Carbohydrate antigen 125 on epicardial fat and its association with local inflammation and fibrosis-related markers.

BACKGROUND: Carbohydrate antigen 125 (CA125) is a proteolytic fragment of MUC-16 that is increased in heart failure (HF) and associated with inflammation, fluid overload, and worse adverse events. Our main objective was to study the expression of CA125 on epicardium and its association with inflammation, adipogenesis, and fibrosis. METHODS: Epicardial fat biopsies and blood were obtained from 151 non-selected patients undergoing open heart surgery. Immunohistochemistry, ELISA, or real-time PCR were used for analyzing protein or mRNA expression levels of CA125 and markers of inflammatory cells, fibroblasts, and adipocytes. Epithelial or stromal cells from epicardium were isolated and cultured to identify CA125 and its association with the adipogenesis and fibrosis pathways, respectively. RESULTS: The median age was 71 (63-74) years, 106 patients (70%) were male, and 62 (41%) had an established diagnosis of HF before surgery. The slice of epicardial fat biopsy determined a positive and colorimetric staining on the epithelial layer after incubating with the CA125 M11 antibody, providing the first description of CA125 expression in the human epicardium. Epicardial CA125 showed a strong and positive correlation with markers of inflammation and fibrosis in the epicardial fat tissue while exhibiting a negative correlation with markers of the adipogenesis pathway. This relationship remained significant after adjusting for potential confounders such as a prior HF diagnosis and plasma CA125 levels. CONCLUSION: Epicardial cells express CA125, which is positively associated with inflammatory and fibroblast markers in epicardial adipose tissue. These results suggest that CA125 may be biologically involved in HF progression (transition from adipogenesis to fibrosis).

Prognostic value of nutrition status in the response of cardiac resynchronization therapy.

BACKGROUND: Cardiac resynchronization therapy (CRT) is indicated in symptomatic heart failure (HF) patients after achieving optimal medical therapy. However, there are still a large percentage of patients who do not respond to CRT. Malnutrition is a frequent comorbidity in patients with HF, and it is associated with a poorer prognosis. Here, we evaluate the nutritional status of patients assessed by Controlling Nutritional Status (CONUT) score and its association with structural remodeling and cardiovascular events. METHODS: We investigated the effect of CONUT on HF/death in 302 consecutive patients with a CRT device implanted between 2005 and 2015 in a single tertiary center. We categorized the patients into three groups: normal nutritional status (CONUT 0-1), mild malnutrition (CONUT 2-4) and moderate-severe malnutrition (CONUT ≥ 5). Changes in nutritional status were assessed in patients with mild-to-severe malnutrition prior to CRT. RESULTS: One hundred and forty-eight patients exhibited normal nutritional status (49.0%), 99 patients exhibited mild malnutrition (32.8%) and 55 patients exhibited moderate-severe malnutrition (18.2%). CONUT scores of at least 2 were associated with higher risk of HF/death compared with CONUT 0-1. Significant left ventricular (LV) reverse remodeling was noted in patients with better nutritional status. In addition, those malnutrition patients at baseline that improved nutritional state exhibited fewer HF/death events at follow-up. CONCLUSION: CONUT score prior to CRT was an independent risk factor of death/HF and was correlated with LV reverse remodeling. Improvements in CONUT score during long-term follow-up were associated with a reduction in the rate of HF/death.

Enhanced Levels of Adiposity, Stretch and Fibrosis Markers in Patients with Coexistent Heart Failure and Atrial Fibrillation.

The coexistence of heart failure (HF) and atrial fibrillation (AF) worsens the prognosis of patients. We aimed to study the inflammation, metabolism, adiposity, and fibrosis markers on epicardial and subcutaneous fat and blood, and their relationship with HF and AF. Samples from 185 patients undergoing cardiac surgery were collected. Levels of multi-markers on fat biopsies and plasma were analyzed. Patients were grouped by HF or AF presence. Plasma adiposity markers were increased in AF patients, while increased stretch markers correlated with HF. Patients with both AF and HF had higher ANP and GDF-15 levels. After excluding AF patients, plasma FABP4 was identified as the main HF predictor. Fat biopsies from AF patients showed an enhanced inflammatory profile. Higher levels of adiposity markers are associated with AF or HF, and higher stretch and fibrosis markers with combined AF and HF, suggesting a role of adiposity-fibrosis pathway in HF and AF coexistence.

