ACE Inhibitors and Angiotensin Receptor Blockers for the Primary and Secondary Prevention of Cardiovascular Outcomes: Recommendations from the 2024 Egyptian Cardiology Expert Consensus in Collaboration with the CVREP Foundation.

INTRODUCTION: The renin-angiotensin-aldosterone system (RAAS) plays a pivotal role in regulating blood pressure (BP), with dysregulation of RAAS resulting in hypertension and potentially heart failure (HF), myocardial infarction (MI), cardio-renal syndrome, and stroke. RAAS inhibitors, such as angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs), have advantages beyond BP control. However, differences between these two drug classes need to be considered when choosing a therapy for preventing cardiovascular events. METHODS: A panel of 36 Egyptian cardiologists developed consensus statements on RAAS inhibitors for primary and secondary prevention of cardiovascular outcomes and stroke, using a modified three-step Delphi process. RESULTS: The consensus statements highlight the importance of effective BP control and the role of RAAS blockade for prevention and management of various cardiovascular diseases. ACEis and ARBs differ in their mode of action and, thus, clinical effects. On the basis of available evidence, the consensus group recommended the following: ACEis should be considered as first choice (in preference to ARBs) to reduce the risk of MI, for primary prevention of HF, and for secondary prevention of stroke. ACEis and ARBs show equivalent efficacy for the primary prevention of stroke. Evidence also favors the preferential use of ACEis in patients with type 2 diabetes, for BP control, for the primary prevention of diabetic kidney disease, and to reduce the risk of major cardiovascular and renal outcomes. Treatment with an ACEi should be started within 24 h of ST segment elevation MI (and continued long term) in patients with HF, left ventricular systolic dysfunction, and/or diabetes. Angiotensin receptor/neprilysin inhibitors (ARNIs) are the first choice for patients with HF and reduced ejection fraction, with ACEis being the second choice in this group. ARBs are indicated as alternatives in patients who cannot tolerate ACEis. ACEis may be associated with cough development, but the incidence tends to be overestimated, and the risk can be reduced by use of a lipophilic ACEi or combining the ACEi with a calcium channel blocker. CONCLUSION: RAAS blockade is an essential component of hypertension therapy; however, the protective effects provided by ACEis are superior to those of ARBs. Therefore, an ACEi is indicated in almost all cases, unless not tolerated.

Overstimulation of the renin­angiotensin­aldosterone system­a key regulator of blood pressure, and fluid and electrolyte balance­is known to cause an increase in blood pressure (also known as "hypertension") and other diseases of the heart and blood vessels (the cardiovascular system). As such, treatments to block (or inhibit) this overstimulation are an essential part of medical strategies designed for the prevention of cardiovascular disease, especially in patients with hypertension (in whom the risk of death due to cardiovascular causes is high). Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are two types of medication that block overstimulation of the renin­angiotensin­aldosterone system, but they work in different ways. Angiotensin-converting enzyme inhibitors are superior to angiotensin receptor blockers after heart attacks (acute myocardial infarction), in patients with heart failure, for the prevention of stroke in individuals who have already had a stroke, and in patients with diabetes. Both types of medication have beneficial effects on the kidneys and associated outcomes, but only angiotensin-converting enzyme inhibitors have been shown to significantly reduce death due to cardiovascular causes, as well as death due to any cause. Overall, the protective effects of angiotensin-converting enzyme inhibitors on the heart are substantially greater than those of angiotensin receptor blockers, meaning that treatment with an angiotensin-converting enzyme inhibitor is preferred in all patients, except those who cannot tolerate the side effects of this drug class.

The effect of virtual reality on pain and anxiety management during outpatient hysteroscopy: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Our study aimed to evaluate the effectiveness of virtual reality (VR) intervention for pain and anxiety relief during outpatient hysteroscopy. METHODS: Various databases were searched for available clinical trials from inception until June 2023. We selected randomized controlled trials (RCTs) that compared virtual reality intervention versus standard care among women undergoing outpatient hysteroscopy. We used Revman software to perform our meta-analysis. The primary outcome was the pain score during the procedure. The secondary outcomes were anxiety during the procedure and pain post-procedure. The Visual Analog Scale (VAS) was used to assess pain and anxiety. RESULTS: Six RCTs were retrieved, involving a total of 457 patients. Virtual reality was associated with a significant reduction in pain score during the procedure in comparison with the control group (MD = - 1.43, 95% CI [- 1.69, - 1.16], p < 0.001). In addition, there was a significant decrease in anxiety during the procedure among the virtual reality group compared to the control group (p = 0.01). The pain score post-procedure significantly decreased within the virtual reality group (MD = - 1.52, 95% CI [- 1.78, - 1.26], p < 0.001). CONCLUSIONS: Virtual reality technology is a simple, feasible, and effective intervention for reducing pain and anxiety during outpatient hysteroscopy. More trials are required to confirm our findings.

