Left ventricular shape predicts arrhythmic risk in fibrotic dilated cardiomyopathy

AIMS

Remodelling of the left ventricular (LV) shape is one of the hallmarks of non-ischaemic dilated cardiomyopathy (DCM) and may contribute to ventricular arrhythmias and sudden cardiac death. We sought to investigate a novel three dimensional (3D) shape analysis approach to quantify LV remodelling for arrhythmia prediction in DCM.

METHODS AND RESULTS

We created 3D LV shape models from end-diastolic cardiac magnetic resonance images of 156 patients with DCM and late gadolinium enhancement (LGE). Using the shape models, principle component analysis, and Cox-Lasso regression, we derived a prognostic LV arrhythmic shape (LVAS) score which identified patients who reached a composite arrhythmic endpoint of sudden cardiac death, aborted sudden cardiac death, and sustained ventricular tachycardia. We also extracted geometrical metrics to look for potential prognostic markers. During a follow-up period of up to 16 years (median 7.7, interquartile range: 3.9), 25 patients met the arrhythmic endpoint. The optimally prognostic LV shape for predicting the time-to arrhythmic event was a paraboloidal longitudinal profile, with a relatively wide base. The corresponding LVAS was associated with arrhythmic events in univariate Cox regression (hazard ratio = 2.0 per quartile; 95% confidence interval: 1.3-2.9), in univariate Cox regression with propensity score adjustment, and in three multivariate models; with LV ejection fraction, New York Heart Association Class III/IV (Model 1), implantable cardioverter-defibrillator receipt (Model 2), and cardiac resynchronization therapy (Model 3).

CONCLUSION

Biomarkers of LV shape remodelling in DCM can help to identify the patients at greatest risk of lethal ventricular arrhythmias.

Myocardial fibrosis predicts ventricular arrhythmias and sudden death after cardiac electronic device implantation

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Unrestricted educational grants

Background

Increasing evidence supports a link between myocardial fibrosis (MF) and ventricular arrhythmias. We sought to determine whether presence of MF on visual assessment (MFVA) and gray zone fibrosis (GZF) mass predicts SCD and ventricular fibrillation / sustained ventricular tachycardia after cardiac implantable electronic device (CIED) implantation.

Methods

In this prospective study, total fibrosis and GZF mass, quantified using cardiovascular magnetic resonance, was assessed in relation to the primary endpoint of sudden cardiac death (SCD) and the secondary, arrhythmic endpoint of SCD or ventricular arrhythmias after CIED implantation.

Results

Among 700 patients (age 68.0 ± 12.0yrs [mean ± SD]), 27 (3.85%) experienced a SCD and 121 (17.3%) met the arrhythmic endpoint over 6.93 yrs (median; interquartile range 5.82-9.32). MFVA predicted SCD (hazard ratio [HR]: HR:26.3 [95% confidence interval [CI] 3.70-3337]; negative predictive value: 100%). In competing risks analyses, MFVA also predicted the arrhythmic endpoint (subdistribution [sHR]: 19.9 [95% CI 6.40-61.9]; negative predictive value:98.6%). Compared with no MFVA, a GZF mass measured with the 5SD method (GZF5SD) > 17 g was associated with highest risk of SCD (HR: 44.6;95% CI 6.12-5685) and the arrhythmic endpoint (sHR: 30.3 [95% CI 9.60-95.8]). Adding GZF5SD mass to MFVA led to reclassification of 39% for SCD and 50.2% for the arrhythmic endpoint. In contrast, LVEF did not predict either endpoint.

Conclusions

In CIED recipients, MFVA excluded patients at risk of SCD and virtually excluded ventricular arrhythmias. Quantified GZF5SD mass added predictive value in relation to SCD and the arrhythmic endpoint.

Heart Rate as a Marker of Relapse During Withdrawal of Therapy in Recovered Dilated Cardiomyopathy

OBJECTIVES

The objective of this study was to determine the relationship between heart rate and relapse among patients in the TRED-HF (Therapy withdrawal in REcovered Dilated cardiomyopathy trial).

BACKGROUND

Understanding markers and mechanisms of relapse among patients with recovered dilated cardiomyopathy (DCM) may enable personalized management.

METHODS

The relationship between serial heart rate measurements and relapse was examined among patients in the TRED-HF trial, a randomized trial which examined the safety and feasibility of withdrawing heart failure therapy from 51 patients with recovered DCM over 6 months. In total, 25 patients were randomized to therapy withdrawal and 26 to continue therapy, of whom 25 subsequently began therapy withdrawal in a single arm crossover phase.