Videolaryngoscope versus conventional technique for insertion of a transesophageal echocardiography probe in intubated ICU patients (VIDLARECO trial): A randomized clinical trial.

BACKGROUND: Transesophageal echocardiogram probe insertion in intubated critically ill patients can be difficult, leading to complications, such as gastric bleeding or lesions in the oropharyngeal mucosa. We hypothesised that the use of a videolaryngoscope would facilitate the first attempt at insertion of the transesophageal echocardiogram probe and would decrease the incidence of complications compared to the conventional insertion technique. METHODS: In this clinical trial, patients were randomly assigned the insertion of a transesophageal echocardiogram probe using a videolaryngoscope or conventional technique. The primary outcome was the successful transesophageal echocardiogram probe insertion on the first attempt. The secondary outcomes included total success rate, number of insertion attempts, and incidence of pharyngeal complications. RESULTS: A total of 100 intubated critically ill patients were enrolled. The success rate of transesophageal echocardiogram probe insertion on the first attempt was higher in the videolaryngoscope group than in the conventional group (90% vs. 58%; absolute difference, 32%; 95% CI 16%-48%; p < 0.001). The overall success rate was higher in the videolaryngoscope group than in the conventional group (100% vs. 72%; absolute difference, 28%; 95% CI 16%-40%; p < 0.001). The incidence of pharyngeal mucosal injury was smaller in the videolaryngoscope group than in the conventional group (14% vs. 52%; absolute difference, 38%; 95% CI 21%-55%; p < 0.001). CONCLUSIONS: Our study showed that in intubated critically ill patients required transesophageal echocardiogram, the use of videolaryngoscope resulted in higher successful insertion on the first attempt with lower rate of complications when compared with the conventional insertion technique. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04980976.

Clinical Profiling and Biomarkers for Post-Operative Atrial Fibrillation Prediction in Patients Undergoing Cardiac Surgery.

Post-operative atrial fibrillation (POAF) is the most common arrhythmia in the post-operative period after cardiac surgery. We aim to investigate the main clinical, local, and/or peripheral biochemical and molecular predictors for POAF in patients undergoing coronary and/or valve surgery. Between August 2020 and September 2022, consecutive patients undergoing cardiac surgery without previous history of AF were studied. Clinical variables, plasma, and biological tissues (epicardial and subcutaneous fat) were obtained before surgery. Pre-operative markers associated with inflammation, adiposity, atrial stretch, and fibrosis were analyzed on peripheral and local samples with multiplex assay and real-time PCR. Univariate and multivariate logistic regression analyses were performed in order to identify the main predictors for POAF. Patients were followed-up until hospital discharge. Out of 123 consecutive patients without prior AF, 43 (34.9%) developed POAF during hospitalization. The main predictors were cardiopulmonary bypass time (odds ratio (OR) 1.008 (95% confidence interval (CI), 1.002-1.013), p = 0.005), and plasma pre-operative orosomucoid levels (OR 1.008 (1.206-5.761). After studying differences regarding sex, orosomucoid was the best predictor for POAF in women (OR 2.639 (95% CI, 1.455-4.788), p = 0.027) but not in men. The results support the pre-operative inflammation pathway as a factor involved in the risk of POAF, mainly in women.

Cardiogenic shock code 2023. Expert document for a multidisciplinary organization that allows quality care.

Despite the efforts made to improve the care of cardiogenic shock (CS) patients, including the development of mechanical circulatory support (MCS), the prognosis of these patients continues to be poor. In this context, CS code initiatives arise, based on providing adequate, rapid, and quality care to these patients. In this multidisciplinary document we try to justify the need to implement the SC code, defining its structure/organization, activation criteria, patient flow according to care level, and quality indicators. Our specific purposes are: a) to present the peculiarities of this condition and the lessons of infarction code and previous experiences in CS; b) to detail the structure of the teams, their logistics and the bases for the management of these patients, the choice of the type of MCS, and the moment of its implantation, and c) to address challenges to SC code implementation, including the uniqueness of the pediatric SC code. There is an urgent need to develop protocolized, multidisciplinary, and centralized care in hospitals with a large volume and experience that will minimize inequity in access to the MCS and improve the survival of these patients. Only institutional and structural support from the different administrations will allow optimizing care for CS.