Ablation targets of scar-related ventricular tachycardia identified by dynamic functional substrate mapping.

BACKGROUND: Dynamic functional substrate mapping of scar-related ventricular tachycardia offers better identification of ablation targets with limited ablation lesions. Several functional substrate mapping approaches have been proposed, including decrement-evoked potential (DEEP) mapping. The aim of our study was to compare the short- and long-term efficacy of a DEEP-guided versus a fixed-substrate-guided strategy for the ablation of scar-related ventricular tachycardia (VT). RESULTS: Forty consecutive patients presenting for ablation of scar-related VT were randomized to either DEEP-guided or substrate-guided ablation. Late potentials were tagged and ablated in the non-DEEP group, while those in the DEEP group were subjected to RV extrastimulation after a drive train. Only potentials showing significant delay were ablated. Patients were followed for a median duration of 12 months. Twenty patients were allocated to the DEEP group, while the other 20 were allocated to the non-DEEP group. Twelve patients (60%) in the DEEP group had ischemic cardiomyopathy versus 10 patients (50%) in the non-DEEP group (P-value 0.525). Intraoperatively, the median percentage of points with LPs was 19% in the DEEP group and 20.6% in the non-DEEP group. The procedural time was longer in the DEEP group, approaching but missing statistical significance (P-value 0.059). VT non-inducibility was successfully accomplished in 16 patients (80%) in the DEEP group versus 17 patients (85%) in the non-DEEP group (P value 0.597). After a median follow-up duration of 12 months, the VT recurrence rate was 65% in both groups (P value 0.311), with a dropout rate of 10% in the DEEP group. As for the secondary endpoints, all-cause mortality rates were 20% and 25% in the DEEP and non-DEEP groups, respectively (P-value 0.342). CONCLUSIONS: DEEP-assisted ablation of scar-related ventricular tachycardia is a feasible strategy with comparable short- and long-term outcomes to a fixed-substrate-based strategy with more specific ablation targets, albeit relatively longer but non-significant procedural times and higher procedural deaths. The imbalance between the study groups in terms of epicardial versus endocardial mapping, although non-significant, warrants the prudent interpretation of our results. Further large-scale randomized trials are recommended. TRIAL REGISTRATION: clinicaltrials.gov, registration number: NCT05086510, registered on 28th September 2021, record https://classic. CLINICALTRIALS: gov/ct2/show/NCT05086510.

Current status of outpatient heart failure management in Egypt and recommendations for the future.

Heart failure (HF) represents one of the greatest healthcare burdens worldwide, and Egypt is no exception. HF healthcare programmes in Egypt still require further optimization to enhance diagnosis and management of the disease. Development of specialized HF clinics (HFCs) and their incorporation in the healthcare system is expected to reduce HF hospitalization and mortality rates and improve quality of care in Egypt. We conducted a literature search on PubMed on the requirements and essential infrastructure of HFCs. Retrieved articles deemed relevant were discussed by a panel of 10 expert cardiologists from Egypt and a basic HFC model for the Egyptian settings was proposed. A multidisciplinary team managing the HFC should essentially be composed of specialized HF cardiologists and nurses, clinical pharmacists, registered nutritionists, physiotherapists, and psychologists. Other clinical specialists should be included according to patients' needs and size and structure of individual clinics. HFCs should receive patients referred from primary care settings, emergency care units, and physicians from different specialties. A basic HFC should have the following fundamental investigations available: resting electrocardiogram, basic transthoracic echocardiogram, and testing for N-terminal pro-B-type natriuretic peptide. Fundamental patients' functional assessments are assessing the New York Heart Association functional classification and quality of life and conducting the 6 min walking test. guideline-directed medical therapy should be implemented, and device therapy should be utilized when available. In the first visit, once HF is diagnosed and co-morbidities assessed, guideline-directed medical therapy should be started immediately. Comprehensive patient education sessions should be delivered by HF nurses or clinical pharmacists. The follow-up visit should be scheduled during the initial visit rather than over the phone, and time from the initial visit to the first follow-up visit should be determined based on the patient's health status and needs. Home and virtual visits are only recommended in limited and emergency situations. In this paper, we provide a practical and detailed review on the essential components of HFCs and propose a preliminary model of HFCs as part of a comprehensive HF programme model in Egypt. We believe that other low-to-middle income countries could also benefit from our proposed model.

