Device-related infective endocarditis in cardiac resynchronization therapy recipients - Single center registry with over 2500 person-years follow up.

AIM: To assess incidence, predisposing factors and outcomes of cardiac device-related infective endocarditis (CDRIE) in patients undergoing cardiac resynchronization therapy (CRT). METHODS AND RESULTS: High-volume, single-center cardiology database was screened to identify all CDRIE cases, based on modified Duke criteria, amongst 765 consecutive CRT implantations between 2002 and 2015 (70.8% de novo implantations, 13.7% and 15.5% up-grades from pacemaker and implantable cardioverter­defibrillator [ICD], respectively). During the median follow-up (FU) of 1207 days (range: 256­2664) overall 38 CDRIE (4.97%) cases were identified (incidence: 15/1000 person-years). Multivariate Cox regression model, incorporating significant baseline differences as covariates (model 1), demonstrated that both up-grade from ICD to CRT and higher baseline NYHA class were independently associated with increased risk of CDRIE (adjusted HR 4.29, 95%CI 1.93­9.57; and HR 2.43, 95%CI 1.32­4.49, respectively). In the second model (including all differences with P < 0.2) up-grade from ICD (HR 4.36, 95%CI 1.96­9.69), higher NYHA class (HR 2.04, 95%CI 1.11­3.75), hypertrophic cardiomyopathy (HR 5.85, 95% CI 1.46­23.52), lower baseline hemoglobin level (HR 0.68, 95%CI 0.50­0.94) and chronic obstructive pulmonary disease (HR 2.46, 95%CI 1.05­5.77) were all independently associated with higher risk of CDRIE. All-cause mortality in patients with CDRIE was significantly higher than in subjects without infective complications (68.4% vs. 33.7%, P < 0.001), and 50% of patients with CDRIE died during index hospitalization. CONCLUSIONS: The prevalence of CDRIE in CRT recipients is almost 5% within 3.5 years post implantation. Up-grade from ICD and high baseline NYHA class flag up patients at high-risk of CDRIE. CRT-related infective complications are associated with very poor prognosis.

Long-term prognosis is related to mid-term changes of glucometabolic status in patients with acute myocardial infarction treated invasively.

BACKGROUND: Glucometabolic status (GS) in patients with acute myocardial infarction (AMI) has an impact on prognosis, but it may change over time. AIM: To evaluate the prognosis after AMI treated invasively with respect to changes in GS assessed by oral glucose tolerance test at discharge and at mid-term follow-up visit (FU-visit). METHODS: Glucometabolic status was assessed by two-hour post-load glycaemia and defined as abnormal glucose tolerance (AGT) or normal glucose tolerance (NGT). Out of 454 in-hospital AMI survivors, 368 (81%) patients completed an FU-visit and were divided into four groups with respect to GS at discharge and FU-visit: group 1 - AGT at discharge and FU-visit (n = 101); group 2 - AGT at discharge and NGT at FU-visit (n = 48); group 3 - NGT at discharge and AGT at FU-visit (n = 114); and group 4 - NGT at discharge and FU-visit (n = 105). All-cause mortality was compared between groups with log-rank test. RESULTS: Median time from AMI to FU-visit was seven months. Median remote follow-up duration after AMI was 31 months. Two-hour post load glycaemia was significantly higher in patients with confirmed AGT at FU-visit than in other groups. Mortality was higher in group 1 (11.9%) than in group 2 (2.1%; p = 0.034) and group 4 (2.9%; p = 0.009). Mortality rates between group 2 and 4 were similar (2.1% vs. 2.9%; p = 0.781). There was no significant difference in mortality between group 1 and group 3 (11.9% vs. 6.1%; p = 0.114). Mortality in group 3 was over two-fold higher than in group 4; however, this difference was statistically non-significant (6.1% vs. 2.9%; p = 0.247). CONCLUSIONS: Prognosis for patients with confirmed AGT was unfavourable; however, patients with AGT at discharge, in whom GS improved, had similar mortality to subjects with persistent NGT. The major clinical implication from this study is the finding that reassessment of GS by repeated oral glucose tolerance test has significant prognostic value and makes initial risk stratification performed at discharge more reliable.