The Effect of Mineralocorticoid Receptor 3 Antagonists on Anti-Inflammatory and Anti-Fatty Acid Transport Profile in Patients with Heart Failure.

Epicardial fat thickness is associated with cardiovascular disease. Mineralocorticoid receptor antagonist (MRA), a pharmaceutical treatment for CVD, was found to have an effect on adipose tissue. Our aim was to analyse the main epicardial fat genesis and inflammation-involved cell markers and their regulation by risk factors and MRA. We included blood and epicardial or subcutaneous fat (EAT or SAT) from 71 patients undergoing heart surgery and blood from 66 patients with heart failure. Cell types (transcripts or proteins) were analysed by real-time polymerase chain reaction or immunohistochemistry. Plasma proteins were analysed by Luminex technology or enzyme-linked immunoassay. Our results showed an upregulation of fatty acid transporter levels after aldosterone-induced genesis. The MRA intake was the main factor associated with lower levels in epicardial fat. On the contrary, MRA upregulated the levels and its secretion of the anti-inflammatory marker intelectin 1 and reduced the proliferation of epicardial fibroblasts. Our results have shown the local MRA intake effect on fatty acid transporters and anti-inflammatory marker levels and the proliferation rate on epicardial fat fibroblasts. They suggest the role of MRA on epicardial fat genesis and remodelling in patients with cardiovascular disease. Translational perspective: the knowledge of epicardial fat genesis and its modulation by drugs might be useful for improving the treatments of cardiovascular disease.

Should PRECISE-DAPT be included for long-term prognostic stratification of diabetic patients with NSTEACS?

AIMS: There are insufficient data regarding risk scores validation in patients with diabetes mellitus and non-ST elevation acute coronary syndrome (NSTEACS). We performed a diabetes mellitus-specific analysis of cardiovascular outcomes after NSTEACS. We tested the predictive power of the Global Registry of Acute Coronary Events (GRACE) and PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Anti-Platelet Therapy (PRECISE-DAPT) scores. METHODS: This work is a retrospective analysis that included 7,415 consecutive NSTEACS patients from two Spanish Universitarian hospitals between the years 2003 and 2017. The area under the ROC curve among with and without diabetes mellitus patients was calculated, to evaluate the predictive power of both scores.  RESULTS: Among the study participants, 2124 patients (28.0%) were diabetic. The median follow-up was 54,3 months (IQR 24,7-80,0 months). Diabetic patients were more women (30.5% vs. 25.7%) and older (70.0 ± 10.8 vs. 65.3 ± 13.2 years old); they had higher GRACE (146 ± 36 vs. 137 ± 36), PRECISE-DAPT (15 ± 7 vs. 18 ± 9) at admission. Early invasive coronary angiography (≤ 24 h after admission) was performed more frequently in non-diabetic. We tested the predictive power of the GRACE and PRECISE-DAPT risk scores among diabetic and non-diabetic. PRECISE-DAPT risk score showed a good predictive power for all-cause mortality, cardiovascular mortality and MACE in diabetic admitted with NSTEACS, without differences compared to non-diabetic. CONCLUSIONS: PRECISE-DAPT risk score has an appropriate predictive power in diabetic patients admitted with NSTEACS compared to non-diabetic NSTEACS. However, GRACE would be predictive worse in diabetic during long-term follow-up in a large contemporary registry.

Early angiography in elderly patients with non-ST-segment elevation acute coronary syndrome: The cardio CHUS-HUSJ registry.