RESULTS

The mean ± SD heart rate for those who had therapy withdrawn and did not relapse was 64.6 ± 10.7 beats/min at baseline and 74.7 ± 10.4 beats/min at follow-up, compared to 68.3 ± 11.3 beats/min at baseline and 86.1 ± 11.8 beats/min at follow-up for those who relapsed. After adjusting for differences in heart rate at baseline, patients who had therapy withdrawn and relapsed had a 10.4 beats/min (95% CI: 4.0-16.8) greater rise in heart rate than patients who had therapy withdrawn and did not relapse (P = 0.002). After data were adjusted for age, log N-terminal pro-B-type natriuretic peptide, and left ventricular ejection fraction (LVEF), heart rate (per 10 beats/min; hazard ratio [HR]: 1.65; 95% CI: 1.10-2.57; P = 0.01) and change in heart rate from baseline (per 10 beats/min; HR: 1.70; 95% CI: 1.12-2.57; p = 0.01) were associated with relapse. The results remained qualitatively the same after adjusting for beta-blocker dose.

CONCLUSIONS

For patients with DCM and improved LVEF, the rise in heart rate after treatment is withdrawn treatment identifies patients who are more likely to relapse. Whether the increase in heart rate is a marker or a mediator of relapse requires investigation. (Therapy withdrawal in REcovered Dilated cardiomyopathy trial [TRED]; NCT02859311).

Can we turn heart failure into heart success by studying myocardial remission?

Collapse

The therapeutic role of ivabradine in heart failure

Heart failure represents a major global cause of morbidity and mortality. Ivabradine is a selective funny current (I_f) inhibitor, which acts on the sinoatrial node, resulting in a reduction in heart rate. Ivabradine is currently licensed for use in patients with symptomatic heart failure with reduced ejection fraction and a heart rate persistently at least 70 beats per minute in spite of otherwise optimal prognostic heart failure pharmacotherapy. In this review article, we examine the mechanism of action of ivabradine, evaluate the clinical trials underpinning its application in heart failure and discuss its current recommended clinical use in this capacity.

A case of myopericarditis caused by Neisseria meningitidis W135 serogroup with protracted inflammatory syndrome

Meningococcal pericarditis is classically divided into three separate entities: isolated meningococcal pericarditis, disseminated meningococcal disease with pericarditis, and reactive (immunopathic) meningococcal pericarditis. We present the case of a 74-year-old woman with meningococcal septicaemia with meningococcal myopericarditis, which demonstrates crossover features.

An unusual cause of hypoxia: getting to the heart of the matter

A 63 year old female presented to hospital with progressive exertional dyspnoea over a 6 month period. In the year preceding her admission, she reported an intercurrent history of abdominal pain, diarrhoea and weight loss. She was found to be hypoxic, the cause for which was initially unclear. A ventilation-perfusion scan identified a right-to-left shunt. Transoesophageal echocardiography (TOE) demonstrated a significant right-to-left intracardiac shunt through a patent foramen ovale (PFO); additionally severe tricuspid regurgitation was noted through a highly abnormal tricuspid valve. The findings were consistent with carcinoid heart disease with a haemodynamically significant shunt, resulting in profound systemic hypoxia. 24 hour urinary 5-Hydroxyindoleacetic acid (5-HIAA) and imaging were consistent with a terminal ileal primary carcinoid cancer with hepatic metastasis. Liver biopsy confirmed a tissue diagnosis. The patient was commenced on medical therapy for carcinoid syndrome. She subsequently passed away while undergoing anaesthetic induction for valvular surgery to treat her carcinoid heart disease and PFO.

Navigating the choice of oral anticoagulation therapy for atrial fibrillation in the NOAC era

Atrial fibrillation (AF) is a major cause of ischaemic stroke. The majority of these strokes can be prevented by treatment with oral anticoagulation therapy. The advent of non-vitamin K antagonist oral anticoagulants (NOACs) has resulted in a choice of therapeutic agents available to physicians for anticoagulation for stroke prevention in patients with AF beyond the long-established vitamin K antagonists (VKAs). Pivotal trials have demonstrated non-inferiority of NOACs compared with VKAs, and in some cases superiority, for the prevention of stroke and systemic embolism in non-valvular AF. Yet there are no direct head-to-head comparator trials for the efficacy of NOACs. Therefore, the question of which oral anticoagulant for each individual patient can present a challenge to physicians. In this review article, we assess which patients with AF require anticoagulation, review the available therapeutic options, assessing the evidence base for each and offering guidance as to patient-specific factors that can influence this choice.

Successful conservative management of a permanent pacemaker pocket infection: a less invasive approach

We present a successful conservative management strategy for a frail elderly patient with a cardiac resynchronisation pacemaker who presented with evidence of an Enterobacter cloacae pacemaker pocket infection. A device washout and debridement procedure was performed, with reburial of the device in a new prepectoral pocket and creation of a closed-loop continuous antibiotic infusion into the infected pacemaker pocket. This was followed by a 6-week course of ambulatory intravenous antibiotic therapy. This conservative management strategy avoided the need for a more invasive and high-risk full device extraction, which the patient clearly stated he did not wish to have. Up-to-date consensus management guidelines recommend extraction of the entire implanted system in this situation; however, in this case we demonstrate an alternative conservative management option, which may be suitable for frail elderly and comorbid patients or for patients who decline device extraction.