Ivabradine effects in hospitalized acute heart failure patients: a single center retrospective study.

BACKGROUND: An increased heart rate (HR) is deleterious in patients with decompensated heart failure. Ivabradine, an HR lowering agent which acts by inhibiting the If current in the sinoatrial node, is indicated for chronic heart failure with reduced ejection fraction. However, data regarding the safety and efficacy of ivabradine in acute decompensated heart failure is limited. This retrospective observational study aimed to investigate the effects of ivabradine on morbidity and short-term mortality of hospitalized patients with acute decompensated heart failure. METHODS: A total of 998 patients with acute decompensated heart failure on top of a chronic status from 1/5/2014 to 1/5/2019 who were already on guideline-directed treatment including a beta-blocker were included. Patients were divided into two groups, the first group (No-ivabradine) where patients continued the same dose of beta-blocker alone while the second group (ivabradine group) ivabradine 5 mg BID was added in addition to the same dose of beta-blocker. Patients with hemodynamic instabilities were excluded from the study. Propensity matching was performed to exclude confounding factors. RESULTS: There was no significant difference between groups regarding baseline patient characteristics, laboratory, and echocardiographic data. There were significant differences between groups regarding average HR (87 ± 15 and 90 ± 12 bpm in ivabradine and control groups, consecutively, P = 0.0006*) and length of hospital stay (5.3 ± 2.3 and 7.7 ± 5.6 days in ivabradine and control groups, consecutively, P < 0.0001*). However, there were no differences in rehospitalization and mortality rates at 1 month and 6 months. CONCLUSION: In a retrospective cohort study aimed to investigate the effects of ivabradine on morbidity and short-term mortality of hospitalized patients with acute decompensated heart failure. Ivabradine was associated with significantly lower average HR and length of hospital stay. However, there was no benefit in the reduction of rehospitalization and mortality rates at 1- and 6-month follow-ups.

Prediction of Cardiac Resynchronization Therapy Response Using Quantitative Gated Myocardial Perfusion Imaging.

Conventional selection criteria are not consistently able to discriminate between responders and non-responders to cardiac resynchronization therapy (CRT). The objective of this study was to evaluate the usefulness of quantitative gated single-photon emission computed tomography (SPECT) in predicting the response to CRT. This prospective cross-sectional study included 25 patients with advanced congestive heart failure who underwent quantitative gated SPECT before and after CRT implantation. Patients with the left ventricular (LV) lead positioned at the latest activation segment away from the scar had a significantly higher chance of responding than those with the lead positioned at a different area. Responders were likely to have a phase standard deviation (PSD) value of >33°, with 86.6% sensitivity and 90% specificity, and a phase histogram bandwidth (PHB) value of >153°, with 100% sensitivity and 80% specificity. Quantitative gated SPECT can help refine patient selection for CRT implantation, using PSD and PHB cutoff points, in addition to guiding the positioning of the LV lead.

Role of Strauss ECG criteria as predictor of response in patients undergoing cardiac resynchronization therapy.