BACKGROUND: In elderly patients with non-ST elevation acute coronary syndrome (NSTEACS), while routine invasive management is established in high-risk NSTEACS patients, there is still uncertainty regarding the optimal timing of the procedure. METHODS: This study analyzes the association of early coronary angiography with all-cause mortality, cardiovascular mortality, heart failure (HF) hospitalization, and major adverse cardiovascular events (MACE) in patients older than 75 years old with NSTEACS. This retrospective observational study included 7811 consecutive NSTEACS patients who were examined between the years 2003 and 2017 at two Spanish university hospitals. There were 2290 patients older than 75 years old. We compared their baseline characteristics according to the early invasive strategy used (coronarography ≤24 h vs. coronarography >24 h) after the diagnosis of NSTEACS. RESULTS: Among the study participants, 1566 patients (68.38%) underwent early invasive coronary intervention. The mean follow-up period was 46 months (interquartile range 18-71 months). This association was also maintained after propensity score matching: early invasive strategy was significantly related to lower all-cause mortality [HR 0.61 (95% CI 0.51-0.71)], cardiovascular mortality [HR 0.52 (95% CI 0.43-0.63)], and MACE [HR 0.62 (CI 95% 0.54-0.71)]. CONCUSIONS: In a contemporary real-world registry of elderly NSTEACS patients, early invasive management significantly reduced all-cause mortality, cardiovascular mortality, and MACE during long-term follow-up. BRIEF SUMMARY: In this real-world retrospective observational study that included 2451 patients older than 75 years old, 1566 patients (68.38%) underwent early invasive coronary intervention. After performing a propensity score matching, the early invasive strategy was still associated with lower all-cause mortality [HR (hazard ratio) 0.61, 95% CI (95% confidence interval) (0.51-0.71)], cardiovascular mortality [HR 0.52 (95%CI 0.43-0.63)], and MACE [HR 0.62 (95%CI 0.54-0.71)] during long-term follow-up.

LVAD as a bridge to decision complicated with pump thrombosis and infection.

Left ventricular assist devices (LVADs) emerged as an effective therapy for the treatment of symptomatic advanced heart failure in spite of maximum tolerated optimal medical treatment. LVADs were initially conceived as a bridge to transplantation, although with the continuing donor shortage, they also serve as a definitive therapy for some patients. Careful evaluation by a multidisciplinary team and proper patient selection are key factors for good outcomes. These patients are very high-risk surgical candidates, and their survival at 1 year after implantation is estimated to be around 81%. We report a unique case of a patient who underwent LVAD implantation as a bridge to candidacy and suffered several complications related to the device. We also present our experience dealing with these complications in a field of limited evidence. This gentleman developed pump thrombosis second- ary to heparin-induced thrombocytopenia, requiring an LVAD exchange during index admission. A year after being discharged from the first episode, he developed mediastinitis, needing removal of the pump, intravenous antibiotics, and veno-arterial extra corporeal membrane oxygenation (VA-ECMO) for hemodynamic support. A new LVAD insertion was required, and the gentleman could be eventually discharged after a prolonged admission.

Long-term cardiac reverse remodeling after cardiac resynchronization therapy.

INTRODUCTION: The benefit of cardiac resynchronization therapy (CRT) in heart failure (HF) patients with reduced left ventricular ejection fraction (LVEF) have been observed in the first year. However, there are few data on long-term follow-up and the effect of changes of LVEF on mortality. This study aimed to assess the LV remodeling after CRT implantation and the probable effect of changes in LVEF with repeated measures on mortality over time in a real-world registry. METHODS: Among our cohort of 328 consecutive CRT patients, mixed model effect analysis have been made to describe the temporal evolution of LVEF and LVESV changes over time up with several explanatory variables. Besides, the effect of LVEF along time on the probability of mortality was evaluated using joint modeling for longitudinal and survival data. RESULTS: The study population included 328 patients (253 men; 70.2 ± 9.5 years) in 4.2 (2.9) years follow-up. There was an increase in LVEF of 11% and a reduction in LVESV of 42 mL during the first year. These changes are more important during the first year, but slight changes remain during the follow-up. The largest reduction in LVESV occurred in patients with left bundle branch block (LBBB) and the smallest reduction in patients with NYHA IV. The smallest increase in LVEF was an ischemic etiology, longer QRS, and LV electrode in a nonlateral vein. Besides, the results showed that the LVEF profiles taken during follow-up after CRT were associated with changes in the risk of death. CONCLUSION: Reverse remodeling of the left ventricle is observed especially during the first year, but it seems to be maintained later after CRT implantation in a contemporary cohort of patients. Longitudinal measurements could give us additional information at predicting the individual mortality risk after adjusting by age and sex compared to a single LVEF measurement after CRT.

