Complexities of treating co-morbidities in heart failure with preserved ejection fraction.

Atrial fibrillation and heart failure with preserved ejection fraction (HFpEF) are frequent concomitant diseases sharing several pathophysiological mechanisms leading to structural remodelling of both atria and ventricles. We present a case of an HFpEF patient with rapid atrial fibrillation who remained symptomatic even after successful cardioversion, initiation of antiarrhythmic therapy, and treatment of comorbidities. Due to asymmetric septal hypertrophy, the stress test was performed to exclude outflow tract obstruction and revealed a low basal heart rate with significant chronotropic insufficiency. In addition to SGLT2 initiation, the beta-blocker dose was reduced, and amiodarone was discontinued. This therapy modification led to a marked improvement in exercise capacity, significant reduction of palpitations, reduction of NT-proBNP, and signs of a decreased left ventricular filling pressure with reverse remodelling of LA. This case shows the importance of both individual tailoring of medical therapy and chronotropic insufficiency in HFpEF patients.

AV-optimized conduction system pacing for treatment of AV dromotropathy: A randomized, cross-over study.

BACKGROUND: Severe first-degree atrioventricular (AV) block may produce symptoms similar to heart failure due to AV dyssynchrony, a syndrome termed AV dromotropathy. According to guidelines, it should be considered for permanent pacemaker implantation, yet evidence supporting this treatment is scarce. OBJECTIVES: This study aimed to determine the impact of AV-optimized conduction system pacing (CSP) in patients with symptomatic severe first-degree AV block and echocardiographic signs of AV dyssynchrony. METHODS: Patients with symptomatic first-degree AV block (PR > 250 ms), preserved left ventricular ejection fraction, narrow QRS, and AV dyssynchrony were included in the study. In a single-blind cross-over design, patients were randomized to AV sequential CSP or backup VVI pacing with a base rate of 40 bpm. We compared exercise capacity, echocardiographic parameters, and symptom occurrence at the end of 3 months of each period. RESULTS: Fourteen patients completed the study. During the AV-optimized CSP compared to the backup pacing period, patients achieved a higher workload on exercise test (147.2 ± 50.9 vs. 140.7 ± 55.8 W; p = .032), with a trend towards higher peak VO2 (23.3 ± 7.1 vs. 22.8 ± 7.1 mL/min/kg; p = .224), and higher left ventricular stroke volume (LVSV 74.5 ± 13.8 vs. 66.4 ± 12.5 mL; p < .001). Symptomatic improvement was recorded, with fewer patients reporting general tiredness and 71% of patients preferring the AV-optimized CSP (p = .008). CONCLUSIONS: AV-optimized CSP could improve symptoms, exercise capacity and LVSV in patients with severe first-degree AV block.

Impact of preventive substrate catheter ablation on implantable cardioverter-defibrillator interventions in patients with ischaemic cardiomyopathy and infarct-related coronary chronic total occlusion.

AIMS: Primary prevention patients with ischaemic cardiomyopathy and chronic total occlusion of an infarct-related coronary artery (CTO) are at a particularly high risk of implantable cardioverter-defibrillator (ICD) therapy occurrence. The trial was designed to evaluate the efficacy of preventive CTO-related substrate ablation strategy in ischaemic cardiomyopathy patients undergoing primary prevention ICD implantation. METHODS AND RESULTS: The PREVENTIVE VT study was a prospective, multicentre, randomized trial including ischaemic patients with ejection fraction ≤40%, no documented ventricular arrhythmias (VAs), and evidence of scar related to the coronary CTO. Patients were randomly assigned 1:1 to a preventive substrate ablation before ICD implantation or standard therapy with ICD implantation only. The primary outcome was a composite of appropriate ICD therapy or unplanned hospitalization for VAs. Secondary outcomes included the primary outcome's components, the incidence of appropriate ICD therapies, cardiac hospitalization, electrical storm, and cardiovascular (CV) mortality. Sixty patients were included in the study. During the mean follow-up of 44.7 ± 20.7 months, the primary outcome occurred in 5 (16.7%) patients undergoing preventive substrate ablation and in 13 (43.3%) patients receiving only ICD [hazard ratio (HR): 0.33; 95% confidence interval (CI): 0.12-0.94; P = 0.037]. Patients in the preventive ablation group also had fewer appropriate ICD therapies (P = 0.039) and the electrical storms (Log-rank: P = 0.01). While preventive ablation also reduced cardiac hospitalizations (P = 0.006), it had no significant impact on CV mortality (P = 0.151). CONCLUSION: Preventive ablation of the coronary CTO-related substrate in patients undergoing primary ICD implantation is associated with the reduced risk of appropriate ICD therapy or unplanned hospitalization due to VAs.