BACKGROUND: Cardiac resynchronization therapy (CRT) is a standard treatment in patients with heart failure; however, approximately 20-40% of recipients of (CRT) do not respond to it based on the current patients' selection criteria. The purpose of this study was to identify the baseline parameters that predict the CRT response and how the ECG morphology can affect the outcome. The study aimed to evaluate the Strauss ECG criteria as a predictor of response in patients undergoing cardiac resynchronization therapy. RESULTS: Out of 70 patients, 3 patients missed the 6-month follow-up after CRT implantation, so the study enrolled 67 patients that have been classified according to ECG morphology of LBBB to 37 patients with non-Strauss ECG criteria-one of whom died after 4 months-and 30 patients with Strauss ECG criteria. The number of responders in the study was 50 patients with percentage 75.8%; 52% of CRT responder (26 patients) had non-Strauss ECG criteria, while 48% of CRT responders (24 patients) had Strauss ECG criteria with P value = 0.463. While there was no statistical significance of overall CRT response nor 6-month hospitalization and mortality between patients of Strauss and non-Strauss ECG criteria, there was a significant improvement in NYHA class, EF assessed by biplane Simpson's, end-systolic volume, global longitudinal strain and global circumferential strain by speckle tracking echocardiography in patients with Strauss ECG criteria of LBBB. CONCLUSIONS: There is no statistical significance in overall CRT response nor the 6-month hospitalization and mortality after 6 months of follow-up between patients with Strauss and non-Strauss ECG criteria of LBBB; however, patients with Strauss ECG criteria have better improvement in NYHA class, echocardiographic parameters such as EF and ESV and speckle tracking parameters (GLS and GCS).

Predictors of right ventricular pacing-induced left ventricular dysfunction in pacemaker recipients with preserved ejection fraction.

BACKGROUND: Pacing is an effective treatment in the management of patients with bradyarrhythmias. Chronic right ventricular pacing may cause electrical and mechanical dyssynchrony leading to a deterioration of left ventricular ejection fraction (LVEF). This deterioration of LVEF has been described as pacing-induced cardiomyopathy (PICM). The incidence of PICM has been described by many studies, ranging between 10% and 26%. Predictors for PICM are not yet established-studies were limited by variations in the definition of PICM and the follow-up period. The authors studied the incidence and predictors of PICM in patients with preserved LVEF who underwent pacemaker implantation. PATIENTS AND METHODS: This retrospective study included 320 patients that underwent single- or dual-chamber pacemaker implantation, with a mean follow up period of 4.7 ± 2.0 years. Implantable cardioverter defibrillator and cardiac resynchronization therapy patients were excluded from this study. Individuals that had a baseline LVEF ≥ 50% before implantation in transthoracic echocardiography were included in the study. RESULTS: Of the 320 patients included in the study, 45% were male, with a mean age 55.5 years. The incidence of PICM was 7.5%. Wider native QRS duration, particularly > 140 ms (P < 0.001), wider paced QRS (pQRS) duration > 150 ms (P < 0.001), low normal ejection fraction < 56% pre-implantation (P = 0.023) and increased LV end diastolic diameter (LVEDD) > 53 mm and LV end systolic diameter (LVESD) > 38 mm (P < 0.001) predicted the development of PICM. There was no association between burden of right ventricular pacing (P = 0.782) or pacing site (P = 0.876) and the development of pacemaker-induced cardiomyopathy. CONCLUSION: Right ventricular pacing-induced left ventricular dysfunction is not uncommon, with an incidence of 7.5%. Wider native and paced QRS durations, low normal ejection fraction (< 56%) pre-implantation and increased LVEDD and LVESD post implantation are the most important predictors for the development of PICM.

Role of paracervical block in reducing postoperative pain after laparoscopic hysterectomy: A systematic reivew and meta-analysis of randomized controlled trials.

OBJECTIVE: We aimed to perform a systematic review and meta-analysis in order to evaluate the effect of paracervical anesthetic block among women undergoing laparoscopic hysterectomy. METHODS: A systematic search was done in Cochrane Library, PubMed, ISI web of science, and Scopus during January 2021. We selected randomized clinical trials (RCTs) compared paracervical anesthetic block versus normal saline (control group) among women undergoing laparoscopic hysterectomy. We pooled the continuous data as mean difference (MD) and dichotomous data as risk ratio (RR) with the corresponding 95% confidence intervals using Revman software. Our primary outcome was pain scores evaluated by visual analog scale (VAS) at 30 min and 1 hour. Our secondary outcomes were postoperative additional opioids requirement and length of hospital stay. RESULTS: Three RCTs met our inclusion criteria with a total number of 233 patients. We found that paracervical anesthetic block was linked to a significant reduction in VAS pain score at 30 min and 1 hour post-hysterectomy (MD= -2.13, 95% CI [-3.09, -1.16], p>0.001 & MD= -1.87, 95% CI [-3.22, -0.52], p = 0.006). There was a significant decrease in additional opioids requirement postoperatively among paracervical anesthetic block group in comparison with control group (p = 0.002). No significant difference was found between both groups regarding the length of hospital stay. CONCLUSION: Paracervical anesthetic block is effective in reducing postoperative pain after laparoscopic hysterectomy with decrease in opioids administration postoperatively.