Prognostic benefit from an early invasive strategy in patients with non-ST elevation acute coronary syndrome (NSTEACS): evaluation of the new risk stratification in the NSTEACS European guidelines.

OBJECTIVES: The objective of our work is to evaluate the prognostic benefit of an early invasive strategy in patients with high-risk NSTACS according to the recommendations of the 2020 clinical practice guidelines during long-term follow-up. METHODS: This retrospective observational study included 6454 consecutive NSTEACS patients. We analyze the effects of early coronary angiography (< 24 h) in patients with: (a) GRACE risk score > 140 and (b) patients with "established NSTEMI" (non ST-segment elevation myocardial infarction defined by an increase in troponins) or dynamic ST-T-segment changes with a GRACE risk score < 140. RESULTS: From 2003 to 2017, 6454 patients with "new high-risk NSTEACS" were admitted, and 6031 (93.45%) of these underwent coronary angiography. After inverse probability of treatment weighting, the long-term cumulative probability of being free of all-cause mortality, cardiovascular mortality and MACE differed significantly due to an early coronary intervention in patients with NSTEACS and GRACE > 140 [HR 0.62 (IC 95% 0.57-0.67), HR 0.62 (IC 95% 0.56-0.68), HR 0.57 (IC 95% 0.53-0.61), respectively]. In patients with NSTEACS and GRACE < 140 with established NSTEMI or ST/T-segment changes, the benefit of the early invasive strategy is only observed in the reduction of MACE [HR 0.62 (IC 95% 0.56-0.68)], but not for total mortality [HR 0.96 (IC 95% 0.78-1.2)] and cardiovascular mortality [HR 0.96 (IC 95% 0.75-1.24)]. CONCLUSIONS: An early invasive management is associated with reduced all-cause mortality, cardiovascular mortality and MACE in NSTEACS with high GRACE risk score. However, this benefit is less evident in the subgroup of patients with a GRACE score < 140 with established NSTEMI or ST/T-segment changes.

Predictors and outcomes of heart failure after transcatheter aortic valve implantation using a self-expanding prosthesis.

INTRODUCTION AND OBJECTIVES: The purpose of this analysis was to assess the incidence, predictors and prognostic impact of acute heart failure (AHF) after transcatheter aortic valve implantation (TAVI) using a self-expanding prosthesis. METHODS: From November 2008 to June 2017, all consecutive patients undergoing TAVI in our center were prospectively included in our TAVI registry. The predictive effect of AHF on all-cause mortality following the TAVI procedure was analyzed using Cox regression models. RESULTS: A total of 399 patients underwent TAVI with a mean age of 82.4 ± 5.8 years, of which 213 (53.4%) were women. During follow-up (27.0 ± 24.1 months), 29.8% (n = 119) were admitted due to AHF, which represents a cumulative incidence function of 13.2% (95%CI, 11.1%-15.8%). At the end of follow-up, 150 patients (37.59%) had died. Those who developed AHF showed a significantly higher mortality rate (52.1% vs 31.4%; HR, 1.84; 95%; CI, 1.14-2.97; P = .012). Independent predictors of AHF after TAVI were a past history of heart failure (P = .019) and high Society of Thoracic Surgeons score (P = .004). We found that nutritional risk index and chronic obstructive pulmonary disease were strongly correlated with outcomes in the AHF group. CONCLUSIONS: TAVI was associated with a high incidence of clinical AHF. Those who developed AHF had higher mortality. Pre-TAVI AHF and high Society of Thoracic Surgeons score were the only independent predictors of AHF in our cohort. A low nutritional risk index and chronic obstructive pulmonary disease were independent markers of mortality in the AHF group.