Fluctuating drowsiness following cardiac catheterisation: artery of Percheron ischaemic stroke causing bilateral thalamic infarcts

An 81-year-old man underwent cardiac catheterisation to investigate breathlessness and left ventricular impairment of unknown cause. He had unobstructed coronary arteries. Immediately following the procedure, he became suddenly unresponsive with vertical gaze palsy, anisocoria and bilateral upgoing plantar responses. He made a rapid recovery to his premorbid state 25 min later with no residual focal neurological signs. He then had multiple unresponsive episodes, interspaced with complete resolution of symptoms and neurological signs. MRI of the brain identified bilateral medial thalamic infarcts and midbrain infarcts, consistent with an artery of Percheron territory infarction. By the time the diagnosis was reached, the thrombolysis window had elapsed. The unresponsive episodes diminished with time and the patient was discharged to inpatient rehabilitation. At 6-month review after the episode, the patient has a degree of progressive cognitive impairment.

Ezetimibe: an update on its clinical usefulness in specific patient groups

The aim of pharmacological lipid modification is to reduce low-density lipoprotein cholesterol (LDL-C) as a means of either secondary or primary prevention of cardiovascular disease. Statins are the first-line therapy for pharmacological lipid modification. Ezetimibe is a drug which reduces LDL-C by selectively inhibiting intestinal cholesterol absorption. This provides an alternative pharmacological approach to that of statin therapy to reduce LDL-C. Ezetimibe has been shown to significantly reduce levels of LDL-C and recently, as demonstrated in the IMPROVE-IT trial, to reduce the rate of cardiovascular events in high-risk patients. Ezetimibe therefore has an important role in pharmacological lipid modification. In this paper, we examine the body of research behind ezetimibe and assess its current clinical applications in different patient subgroups.

Feasibility of Left Atrial Appendage Occlusion Without Preprocedural Transesophageal Echocardiography or CT Scanning

OBJECTIVE

To assess the success rate and safety outcomes of left atrial appendage occlusion (LAAO) procedures in a cohort of patients who had not undergone preprocedural imaging.

BACKGROUND

LAAO patients usually undergo imaging with either transesophageal echocardiography (TEE) or computed tomography (CT) prior to the procedure itself. This preprocedural imaging may not be necessary.

METHODS

The procedural success and major complication rates were assessed in a cohort of 52 patients who underwent LAAO without preprocedural imaging.

RESULTS

Mean patient age was 75 ± 8 years. Median CHA2DS2-VASc score was 4 and median HASBLED score was 3. The LAAO procedure was successful in 51/52 cases (98.1%). In 1 case, the LAAO procedure did not proceed because the LAA was too large for the available occlusion devices. No patient had left atrial appendage thrombus, despite the fact that only 4 patients were taking oral anticoagulation therapy at the time. Major complications occurred in 2/52 cases (3.8%), both due to vascular injuries causing pseudoaneurysm formation.

CONCLUSION

LAAO in this series was not adversely affected by lack of preprocedural imaging. Omitting preprocedural imaging reduces risk attributable to the modality, reduces patient inconvenience and discomfort, reduces cost, and does not appear to significantly reduce the proportion of patients who can undergo a successful procedure. Further larger studies are warranted.

Improving patient handover between teams using a business improvement model: PDSA cycle

BACKGROUND

Medical admission units are continuously under pressure to move patients off the unit to outlying medical wards and allow for new admissions. In a typical district general hospital, doctors working in these medical wards reported that, on average, three patients each week arrived from the medical admission unit before any handover was received, and a further two patients arrived without any handover at all. A quality improvement project was therefore conducted using a 'Plan, Do, Study, Act' cycle model for improvement to address this issue.

METHOD

P - Plan: as there was no framework to support doctors with handover, a series of standard handover procedures were designed. D - Do: the procedures were disseminated to all staff, and championed by key stakeholders, including the clinical director and matron of the medical admission unit.

RESULTS

S - STUDY: Measurements were repeated 3 months later and showed no change in the primary end points. A - ACT: The post take ward round sheet was redesigned, creating a checkbox for a medical admission unit doctor to document that handover had occurred. Nursing staff were prohibited from moving the patient off the ward until this had been completed. This later evolved into a separate handover sheet. Six months later, a repeat study revealed that only one patient each week was arriving before or without a verbal handover.

CONCLUSIONS

Using a 'Plan, Do, Study, Act' business improvement tool helped to improve patient care.