel insights into the mechanisms underlying this phenomenon. NEW & NOTEWORTHY Our study sheds some light on the long-standing debate over the relevance of autoantibodies in heart failure and might stimulate future research in the field. The observation of extracellular matrix-specific antibodies and the detection of Fcγ receptor-expressing cells within the scar provide novel insights into the mechanisms by which antibodies may contribute to adverse remodeling.

Predictors of mortality in ischaemic versus non-ischaemic functional mitral regurgitation after successful transcatheter mitral valve repair using MitraClip: results from two high-volume centres

INTRODUCTION

Transcatheter edge-to-edge mitral valve repair using the MitraClip has been widely performed in surgical high-risk patients with reduced left ventricular systolic function and severe functional mitral regurgitation (FMR). Ischaemic heart disease is the leading aetiology of heart disease worldwide. We aimed to assess the clinical implications of ischaemic aetiology in patients with severe FMR who underwent MitraClip implantation.

METHODS AND RESULTS

From two high-volume centres in Germany, we retrospectively compared the clinical outcomes and clinical predictors of all-cause mortality after MitraClip implantation in patients with ischaemic (I-FMR) and non-ischaemic FMR (NI-FMR). In the overall FMR cohort (n = 575), there were 336 (58%) patients with I-FMR and 239 (42%) with NI-FMR. There was no significant difference in survival between the two groups (log-rank p = 0.78). In a multivariable Cox regression analysis of all-cause mortality, different predictors were observed for either group. In I-FMR patients, decreasing tricuspid annular systolic excursion [adjusted hazard ratio (HR_adj) 1.06, 95% confidence interval (95% CI) 1.01-1.14 /1 mm, p = 0.028] and increasing logistic EuroSCORE (HR_adj 1.02, 95% CI 1.00-1.03, p = 0.037) were independent predictors, whereas in NI-FMR patients, NT-pro BNP (HR_adj 1.05, 95% CI 1.02-1.08, p = 0.001) and age (HR_adj 1.06, 95% CI 1.01-1.11, p = 0.013) were independently predictive of mortality.

CONCLUSIONS

Despite the similar survival between ischaemic and non-ischaemic FMR, different predictors of all-cause mortality were demonstrated. Further clinical studies are mandated to focus on each FMR subgroup with stratification by ischaemic origin.

Ventricular arrhythmias and myocardial inflammation: Long-term follow-up of patients with suspected myocarditis

BACKGROUND

Inflammatory heart disease is known to be associated with ventricular arrhythmias (VA) and impaired ventricular function at presentation or during follow-up. We aimed to investigate the need for implanted cardioverter defibrillator (ICD) due to ventricular dysfunction and occurrence of VA during long-term follow-up in patients admitted with suspected myocarditis.

METHODS

Between 2000 and 2016, 191 patients (age 43 ± 13 years, 71% male, mean left ventricular ejection fraction (LVEF) 33 ± 15%) with clinically suspected myocarditis, who underwent endomyocardial biopsies (EMB), were prospectively enrolled and followed up in 6-months-intervals (median follow-up was 83 (49-156) months). The primary endpoint was deterioration of cardiac function (LVEF ≤ 35%) or occurrence of VA leading to ICD implantation.

RESULTS

According to EMB results, patients were stratified in three diagnostic groups: acute myocarditis (5%), chronic myocarditis (50%) and dilated cardiomyopathy (DCM) (45%). An ICD implantation was performed in 58 patients (30%, n = 38 for primary prevention). Besides LVEF at baseline, chronic myocardial inflammation was the only independent predictor of ICD implantation for primary prevention (hazard ratio 2.48 (95% confidence interval 1.02-5.5); p = 0.045). VA requiring ICD therapy occurred in 29 of 58 patients (50%) after a median of 14 (2-37) months without a significant difference between presence and absence of myocardial inflammation.