Prediction of major adverse cardiac, cerebrovascular events in patients with diabetes after acute coronary syndrome.

BACKGROUND AND OBJECTIVES: The risk of major adverse cardiac and cerebrovascular events following acute coronary syndrome is increased in people with diabetes. Predicting out-of-hospital outcomes upon follow-up remains difficult, and no simple, well-validated tools exist for this population at present. We aim to evaluate several factors in a competing risks model for actionable evaluation of the incidence of major adverse cardiac and cerebrovascular events in diabetic outpatients following acute coronary syndrome. METHODS: Retrospective analysis of consecutive patients admitted for acute coronary syndrome in two centres. A Fine-Gray competing risks model was adjusted to predict major adverse cardiac and cerebrovascular events and all-cause mortality. A point-based score is presented that is based on this model. RESULTS: Out of the 1400 patients, there were 783 (55.9%) with at least one major adverse cardiac and cerebrovascular event (417 deaths). Of them, 143 deaths were due to non-major adverse cardiac and cerebrovascular events. Predictive Fine-Gray models show that the 'PG-HACKER' risk factors (gender, age, peripheral arterial disease, left ventricle function, previous congestive heart failure, Killip class and optimal medical therapy) were associated to major adverse cardiac and cerebrovascular events. CONCLUSION: The PG-HACKER score is a simple and effective tool that is freely available and easily accessible to physicians and patients. The PG-HACKER score can predict major adverse cardiac and cerebrovascular events following acute coronary syndrome in patients with diabetes.

Impact of Coronary Revascularization in Patients Who Underwent Transcatheter Aortic Valve Implantation.

Coronary artery disease (CAD) is a common co-morbidity in transcatheter aortic valve implantation (TAVI) patients, but the prognostic value of coronary revascularization before TAVI is currently unknown. The aim of the present study was to assess the impact of coronary revascularization in patients who underwent TAVI. Patients underwent TAVI from 2008 to 2016 were included in the study. Baseline SYNTAX score and residual SYNTAX score (rSS) after percutaneous coronary intervention were calculated. Based on rSS, patients were classified as complete revascularization (rSS = 0), reasonably incomplete revascularization (rSS >0 and <8), and incomplete revascularization (rSS ≥8). The primary objective was to evaluate the impact of CAD and rSS on major cardiovascular adverse events (MACEs). The secondary objective was to assess the impact of rSS on hospitalization for heart failure. A total of 349 patients (mean age 82.4 ± 5.7 years, 53% women) were included in the study. A total of 187 patients (53.6%) had CAD (mean baseline SYNTAX score 9.2 ± 8.1). Percutaneous coronary intervention was performed in 29.9% of patients, achieving reasonably incomplete revascularization in 45.4%, and incomplete revascularization in 24.5%. The mean follow-up was 35.2 ± 25.3 months. No differences were observed in MACE rate between the CAD and non-CAD groups, or between the different degrees of revascularization. Differences were also not seen in the different levels of revascularization and hospitalization due to heart failure. In patients who underwent TAVI in this study, no association was found between the presence of CAD or the degree of revascularization in a long-term follow-up.

Cardiac resynchronization therapy outcomes in patients under nonoptimal medical therapy.

BACKGROUND: Cardiac resynchronization therapy (CRT) is indicated in symptomatic heart failure (HF) patients after achieving optimal medical therapy (OMT). However, many patients may not be under OMT when the CRT device is implanted. Here, we evaluate the long-term benefits of CRT in symptomatic HF patients receiving or not OMT. METHODS: We investigated the effect of OMT on HF developing or death in 328 consecutive patients with a CRT device implanted between 2005 and 2015 in a single tertiary center. After the CRT implant, we categorized the patients into three groups: no OMT, OMT at baseline and after 1 year of follow-up, and OMT only at the 1-year follow-up but not at baseline. We used multivariate Cox proportional hazards model to determine the effect of OMT on clinical outcomes. RESULTS: One hundred and twenty-two patients (37.2%) received OMT prior to CRT. OMT at baseline was not associated with a reduced risk of death or HF (HR 0.72; 95% CI 0.50-1.02; P = 0.067) compared with no-basal-OMT patients. After CRT, patients without OMT had a higher risk of death or HF than patients who received OMT in follow-up (HR 1.72, 95% CI 1.07-2.78, P = 0.025), and the risk of the patients who received OMT at baseline and at the 1-year follow-up was similar to that of the patients who achieved OMT at the 1-year follow-up (HR 0.90, 95% CI 0.54-1.50, P = 0.682). CONCLUSION: Basal OMT prior to CRT is not associated with better outcomes in terms of HF/death compared with no basal OMT. The subgroup of patients who achieved OMT at the 1-year follow-up exhibited a reduced risk of HF and death compared with patients who did not.

