Programmed ventricular stimulation predicts arrhythmic events and survival in hypertrophic cardiomyopathy.

BACKGROUND: Sudden cardiac death (SCD) risk stratification in hypertrophic cardiomyopathy (HCM) in the context of primary prevention remains suboptimal. The purpose of this study was to examine the additional contribution of programmed ventricular stimulation (PVS) on established risk assessment. METHODS: Two-hundred-and-three consecutive patients with diagnosed HCM and ≥1 noninvasive risk factors were prospectively enrolled over 19years. Patients were risk stratified, submitted to PVS and received an implantable cardioverter-defibrillator (ICD) according to then-current American Heart Association (AHA) guidelines and inducibility. Participants were prospectively followed-up for primary endpoint occurrence (appropriate ICD therapy or SCD). Contemporary (2015) AHA and European Society of Cardiology (ESC) guidelines were retrospectively assessed. RESULTS: During a median follow-up period of 60months the primary endpoint occurred in 20 patients, 19 of whom were inducible and received an ICD. Overall, 79 patients (38.9%) were inducible and 92 patients (45.3%) received an ICD (PVS sensitivity=95%, specificity=67.2%, positive predictive value=24%, negative predictive value=99.2%). AHA and ESC guidelines application misclassified 3 and 9 primary endpoint-meeting patients, respectively. Inducibility was the most important determinant of event-free survival in multivariate Cox regression (hazard ratio=33.3). A combined approach of ESC score≥6% or AHA indication for ICD with PVS inducibility yielded absolute sensitivity and negative predictive value, the former at a more cost-effective and specific way. CONCLUSIONS: Inducibility at PVS predicts SCD or appropriate device therapy in HCM. Non-inducibility is associated with prolonged event-free survival, while the procedure was proven safe. Reintegration of PVS into established risk stratification models in HCM may improve patient assessment.

Outcomes of Same Day Pacemaker Implantation after TAVI.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is often associated with conduction disturbances, followed by permanent pacemaker (PPM) implantation. Because of the potential reversibility of these conduction disorders, controversy exists regarding the right timing of PPM implantation. TAVI is routinely performed under dual-antiplatelet and antithrombotic therapy, which poses an additional hemorrhagic risk on a same-day procedure. The aim of the present study was to evaluate the safety and effectiveness of same-day PPM implantation in patients undergoing TAVI. METHODS: Consecutive patients undergoing TAVI with Medtronic Corevalve bioprosthesis (Medtronic Inc., Minneapolis, MN, USA) in a tertiary center were divided into two study groups. Group A included patients undergoing PPM implantation the same day with TAVI, and Group B patients were implanted with a PPM later after TAVI and before hospital discharge. The two study groups were compared for all complications associated with PPM implantation. RESULTS: In total, 168 patients were included in the study. PPM was implanted in 65 patients (38.7%). In 23 patients, a PPM was implanted the same day with TAVI (Group A) and in 42 patients PPM implantation was postponed at least 1 day (Group B). Cephalic vein was the access used for the leads in the majority of cases. There was only one case of pneumothorax in Group B. There were no differences in the incidence of pocket hematomas between the study groups. CONCLUSIONS: Same-day PPM implantation after TAVI is safe and feasible. Strategies reducing pocket hematomas are essential in such patients of high hemorrhagic risk.

Electrical storm is an independent predictor of adverse long-term outcome in the era of implantable defibrillator therapy.

AIMS: Electrical storm (ES) is a life-threatening arrhythmia complication affecting patients treated with an implantable cardioverter defibrillator (ICD). Despite its increasing importance, existing data on prognosis and management of ICD patients affected by ES are limited and conflicting. METHODS: We prospectively studied 169 consecutive patients receiving an ICD. Thirty-two patients presented with at least one episode of ES during the period of observation (33+/-26 months). ES patients were older (64+/-9 vs. 59+/-13 years, P=0.013) with more advanced congestive heart failure (CHF) but a similar incidence of an underlying organic heart disease. RESULTS: Long-term total and cardiac mortality were both increased among ES patients. Seventeen of the 32 ES patients died as opposed to 19 of the 137 ICD patients without ES (53 vs. 14%, P<0.001). In multivariate Cox regression analysis adjusted for the main confounders, history of ES was significantly and independently associated with total and cardiac mortality (risk ratio (RR)=2.13, P=0.031 and RR=2.59, P=0.019, respectively). CONCLUSION: ES is a relatively frequent complication affecting ICD patients treated for secondary prevention of sudden cardiac death (SCD). Although the acute management of this serious arrhythmia complication is usually successful, occurrence of ES is a strong independent predictor of poor outcome in ICD patients.