Diagnosing Arterial Stiffness in Pregnancy and Its Implications in the Cardio-Renal-Metabolic Chain.

Cardio-renal and metabolic modifications during gestation are crucial determinants of foetal and maternal health in the short and long term. The cardio-renal metabolic syndrome is a vicious circle that starts in the presence of risk factors such as obesity, hypertension, diabetes, kidney disease and ageing, all predisposing to a status dominated by increased arterial stiffness and alteration of the vascular wall, which eventually damages the target organs, such as the heart and kidneys. The literature is scarce regarding cardio-renal metabolic syndrome in pregnancy cohorts. The present paper exposes the current state of the art and emphasises the most important findings of this entity, particularly in pregnant women. The early assessment of arterial function can lead to proper and individualised measures for women predisposed to hypertension, pre-eclampsia, eclampsia, and diabetes mellitus. This review focuses on available information regarding the assessment of arterial function during gestation, possible cut-off values, the possible predictive role for future events and modalities to reverse or control its dysfunction, a fact of crucial importance with excellent outcomes at meagre costs.

Nonischemic Super-Responders in Fusion CRT Pacing with Normal Atrioventricular Conduction.

Background: Fusion CRT pacing (FCRT) is noninferior to biventricular pacing, according to the current data. The aim of this study is to assess the response to FCRT and to identify predictors of super-responders (SRs) in a nonischemic population with normal AV conduction. Methods: LV-only CRT patients (pts) with a right atrium/left ventricle pacing system implanted in two CRT centers in Romania were included. Device interrogation, exercise tests, echocardiography, and individualized drug optimization were performed every 6 months during close follow-up. SRs pts were defined as those with left ventricular end-systolic volume (LVESV) improvement ≥30% and stable ejection fraction (LVEF) ≥45%. Results: A total of 25 out of 83 pts (31%) were SRs, with nonischemic LBBB low EF cardiomyopathy (50 male, 62 ± 9 y.o.) initially included. Mean follow-up was 5 years ± 27 months. Patients were divided in two groups: SRs and non-SRs (52 responders/6 hypo-responders). Two predictors were found in the SRs group: a higher baseline LVEF (SRs 29 ± 5% vs. non-SRs 26 ± 5%, p = 0.02) and a lower pulmonary arterial systolic pressure (SRs 38 ± 11 mm Hg vs. non-SRs 50 ± 15 mmHg, p = 0.003). Baseline severe mitral regurgitation was found in 11% of SRs vs. 64% in the non-SRs group. Conclusions: SRs in the selected NICM-FCRT group are significative high. Higher baseline LVEF and mild pulmonary arterial hypertension were independently associated with super-response.

Betablockers and Ivabradine Titration According to Exercise Test in LV Only Fusion CRT Pacing.

Background: Betablockers (BB)/ivabradine titration in fusion CRT pacing (CRTP) is understudied. Aim: To assess drug optimization using systematic exercise tests (ET) in fusion CRTP with preserved atrioventricular conduction (AVc). Methods: Changes in drug management were assessed during systematic follow-ups in CRTP patients without right ventricle lead. Shorter AVc (PR interval) allowed BB up-titration, while longer AVc needed BB down-titration, favoring ivabradine. Constant fusion pacing was the goal to improve outcomes. Results: 64 patients, 62.5 ± 9.5 y.o divided into three groups: shorter PR (<160 ms), normal (160−200 ms), longer (200−240 ms); follow-up 59 ± 26 months. Drugs were titrated in case of: capture loss due to AVc shortening (14%), AVc lengthening (5%), chronotropic incompetence (11%), maximum tracking rate issues (9%), brady/tachyarrhythmias (8%). Interventions: BB up-titration (78% shorter PR, 19% normal PR, 5% longer PR), BB down-titration (22% shorter PR, 14% normal PR), BB exclusion (16% longer PR), adding/up-titration ivabradine (22% shorter PR, 19% normal PR, 5% longer PR), ivabradine down-titration (22% shorter PR, 3% normal PR), ivabradine exclusion (11% normal PR, 5% longer PR). Drug strategy was changed in 165 follow-ups from 371 recorded (42% patients). Conclusions: BBs/ivabradine titration and routine ET during follow-ups in patients with fusion CRTP should be a standard approach to maximize resynchronization response. Fusion CRTP showed a positive outcome with important LV reverse remodeling and significant LVEF improvement in carefully selected patients.