Do we need to monitor the percentage of biventricular pacing day by day?

BACKGROUND: Incidence and clinical significance of transient, daily fluctuations of biventricular pacing percentage (CRT%) remain unknown. We assessed the value of daily remote monitoring in identifying prognostically critical burden of low CRT%. METHODS AND RESULTS: Prospective, single-centre registry encompassed 304 consecutive heart failure patients with cardiac resynchronization therapy defibrillators (CRT-D). Patients with 24-h episodes of CRT% loss<95% were assigned to quartiles depending on cumulative time spent in low CRT%: quartile 1 (1-8days), 2 (9-20days), 3 (21-60days) and quartile 4 (>60days). During median follow-up of 35months 51,826 transmissions were analysed, including 15,029 in 208 (68.4%) patients with episodes of low CRT%. Overall, mean CRT%≥95% vs. <95% resulted in a 4-fold lower mortality (17.3 vs. 68.2%; p<0.001). Fifty-four percent of patients experienced episodes of CRT% loss, despite 85.6% having mean CRT%≥95%. Mortality was lowest in quartile 1 (7.7%), while longer periods of CRT% loss resulted in significantly higher death rates (25.0 vs. 34.6 vs. 57.7%; quartiles 2-4 respectively, p<0.001), despite mean CRT% still being ≥95% in quartiles 1-3. Cumulative low CRT% burden was the independent risk factor for death (HR 1.013; 95% CI 1.006-1.021; p<0.001). Mortality rose by 1.3 and 49% with every additional day and quartile of CRT% loss, respectively. CONCLUSIONS: Daily remote monitoring allows one to detect 24-h episodes of CRT% loss<95% in over two-thirds of CRT-D recipients during median observation of 3years. Cumulative low CRT% burden (in days) independently predicts mortality before mean CRT% drop.

Day by day telemetric care of patients treated with cardiac resynchronisation therapy: first Polish experience.

BACKGROUND: Due to the recent rapid increase in the number of patients implanted with pacemakers, cardioverter-defibrillators (ICD), and cardiac resynchronisation therapy devices (CRT), conventional monitoring at specialist clinics is becoming increasingly difficult. The development of technology has enabled remote device monitoring with the use of teletransmission systems. AIM: To assess the effectiveness of transmission and the possibility of using telemetric data for further clinical management of patients with heart failure (HF) treated with CRT-D. METHODS: The analysis included 305 consecutive patients with chronic HF, New York Heart Association functional classes II-IV, treated with the use of CRT-D by Biotronik or Medtronic in the years 2006-2012. The patients received transmitters, enabling the remote monitoring of the implanted device from the patients' houses. Scheduled reports were automatically sent every month. The triggers for pre-specified emergency alert transmissions were as follows: ventricular tachycardia (VT) or ventricular fibrillation (VF) episodes, CRT-D intervention, ventricular extrasystoles > 110/h, any episode of atrial fibrillation (AF), atrial flutter (AFL) or supraventricular tachycardia, mean heart rate (HR) during, mean 24-h HR, CRT pacing < 95%, Elective Replacement Indicator, or End Of Service and device malfunction. The all-cause mortality of the study population has been assessed at the end of the follow-up period (mean of 20.5 months). RESULTS: Devices manufactured by Biotronik were provided to 71% of the study population, while 29% received devices by Medtronic. In 97.3% of cases, the monitors were wireless, fully automatic, and capable of immediate data transmission whenever a pre-specified alert notification was fulfilled. The analysis of long-term outcomes revealed that all-cause mortality of the whole study population was 13%. The effectiveness of report transmission was 98%. During follow-up a total of 31,198 transmissions were received and analysed, which constituted, on average, 4.9 transmissions per patient per month. Among analyses, 30% were reports generated by scheduled remote follow-ups, and 70% were caused by unscheduled device alerts. Correct functioning of the system was confirmed; the quality of the received data was 100%. In 63.9% of patients, decisions based on the information obtained from telemonitoring reports were made to modify the therapy, refer the patients to cardiology or electrophysiology clinics, or hospitalise them urgently. The most common medical reaction was device reprogramming (46.8%). Pharmacotherapy was modified in 33.7% of patients: beta-blocker dose increase (25.9%), anticoagulant treatment inclusion (15.7%), amiodarone inclusion (1.9%), or digoxin inclusion (4.5%). The remaining medical responses were referring patients for atrioventricular junction ablation (8.1%), VT ablation (2.9%), or AF/AFl ablation (1.6%). CONCLUSIONS: Remote monitoring of implantable devices is feasible, safe, and effective in supervising patients with CRT-D devices. Daily-based remote monitoring of a large population of HF patients allows continuous "triage" of high-risk patients and selection of individuals who require urgent intervention.