CONCLUSIONS

Nearly one third of patients with suspected myocarditis require an ICD due to impaired LVEF or occurrence of VA. Half of these patients experienced VA with adequate ICD therapy.

Transcatheter aortic valve implantation in patients younger than 75 years: Guidelines-based patients selection and clinical outcome

BACKGROUND

Patients treated by transcatheter aortic valve implantation (TAVI) in all major recent trials are still mostly octogenarians. Aim of this study is to analyze the risk profile and outcome of TAVI patients <75 years.

METHODS AND RESULTS

We retrospectively analyzed 172 patients <75 years with symptomatic severe native AS or degeneration of surgical aortic bioprosthesis treated with TAVI. The level of surgical risk was reassessed according to multiparametric ACC classification (prohibitive in 68 patients, high in 34, intermediate in 70). Mean age was 69.02 ± 6.18 years, mean STS score 5.56 ± 5.21. The majority of them presented one or more clinical or anatomical characteristics favoring TAVI according to ECS guidelines, despite the young age. Vascular access was transfemoral in 76%. According to the VARC-2 definitions, device success was high (90%) in all groups. The early safety was 89%, clinical recovery was slower in prohibitive risk patients. Bleeding events were more frequent in prohibitive and high surgical risk classes. Clinical efficacy at 1 year was overall 83%, and significantly better in intermediate risk patients (p = 0.004). The functional status remained stable over time as well as prostheses performance.

CONCLUSION

About 40% of patients <75 years were treated by TAVI due to the presence of a prohibitive risk, mainly related to technical impediments. The remaining was referred to TAVI due to an estimated high or intermediate surgical risk driven by STS score, frailty and/or major organ system compromise. Early and mid-term clinical and hemodynamic outcomes were good, in particular in intermediate risk patients.

Validation of an algorithm to reveal the U wave in atrial fibrillation

Major cardiac organisations recommend U wave abnormalities should be reported during ECG interpretation. However, U waves cannot be measured in patients with atrial fibrillation (AF) due to the obscuring fibrillatory wave. The aim was to validate a U wave measurement algorithm for AF patients. Multi-beat averaging was applied to ECGs of 25 patients during paroxysms of AF and the presence of U waves compared to those from the same patients during sinus rhythm (SR). In a further database of 10 long-term AF recordings, the number of beats for effective U wave extraction by the algorithm was calculated. U waves were revealed in all AF recordings and there was no significant difference between the presence of U waves in AF and SR (p = 0.88). U wave amplitude was significantly increased in AF (mean (s.d.) amplitude 55 (39) AF vs 37 (28) μV SR, p = 0.005). The presence of U waves could easily be discerned when as few as 10 beats were used in the algorithm. The study demonstrates the validity of the algorithm to reveal U waves in AF recordings. The algorithm offers the potential to detect U wave abnormalities in patients with AF.

Associations and prognostic significance of diffuse myocardial fibrosis by cardiovascular magnetic resonance in heart failure with preserved ejection fraction

BACKGROUND

Increased myocardial fibrosis may play a key role in heart failure with preserved ejection fraction (HFpEF) pathophysiology. The study aim was to evaluate the presence, associations, and prognostic significance of diffuse fibrosis in HFpEF patients compared to age- and sex-matched controls.

METHODS

We prospectively included 118 consecutive HFpEF patients. Diffuse myocardial fibrosis was estimated by extracellular volume (ECV) quantified by cardiovascular magnetic resonance with the modified Look-Locker inversion recovery sequence. We determined an ECV age- and sex-adjusted cutoff value (33%) in 26 controls.