Validating Left Atrial Low Voltage Areas During Atrial Fibrillation and Atrial Flutter Using Multielectrode Automated Electroanatomic Mapping.

OBJECTIVES: This study aimed: 1) to determine the voltage correlation between sinus rhythm (SR) and atrial fibrillation (AF)/atrial flutter (AFL) using multielectrode fast automated mapping; 2) to identify a bipolar voltage cutoff for scar and/or low voltage areas (LVAs); and 3) to examine the reproducibility of voltage mapping in AF. BACKGROUND: It is unclear if bipolar voltage cutoffs should be adjusted depending on the rhythm and/or area being mapped. METHODS: High-density mapping was performed first in SR and afterward in induced AF/AFL. In some patients, 2 maps were performed during AF. Maps were combined to create a new one. Points of <1 mm difference were analyzed. Correlation was explored with scatterplots and agreement analysis was assessed with Bland-Altman plots. The generalized additive model was also applied. RESULTS: A total of 2,002 paired-points were obtained. A cutoff of 0.35 mV in AFL predicted a sinus voltage of 0.5 mV (95% confidence interval [CI]: 0.12 to 2.02) and of 0.24 mV in AF (95% CI: 0.11 to 2.18; specificity [SP]: 0.94 and 0.96; sensitivity [SE]: 0.85 and 0.75, respectively). When generalized additive models were used, a cutoff of 0.38 mV was used for AFL for predicting a minimum value of 0.5 mV in SR (95% CI: 0.5 to 1.6; SP: 0.94, SE: 0.88) and of 0.31 mV for AF (95% CI: 0.5 to 1.2; SP: 0.95, SE: 0.82). With regard to AF maps, there was no change in the classification of any left atrial region other than the roof. CONCLUSIONS: It is possible to establish new cutoffs for AFL and/or AF with acceptable validity in predicting a sinus voltage of <0.5 mV. Multielectrode fast automated mapping in AFL and/or AF seems to be reliable and reproducible when classifying LVAs. These observations have clinical implications for left atrial voltage distribution and in procedures in which scar distribution is used to guide pulmonary vein isolation and/or re-isolation.

Cardiac resynchronization therapy response in heart failure patients with different subtypes of true left bundle branch block.

PURPOSE: Left bundle branch block (LBBB) configuration has been described as a predictor of response to cardiac resynchronization therapy (CRT). We investigated whether different subtypes of true LBBB configuration could help select patients with better response and clinical outcome. METHODS: This retrospective study included 198 consecutive LBBB patients implanted with a CRT. True LBBB was defined using the Strauss and the Predict study criteria. Echocardiographic response was evaluated by the reduction in left ventricular end-systolic volume (LVESV) and the increase in left ventricular ejection fraction (LVEF). Clinical response was defined as an improvement in one category of the NYHA functional class. RESULTS: Patients with true LBBB had a greater improvement in both LVESV reduction (median = - 27.6%, interquartile range = [- 4.9, - 50.1]) and LVEF increase (median 10.8 ± 10) than those with non-true LBBB (- 19.7%, [16.7, - 48.0]) p = 0.04 and 5.1 ± 10, p = 0.03, respectively. No differences were exhibited between true LBBB Strauss group (- 26.7%, [- 11.0, - 46.9]) and true LBBB Predict group (- 26.6%, [- 15.9, - 39.4]). There were no statistically significant differences in the percentage of patients with clinical response, assessed by NYHA improvement, among all groups. In the Cox model for death, age, ischemic etiology, and ΔLVESV were independent predictors of mortality. True LBBB (Strauss + Predict) patients had a trend towards lower mortality than non-true LBBB [HR = 0.55, 95% CI = (0.22-1.15)], p = 0.08. In the Cox model for HF hospitalization, age, sex male, prior LVEF, and ΔLVESV were independent predictors. True LBBB (Strauss + Predict) patients had a significantly lower risk of developing HF hospitalization than those with non-true LBBB [0.45 (0.21-0.90)], p = 0.029. CONCLUSIONS: Patients with true LBBB, either Strauss or Predict criteria, had greater echocardiographic response and lower incidence of HF hospitalization than non-true LBBB when implanted with CRT.