Can we rely on machines? Device-detected atrial high rates correspond well with atrial arrhythmias in cardiac resynchronization recipients.

AIMS: The aim of the study was to verify in what proportion of patients, device-detected atrial high rate (AHR) episodes are indeed atrial arrhythmias (AAs). We investigated also the reasons for inappropriate arrhythmia classification and assessed if patients with misdiagnosed arrhythmias have distinct characteristics that would help to identify them. METHODS AND RESULTS: The study population consisted of 304 consecutive patients implanted with cardiac resynchronization therapy defibrillators (CRT-Ds) and subsequently monitored via remote monitoring for a median follow-up (FU) of 30.5 months. Intracardiac electrograms of every recorded AHR episode were assessed and classified (AA vs. no AA) by two experienced cardiologists. During FU, 14 386 episodes of AHR were recorded and classified in 176 (57.9%) patients. In 89.2% of them, these episodes were true AA (94% atrial fibrillation, 62% de novo). The reasons for AHR misdiagnosis were atrial far-field signals (89.5%) and noise (10.5%). The mean per cent of day spent in AHR (54.9 vs. 5.86%; P < 0.001) and the occurrence of periods with low CRT pacing (82.8 vs. 55%; P = 0.003) were significantly higher in AA subjects than in those with misdiagnosed AHR. Episode duration of properly detected AHRs was longer than that of misdiagnosed AHRs. Higher per cent of time spent in AHR was an independent marker of appropriate arrhythmia detection [adjusted hazard ratio (HR) 1.04; P = 0.023]. CONCLUSION: Nearly two-thirds of CRT-D patients had AHR episodes within 2.5 years after implantation. Almost 90% of AHRs were indeed AA. Misdetections were caused by far-field sensing or noise. A two-step diagnostic algorithm (>9% of time spent in AHRs and episode duration >36 s) allowed for proper detection of AA with a high hit-rate and specificity.

Platelet count and volume indices in patients with contrast-induced acute kidney injury and acute myocardial infarction treated invasively.