Effect of Coronary Sinus Reducer Implantation on Aerobic Exercise Capacity in Refractory Angina Patients-A CROSSROAD Study.

Coronary sinus reducer (CSR) implantation is a new treatment option for patients with refractory angina pectoris. However, there is no evidence from a randomized trial that would show an improvement in exercise capacity after this treatment. The aim of this study was to evaluate the influence of CSR treatment on maximal oxygen consumption and compare it to a sham procedure. Twenty-five patients with refractory angina pectoris (Canadian Cardiovascular Society (CCS) class II-IV) were randomized to a CSR implantation (n = 13) or a sham procedure (n = 12). At baseline and after 6 months of follow-up, the patients underwent symptom-limited cardiopulmonary exercise testing with an adjusted ramp protocol and assessment of angina pectoris using the CCS scale and Seattle angina pectoris questionnaire (SAQ). In the CSR group, maximal oxygen consumption increased from 15.56 ± 4.05 to 18.4 ± 5.2 mL/kg/min (p = 0.03) but did not change in the sham group (p = 0.53); p for intergroup comparison was 0.03. In contrast, there was no difference in the improvement of the CCS class or SAQ domains. To conclude, in patients with refractory angina and optimized medical therapy, CSR implantation may improve oxygen consumption beyond that of optimal medical therapy.

Biventricular versus Conduction System Pacing after Atrioventricular Node Ablation in Heart Failure Patients with Atrial Fibrillation.

Conduction system pacing (CSP) modalities, including His-bundle pacing (HBP) and left bundle branch pacing (LBBP), are increasingly used as alternatives to biventricular (BiV) pacing in heart failure (HF) patients scheduled for pace and ablate strategy. The aim of the study was to compare clinical outcomes of HF patients with refractory AF who received either BiV pacing or CSP in conjunction with atrio-ventricular node ablation (AVNA). Fifty consecutive patients (male 48%, age 70 years (IQR 9), left ventricular ejection fraction (LVEF) 39% (IQR 12)) were retrospectively analysed. Thirteen patients (26%) received BiV pacing, 27 patients (54%) HBP and 10 patients (20%) LBBP. All groups had similar baseline characteristics and acute success rate. While New York Heart. Association (NYHA) class improved in both HBP (p < 0.001) and LBBP (p = 0.008), it did not improve in BiV group (p = 0.096). At follow-up, LVEF increased in HBP (form 39% (IQR 15) to 49% (IQR 16), p < 0.001) and LBBP (from 28% (IQR 13) to 40% (IQR 13), p = 0.041), but did not change in BiV group (p = 0.916). Conduction system pacing modalities showed superior symptomatic and echocardiographic improvement compared to BiV pacing after AVNA. With more stable pacing parameters, LBBP could present a more feasible pacing option compared to HBP.

Efficacy of coronary sinus reducer implantation in patients with chronic total occlusion of the right coronary artery.

BACKGROUND: Clinical efficacy of coronary sinus reducer (CSR) in refractory angina (RA) patients with ischemia due to the chronic total occlusion (CTO) of the right coronary artery (RCA) remains unknown. AIMS: To evaluate the efficacy of CSR implantation in RA patients with CTO RCA and compare them to CSR recipients with left coronary artery (LCA) ischemia. METHODS: Consecutive patients with CTO RCA from 2 centers were prospectively included and compared to patients with LCA ischemia. All patients underwent evaluation of angina severity and quality of life (QoL) at baseline and after 12 months. In a subgroup of CTO RCA patients, stress cardiac magnetic resonance (CMR) imaging was also performed. RESULTS: Twenty-two patients with CTO RCA and predominant inferior and/or inferoseptal wall ischemia (the CTO RCA group) were compared to 24 patients with predominant anterior, lateral, and/or anteroseptal wall ischemia (the LCA group). While the Canadian Cardiovascular Society (CCS) anginascore mean (SD) improved in the CTO RCA group from 2.73 (0.46) to 1.82 (0.73) (P <0.001) and in the LCA group from 2.67 (0.57) to 1.92 (0.72) (P <0.001), there was no intergroup difference (P = 0.350). Significant improvement in all domains of the Seattle Angina Questionnaire was observed. Stress CMR did not show a significant reduction of ischemic inferior and/or inferoseptal segments, however, improvements in the transmurality index (P = 0.03) and the myocardial perfusion reserve index in segments with inducible ischemia (P = 0.03) were observed in the CTO RCA group. CONCLUSIONS: In CTO RCA patients, CSR implantation alleviated angina symptoms and improved QoL. The extent of improvement was comparable to that observed in patients with LCA ischemia.