Additive value of the CRUSADE score to the GRACE score for mortality risk prediction in patients with acute coronary syndromes.

INTRODUCTION: Acute coronary syndrome (ACS) treatments increase bleeding complications that also impair prognosis. Bleeding risk scores reclassification of actual mortality risk estimated by the GRACE score might improve overall estimation. METHODS: Observational and prospective study of all ACS patients admitted in two hospitals. Mortality risk was assessed by the GRACE score and bleeding risk by the CRUSADE score. We analyzed the net reclassification improvement (NRI) of adding the CRUSADE score to the GRACE score. RESULTS: We included 6997 patients, mean age 67.4 (12.9), 38.0% ST-elevation ACS, mean GRACE score 145.2 (39.9). The percentage of patients with CRUSADE score >20 or >50 increased as the GRACE score was higher. Hospital mortality was 5.3% and the addition of the CRUSADE score reclassified a relevant percentage of patients with GRACE score >109; NRI was 3.80% (1.10-6.10). During follow-up, (median 53.0months) mortality rate was 22.6% and patients with CRUSADE score >50 had significantly higher mortality rates in all GRACE score categories; NRI was high (46.6%, 95% CI 41.0-53.1). The multivariate analysis outlined the independent predictive value of CRUSADE score >20 or >50 as well as GRACE scores 109-139 and >140. CONCLUSIONS: The addition of the CRUSADE score to the GRACE score improved mortality risk estimation. A CRUSADE score >50 identified patients with higher post-discharge mortality and higher hospital mortality if GRACE score was >109. The CRUSADE score improved hospital and long-term mortality prediction in patients with GRACE score >140. Individual mortality risk estimation should integrate the CRUSADE and GRACE scores.

Comparison and Validation of Recommended QT Interval Correction Formulas for Predicting Cardiac Arrhythmias in Patients With Advanced Heart Failure and Cardiac Resynchronization Devices.

QT interval prolongation is an important marker for the development of cardiac arrhythmias (CAs). Optimal methods to estimate QT/QTc intervals in patients with ventricular pacing (VP) and its correlation with CA have not been widely investigated. We aimed to validate the currently available formulas for QT determination during VP and to compare their abilities in predicting the occurrence of CA (atrial fibrillation [AF] and malignant ventricular arrhythmias [VAs] in patients with advanced heart failure and cardiac resynchronization therapy). Consecutive patients with advanced heart failure who underwent cardiac resynchronization therapy implantation between August 2001 and April 2015 were included in a retrospective study. Four proposed formulas for QT correction in VP rhythms were evaluated. One hundred eighty patients were enrolled. During 44 months of follow-up, 43 patients (37.7%) developed AF and 16 patients (8.9%) developed VA. There was no correlation between corrected QT increments and AF risk with any of the formulas for paced rhythms. Regarding VA, higher corrected QT values measured with Massachusetts' formula (QTcM) were found to have a higher risk of event (p = 0.036) (Beta = 1.012 [1.001 to 1.023]). Each 1 ms increase in QTc increased the probability of experiencing VA by 12‰. QTcM >444 was found to be a strong predictor of VA. In conclusion, there are significant differences in mean QTc interval measured by the currently advised formulas. QTc interval was not associated with AF in any of the formulas. Only the QTcM formula showed a significant stepwise increase in the risk of experiencing malignant VA.