RESULTS

Mean ECV was significantly higher in HFpEF patients versus healthy controls (32.9 ± 4.8% vs 28.2 ± 2.4%, P <  0.001). Multivariate logistic regression showed that body mass index (BMI) (odds ratio (OR) =0.92 [0.86-0.98], P = 0.011), diabetes (OR = 2.62 [1.11-6.18], P = 0.028), and transmitral peak E wave velocity (OR = 1.02 [1.00-1.03], P = 0.022) were significantly associated with abnormal ECV value. During a median follow-up of 11 ± 6 months, the primary outcome (all-cause mortality or first heart failure hospitalization) occurred in 38 patients. In multivariate Cox regression analysis, diabetes (hazard ratio (HR) =1.98 [1.04; 3.76], P = 0.038) and hemoglobin level (HR = 0.81 [0.67; 0.98], P = 0.028) were significant predictors of composite outcome. The ECV ability to improve this model added significant prognostic information. We then developed a risk score including diabetes, hemoglobin and ECV > 33% demonstrating significant prediction of risk and validated this score in a validation cohort of 53 patients. Kaplan-Meier curves showed a significant difference according to tertiles of the probability score (P <  0.001).

CONCLUSION

Among HFpEF patients, high ECV, likely reflecting abnormal diffuse myocardial fibrosis, was associated with a higher rate of all-cause death and first HF hospitalization in short term follow up.

TRIAL REGISTRATION

Characterization of Heart Failure With Preserved Ejection Fraction.

TRIAL REGISTRATION NUMBER

NCT03197350 . Date of registration: 20/06/2017. This trial was retrospectively registered.

Heart Failure With Improved Ejection Fraction: Is it Possible to Escape One's Past?

Among patients with heart failure with reduced ejection fraction, investigators have repeatedly identified a subgroup whose left ventricular ejection fraction and structural remodeling can improve to normal or nearly normal levels with or without medical therapy. This subgroup of patients with "heart failure with improved ejection fraction" has distinct clinical characteristics and a more favorable prognosis compared with patients who continue to have reduced ejection fraction. However, many of these patients also manifest clinical and biochemical signs of incomplete resolution of heart failure pathophysiology and remain at some risk of adverse outcomes, thus indicating that they may not have completely recovered. Although rigorous evidence on managing these patients is sparse, there are several reasons to recommend continuation of heart failure therapies, including device therapies, to prevent clinical deterioration. Notable exceptions to this recommendation may include patients who recover from peripartum cardiomyopathy, fulminant myocarditis, or stress cardiomyopathy, whose excellent long-term prognoses may imply true myocardial recovery. More research on these patients is needed to better understand the mechanisms that lead to improvement in ejection fraction and to guide their clinical management.

Should heart failure patients be left to fate? Temporary implementation of veno-arterial extracorporeal membrane oxygenation for haemodynamic support during excision of rectal carcinoma in an end-stage biventricular heart failure patient

Management of end-stage heart failure patients requiring major general surgery is not well defined. Due to poor cardiorespiratory reserve, perioperative morbidity and mortality are excessively high. We report a case of temporary implementation of veno-arterial extracorporeal membrane oxygenation for haemodynamic support during excision of rectal carcinoma in an end-stage heart failure patient and describe perioperative management.

Detection of Atrial Fibrillation in Cryptogenic Stroke

PURPOSE OF REVIEW

To summarize the literature on the detection of atrial fibrillation (AF) in patients with "cryptogenic" stroke, a cohort including about 25% of all ischemic stroke patients and patients with embolic stroke of undetermined source (ESUS).

RECENT FINDINGS

A first episode of AF is detected in up to one third of cryptogenic stroke and in up to one fourth of ESUS patients during long-term monitoring. AF prevalence correlates to patient selection, duration, and quality of ECG monitoring. Higher rates of AF were reported in stroke patients with left atrial pathology, specific ECG alterations, or increased natriuretic peptides. While AF detection impacts on medical stroke prevention in the vast majority of patients, patient selection for prolonged monitoring is largely left at the physician's discretion. AF detection after cryptogenic stroke or ESUS is a frequent, potentially causal condition. Whether subsequent oral anticoagulation may improve outcome remains open.