Ivabradine and AF: Coincidence, Correlation or a New Treatment?

Ivabradine is a heart rate-lowering agent that inhibits pacemaker funny current (If). It has been approved by the European Medicines Agency and the US Food and Drug Administration for patients with stable angina and heart failure (HF). AF is a common issue especially in ischaemic heart disease and HF patients. In contrast to experimental findings and a limited number of clinical trials that demonstrate the emerging role of ivabradine for heart rate control in AF or maintenance of sinus rhythm, there is accumulating contradictory data indicating that there is, in fact, an increased incidence of new-onset AF among people who are taking ivabradine in clinical practice. This article reviews the most recent evidence highlighting the diversity of data in relation to the use of ivabradine and the onset of AF and whether it has a legitimate role in AF treatment and the maintenance of sinus rhythm.

Frequency of de novo atrial fibrillation in patients presenting with acute ischemic cerebrovascular stroke.

BACKGROUND: Atrial fibrillation (AF) affects millions of people worldwide and can remain undiagnosed for years. It is a major cause of cerebrovascular stroke (CVS); hence, early detection is extremely important in order to decrease the risk of CVS. We conducted a retrospective observational study looking into the prevalence of silent AF in 3299 patients admitted from January 2014 to December 2017 in a tertiary care stroke specialized center. Ischemic CVS was confirmed either by using multislice computed tomography (MSCT) or magnetic resonance imaging (MRI) of the brain. AF was diagnosed by electrocardiography (ECG) at the time of admission or during the hospital stay. Patients with a history of AF were excluded from the study. RESULTS: Of the 3299 patients admitted by acute ischemic CVS, 707 (21.43%) had a history of AF and thus were excluded from the study. Of the remaining 2592 patients eligible for the study, 1666 (64.27%) were males with a mean age of 56.06 years (± 16.01). A total of 2313 (89.24%) patients remained in sinus rhythm throughout the hospital stay, 211 (8.14%) patients were in AF on admission, and 68 (2.62 %) patients developed AF during their hospital stay. The total number of newly diagnosed patients with AF was 279 (10.76%). CONCLUSION: The prevalence of de novo atrial fibrillation in patients presented with acute cerebrovascular stroke is high. The implementation of good screening programs can significantly reduce the risk of disabilities and morbidities.

The Effect of Antenatal Vaginal Progesterone Administration on Uterine, Umbilical, and Fetal Middle Cerebral Artery Doppler Flow: A Cohort Study.

OBJECTIVE: This study aimed to evaluate the effect of vaginal progesterone (P) administration during the second and third trimesters of pregnancy on Doppler velocimetry of uterine, umbilical, and middle cerebral vessels. STUDY DESIGN: A prospective cohort study conducted on 80 women at risk for preterm labor. Uterine artery, umbilical artery, and middle cerebral artery (MCA) Doppler indices were measured before and after 1 week of administration of 200 mg twice daily vaginal P. The primary outcome parameter was the change of MCA pulsatility index (PI) after P administration. Secondary outcomes included changes in uterine artery and umbilical artery Doppler measurement. RESULTS: There was no significant changes of umbilical artery resistance index (RI) (0.69 ± 0.049 vs. 0.68 ± 0.041), umbilical artery PI (1.14 ± 0.118 vs. 1.11 ± 0.116), uterine artery RI (0.66 ± 0.12 vs. 0.66 ± 0.107), uterine artery PI (1.00 ± 0.26 vs. 1.016 ± 0.24), and MCA PI (1.27 ± 0.18 vs. 1.26 ± 0.23) measurements before and after 1 week of P administration, respectively. CONCLUSION: Administration of vaginal P has no significant effects on uterine artery, umbilical artery, and MCA Doppler indices.

Left atrium in cardiac resynchronization therapy: Active participant or innocent bystander.