Correction: Complete Revascularization and Survival in STEMI.

[This corrects the article DOI: 10.5334/gh.1040.].

Complete Revascularization and Survival in STEMI.

Background: Complete revascularization (CR) of ST-elevation myocardial infarction patients with multivessel coronary artery disease (MVD) has proven better regarding combined endpoints than incomplete revascularization (IR) in recent randomized control trials with no impact on survival. Objective: To retrospectively evaluate the impact of complete CR during the index hospitalization on survival in STEMI patients with MVD. Methods and results: We included all patients with MVD who underwent successful primary percutaneous coronary intervention for STEMI during their index hospitalization at the University Medical Centre Ljubljana, Slovenia (from 1 January 2009 to 3 April 2011). Coronary angiograms were reviewed for non-culprit coronary arteries (>2 mm in diameter and ≥50% stenosis) treated with percutaneous coronary intervention. Rates of all-cause and cardiovascular death were compared between 235 patients who underwent CR (N = 70) or IR (N = 165). After a median follow-up of 7.0 years (interquartile range 6.0-8.2) the CR group had lower rates of all-cause death (15.7% vs 35.8%, log-rank p = 0.003) and cardiovascular death (12.9% vs 23.6%, log-rank p = 0.046). Multivariable analysis with adjustment for confounders showed no benefit of CR for all-cause death (hazard ratio [HR] 0.60, 95% confidence interval [CI] 0.31-1.18, p = 0.139) or cardiovascular death (HR 0.80, 95% CI 0.37-1.72, p = 0.560). Age, elevated serum creatinine at inclusion, diabetes and cardiogenic shock at presentation were predictors of death. Conclusions: Patients with STEMI and MVD who underwent CR showed lower all-cause and cardiovascular death during follow-up than those who underwent IR. However, after adjustment for confounders, the real determinates of survival were independent of the revascularization method.

Resynchronization therapy with His bundle pacing in a patient after coronary sinus reducer implantation.

Symptomatic heart failure patients with ischemic heart disease may require both coronary sinus reducer (CSR) implantation due to refractory angina pectoris and cardiac resynchronization therapy (CRT). Optimal approach to CRT in these patients is unknown as CSR implantation in the distal coronary sinus could deter left ventricular lead placement and thus preclude conventional CRT with biventricular pacing. We present a 70-year-old patient with ischemic cardiomyopathy and wide QRS complex after CSR implantation in whom we achieved successful cardiac resynchronization with His bundle pacing (HBP). HBP led to acute improvement in hemodynamic parameters and exercise capacity that persisted at follow-up. This case represents the first description of successful CRT with HBP in a patient after CSR implantation. HBP could present a feasible and safe resynchronization approach in these patients. .

Robustness of Percutaneously Completed Coronary Revascularization in Stable Coronary Artery Disease: Obstructive Versus Occlusive Lesions.

Our study sought to assess long-term outcomes of percutaneously completed coronary revascularization (CCR) in patients with obstructive coronary artery disease (CAD) comprising chronic total occlusions (CTOs). Between 2010 and 2014, percutaneous coronary interventions (PCIs) of the CTOs were attempted in 213 patients: the CCR was achieved in 125 patients (group 1), while the PCI failed in 88 patients (group 2). They were matched against 252 patients (group 3) with the CCR obtained by the non-CTO PCIs. In the 5-year follow-up, more adverse cardiovascular (CV) events occurred in group 2 (29.5% vs 4.8% in group 1 vs 3.5% in group 3, P = .0001), mainly due to recurrent severe symptoms and additional revascularization of the CTOs; CV mortality did not seem to be significantly affected. Survival curves for the successful CTO and non-CTO PCIs appeared indistinguishable. Stent thromboses were infrequent in the CCR groups. In conclusion, long-term outcomes of the patients with the obstructive CAD containing the CTOs showed a favorable outcome if the CCR had been achieved percutaneously.