BACKGROUND: The aetiology of contrast-induced acute kidney injury (CI-AKI) is not well understood. We hypothesised that the pathophysiology of CI-AKI and impaired coronary reperfusion (IR), observed after invasive treatment of acute myocardial infarction (AMI), could be similar and might be related to platelet count (PC) and platelet volume indices (PVI). AIM: To evaluate the relation between PC, PVI, IR, and CI-AKI in patients with AMI treated invasively. METHODS: A single-centre study evaluated 607 consecutive AMI-patients treated invasively. Comparative analyses were performed between patients with CI-AKI and without CI-AKI for the total study population (CI-AKI, n = 156; 25.7% vs. nCI-AKI, n = 451; 74.3%), for patients with diabetes mellitus (CI-AKI-DM, n = 56; 9.2% vs. nCI-AKI-DM, n = 123; 20.3%), and for patients with baseline kidney dysfunction (CI-AKI-BKD, n = 31; 5.1% vs. nCI-AKI-BKD, n = 67; 11.0%). Subjects with IR, who developed CI-AKI, were compared to the remaining patients with respect to platelet parameters (CI-AKI-IR, n = 47; 7.7% vs. controls, n = 560; 92.3%). For total population, as well as studied subgroups, multivariate logistic regression analyses were performed to reveal independent factors associated with CI-AKI. The results of the models were reported as odds ratios (OR) and 95% confidence intervals (95% CI). RESULTS: PC was higher in CI-AKI-DM-patients (224.8 ± 62.8 × 10(9)/L vs. 197.9 ± 63.3 × 10(9)/L; p = 0.014) and in CI-AKI-BKD-patients (248.9 ± 86.5 × 10(9)/L vs. 202.5 ± 59.3 × 10(9)/L; p = 0.004) than in appropriate controls. Within the studied groups, there were no differences between CI-AKI and nCI-AKI patients with respect to PVI. Comparing CI-AKI-IR-patients with controls, no differences in PC or PVI were found. IR was observed more often in CI-AKI-patients than in nCI-AKI-patients only among diabetics (48.2% vs. 27.6%; p = 0.008). Increase in admission PC was independently associated with CI-AKI in patients with diabetes (per one unit increase OR 1.006; CI 1.0-1.01; p = 0.04) as well as with baseline kidney dysfunction (per one unit increase OR 1.01; CI 1,0-1,02; p = 0.02). CONCLUSIONS: Any similarities in the pathophysiology of CI-AKI and IR were not reflected in platelet parameters. CI-AKI development was not related to PVI; however, higher PC was an independent risk factor for CI-AKI in patients with diabetes or baseline kidney dysfunction.

[Activity of cathepsin D in the blood serum and urine of patients with cancer of the stomach, pancreas and liver]. / Aktywnosc katepsyny D w surowicy krwi i moczu chorych na raka zoladka, trzustki lub watroby.

Cathepsin D is a protease involved in invasion of the cancer and metastasis formation. The purpose of the study was to evaluate a prognostic value of cathepsin D activity in blood serum and urine of patients with cancer of the stomach, pancreas and liver. The study was carried out on the samples of blood serum and urine obtained from patients with cancer of the stomach, pancreas and liver treated surgically at the First Department of General Surgery and Endocrinology of the Medical University of Bialystok. The control group consisted of healthy individuals. Activity of cathepsin D was determined in serum and urine by the Folin-Ciocaltau method with the cupric modification and was expressed in nmol Tyr/ml/6h. Specific activity of cathepsin D was determined in the urine, and was expressed in nmol Tyr/mg of protein/6h. Protein concentration in serum was assessed with Lowry et al. method and results were expressed in mg/ml. A significant increase in activity of cathepsin D in serum (p = 0.0169) and urine (p = 0.0008) and an enhanced specific activity in the urine (p = 0.0085) was found in patients with cancer of the pancreas as compared with the controls. A significantly increased activity of cathepsin was revealed in serum (p = 0.0233) of patients with cancer of the stomach. No significant differences of cathepsin D activity were found in urine of the patients with cancer of the stomach when compared to the controls. Additionally, an upward tendency (almost two-fold increase) of cathepsin D activity was shown in blood serum and an increase in the activity and in specific activity was observed in urine of both patients with cancer of the liver in comparison with the healthy individuals. There were no significant differences in the activity of cathepsin D in serum of the patients with cancer of the pancreas and stomach (p = 0.4156). A statistically significantly higher activity (p = 0.0004) and specific (0.0048) cathepsin D activity was demonstrated in urine of the patients with cancer of the pancreas in comparison with the patients with cancer of the stomach. Determination of protein level in urine proved a downward tendency in the patients with cancer of the stomach (p = 0.11109), as compared to the controls, and a statistically significant increase found in the patients with cancer of the pancreas (p = 0.0238), in comparison with the patients with cancer of the stomach. In conclusion, investigation of cathepsin D activity in the blood serum of patients with cancer of the stomach and pancreas and in the urine of the patients with cancer of the pancreas may be usefull in clinical oncological diagnostics. However, further studies of the enzyme are necessary to establish the clinical value of cathepsin D measurement.