BACKGROUND: Cardiac resynchronization therapy (CRT) is an established treatment for patients with advanced heart failure that results in improvement of left ventricle (LV) systolic function and LV reverse remodeling. This may have a positive effect on the size and the function of the left atrium (LA). We assessed the LA function, dimensions, and volumes before and after CRT implantation. METHODS: A total of 37 patients with mean age of 55.3 ± 9.64 years including 11 (29.7%) females, having symptomatic heart failure [ejection fraction (EF) <35%, left bundle branch block >120 ms, with New York Heart Association III or ambulatory class IV] were enrolled, and underwent CRT implantation. M-mode, two-dimensional (2D) echocardiography, tissue Doppler imaging, and 2D strain (ɛ) imaging were done assessing LV volumes, ejection fraction, and diastolic function, LA diameter, area, maximal and minimal volumes, LA EF, and longitudinal strain (ɛ). Patients were reassessed after 3 months. A reduction in LV end-systolic volume of ≥10% was defined as volumetric responders to CRT. Patients with decompensated New York Heart Association class IV, sustained atrial arrhythmias, rheumatic or congenital heart diseases, nonleft bundle branch block, and those who were poorly echogenic, were excluded. RESULTS: Twenty-four (64.8%) patients were volumetric responders (group A). Both groups were matched regarding demographic, clinical, electrocardiographic, and echocardiographic criteria apart from the LA dimension and volumes which were significantly lower in the responders group prior to CRT. At the end of the follow-up, only the responders group had further significant reduction in LA diameter (41.6 ± 1.67 vs. 43.88 ± 1.82 mm, p < 0.01), maximal volume (62.2 ± 18.3 vs. 73.04 ± 21.78 ml, p < 0.01), minimal volume (32.6 ± 12.3 vs. 41.8 ± 13.97, p < 0.01), together with a significant increase in LA EF (48.3 ± 11.3 vs. 41.99 ± 13.9, p < 0.01), positive longitudinal strain (16.59% ± 5.89 vs. 12.45% ± 6.12, p < 0.01), and negative longitudinal strain (-3.3 ± 1.9 vs. -1.62 ± 1.2, p < 0.01) compared to baseline readings, a finding that was not present in the nonresponders group. In addition, atrial fibrillation was significantly higher in the nonresponders group. Baseline LA diameter and volumes were found to be independent predictors of response to CRT by multivariate analysis. CONCLUSIONS: CRT induces LA anatomic, electrical, and structural reverse remodeling that could be assessed by conventional 2D echocardiography and 2D (ɛ) strain imaging. LA dimension and volumes were independent predictors of response to CRT and can help in selection of candidates for it.

Using three-dimensional echocardiography to guide left ventricle lead position in cardiac resynchronization therapy: does it make any difference.

BACKGROUND: Cardiac resynchronization therapy (CRT) is an effective treatment for patients with advanced heart failure. Nearly 30% of candidates are inadequate responders. Proper patient selection, left ventricle (LV) lead placement optimization, and optimization of the programming of the CRT device are important approaches to improve outcome of CRT. We examined the role of three-dimensional (3D) echocardiography in determining the optimal LV lead position as a method of optimizing CRT response. METHODS: Forty-seven patients with a mean age of 60.2 ± 11.1 years including five (10.6%) females, all having advanced CHF (EF <35%, LBBB >120 mesc, or non-LBBB >150 msec, with NYHA II-III or ambulatory class IV) were enrolled. Detailed history (NYHA class, Minnesota living with heart failure questionnaire), clinical examination, 6-min walk test, and standard 2D echocardiography were done in all cases. 3D echo detailed analysis of the LV 16 segments was done to determine the latest wall to reach the minimal systolic volume. Multisite pacing was done blind to the 3D echo data achieving a stable LV lead position in mid LV segment. This exact fluoroscopic site was determined (in two orthogonal views) and correlated with 3D most delayed area using a resized 16-segment schema. Patients were classified retrospectively into group A with concordance between the delayed LV area and LV lead position and group B with discordance between both. Patients were followed up after 3-6 (5.1 ± 1.8) months. Patients with reduction of 2D LV end-systolic volume of ≥10% at follow-up were termed volumetric responders. Poorly echogenic patients and those with decompensated NYHA class IV, sustained atrial arrhythmias, and rheumatic or congenital heart diseases were excluded. RESULTS: LV lead placement was concordant in 22 (46.8%) cases. After the follow-up period, 31 (65.9%) of the study population were considered volumetric responders with no significant difference among both groups (14 (63.3%) in group A vs 17 (68%) in group B, p > 0.05). CRT insertion resulted in significant improvement of NYHA class in 36 (76.5%) cases, 6-min walk test (447.2 ± 127.0 vs 369.6 ± 87.5 m, p < 0.01), MLHFQ (58.1 ± 19.7 vs 69.6 ± 13.5, p < 0.01), QRS duration (131.2 ± 13.8 vs 149.4 ± 16 msec, p < 0.01), 2D LV EF 33.0 ± 9.5 vs 25.3 ± 6.5, p < 0.001), LVESV (156.0 ± 82.9 vs177.6 ± 92.7 ml, p < 0.05), and 3D LVEF (29.1 ± 9.0 vs 23.6 ± 5.9, p < 0.001) irrespective of the etiology of heart failure. However, there were no significant differences between both groups regarding the same parameters (6-min walk test 470.8 ± 128.7 vs 428.3 ± 126.8 m, MLHFQ 56.8 ± 20.0 vs 58.11 ± 19.0, QRS duration 129.9 ± 12.4 vs 132.1 ± 15.1 msec, 2D LVEF 30.9 ± 8.3 vs 34.58 ± 10.9, LVESV 173.0 ± 110.0 vs 143.0 ± 67.9, 3D LVEF 26 ± 8 vs 31 ± 9, for groups A and B, respectively, p < 0.05). CONCLUSIONS: Standard anatomical LV lead placement remains a simple, practical, and effective method in patients undergoing CRT. 3D echocardiography-guided LV lead placement added no clinical benefit compared to standard techniques.