Perioperative erythropoietin protects the CNS against ischemic lesions in patients after open heart surgery.

AIM: The aim of this study was to establish erythropoietin as a protective factor against brain ischemia during open heart surgery. METHODS: A total of 36 consecutive patients scheduled for revascularization heart surgery were included in the study. Of the patients 18 received 3 intravenous doses of recombinant human erythropoietin (rHuEpo, 24,000 IU) and 18 patients received a placebo. Magnetic resonance imaging (MRI) to detect new brain ischemic lesions was performed. Additionally, S100A, S100B, neuron-specific enolase A and B (NSE-A and B) and the concentration of antibodies against N­methyl-D-aspartate receptors (NMDAR) to identify new neurological complications were determined. RESULTS: Patients who received rHuEpo showed no postoperative ischemic changes in the brain on MRI images. In the control group 5 (27.8 %) new ischemic lesions were found. The NMDAR antibody concentration, S100A, S100B and NSE showed no significant differences between the groups for new cerebral ischemia. High levels of lactate before and after external aortic compression (p = 0.022 and p = 0.048, respectively) and duration of operation could predict new ischemic lesions (p = 0.009). CONCLUSIONS: The addition of rHuEpo reduced the formation of lesions detectable by MRI in the brain and could be used clinically as neuroprotection in cardiac surgery.

Transcatheter aortic valve implantation in a cancer patient denied for surgical aortic valve replacement-a case report.

BACKGROUND: Aortic stenosis is a progressive disease. Symptomatic aortic stenosis has a poor prognosis, which is frequently worse than that of a malignant disease. Cancer patients with severe aortic stenosis may be denied for optimal oncologic treatment because of high operative risk and for aortic valve replacement because of the significant comorbidity itself. In patients treated with medical therapy alone, 1-year-mortality exceeds 50 %. CASE REPORT: A 71-year-old woman with well-differentiated, surgically treated, ovarian carcinoma and two relapses treated with chemo- and radiotherapy presented with symptomatic severe aortic stenosis (aortic valve area 0.6 cm(2), mean gradient 60 mmHg). The tumor was in stagnation. She was rejected for surgical valve replacement. We implanted a 29 mm CoreValve aortic prosthesis via transfemoral approach. After the procedure haemodynamic variables remain stable, patient's exertional capacity is excellent. CONCLUSION: Aortic valve replacement improves survival of cancer patients with symptomatic aortic stenosis. Transcatheter aortic valve replacement (TAVI) is a treatment option in inoperable patients and patients at high surgical risk. Symptoms should not be confused for the progression of the malignant disease. In patient selection emphasis should be made on their frailty and futility. Eligible patients must have a life expectancy of at least 1 year. Final decision has to be made by a multidisciplinary heart team. TAVI can reduce treatment risk and facilitate the oncologic treatment.

All-comer treatment with bioresorbable vascular scaffold.

BACKGROUND: Bioresorbable vascular scaffolds (BVS) could overcome drug-eluting stents (DES) drawbacks connected with their permanent presence in the vessel wall. Studies exploring the clinical use of BVS are limited to the patients presenting with noncomplex, short and stable lesions. There are no prospective and randomized studies available in all-comer patients. METHODS AND RESULTS: We analyzed 31 patients, who received at least one BVS (Absorb(™)) between September 1, 2012 and November 1, 2014. Median follow-up period was 424 days. In one (3.2%) patient, we performed a target vessel revascularization (TVR). The death rate was 6.5%. One (3.2%) patient, who received both BVS and a bare metal stent (BMS), died of an acute stent thrombosis 8 days after the initial procedure. One (3.2%) patient died of a non-cardiac death. We did not encounter any target lesion revascularization (TLR) or myocardial infarction (MI). The major adverse cardiac events (MACE) rate was 3.2%. CONCLUSIONS: Implantation of BVS is a safe treatment option. Lesions should be carefully selected and prepared before BVS implantation. We need more data about the safety of BVS and BMS overlapping.