Outflow tract ventricular premature beats ablation in the presence or absence of structural heart disease: Technical considerations and clinical outcomes.

BACKGROUND: Premature ventricular beats (PVBs) are early depolarization of the myocardium originating in the ventricle. In case of very frequent PVBs, patients are severely symptomatic with impaired quality of life and are at risk of pre-syncope, syncope, heart failure, and sudden cardiac death particularly in the presence of structural heart disease. Ventricular outflow tracts are the most common sites of origin of idiopathic PVBs especially in patients without structural heart disease. We examined the role of radiofrequency catheter ablation in suppression of monomorphic PVBs of outflow tract origin in the presence or absence of structural heart disease, and its impact on improvement of left ventricular (LV) systolic function. METHODS: Thirty-seven highly symptomatic patients with PVBs burden exceeding 10% were enrolled, provided that PVBs are monomorphic, originating in ventricular outflow tracts and regardless the presence or absence of structural heart disease. Patients were divided into 2 groups according to PVB site origin (RVOT vs. LVOT). 3D electro-anatomical mapping modalities were used in all patients employing activation mapping technique in the majority of cases. Acute success was considered when PVBs completely disappeared or when residual sporadic PVBs ≤ 1 beats/min or ≤10 beats/30 min after RF ablation. Patients were followed up for a mean period of 5.4 ± 1.2 months with long-term success defined as complete disappearance or marked reduction by more than 75% in the PVBs absolute number on 24 h holter monitoring. RESULTS: Mean age of the study group was 39.9 ± 12.97 years, including 22 (59.4%) males. PVBs originated in RVOT in 17 cases and in LVOT in the remaining 20 cases. Prevalence of structural heart disease and consequently shortness of breath was higher in LVOT group. Initial ECG localization matched EP localization in the majority (94%) of cases. R wave duration index was the only significant independent predictor for RVOT origin with cut off value of <0.3 (P = 0.0057) upon multivariate analysis. Acute success was encountered in 32 (86%) patients with all cases of failure in the LVOT group. Recurrence occurred in 5 (15%) cases without significant difference between both groups. All cases of recurrence had residual PVBs at the end of the procedure. 18 cases out of the study group showed significant improvement of their EF (>5%) at the end of the follow-up period with no significant differences between both groups (p = 0.09). A linear correlation was observed between PVBs burden at follow up and magnitude of improvement of LV EF, particularly in patients with resting LV dysfunction and increased LV internal dimensions. CONCLUSIONS: RF ablation is an effective and safe method for elimination of outflow tract PVBs irrespective of their origin and the presence or absence of structural heart disease. PVBs burden after ablation appears to be the main determinant for reversal of PVB induced myopathy particularly in those with increased LV internal dimensions.

Are plasma natriuretic peptide levels influenced by automatic pacemaker algorithms for ventricular pacing minimization?

BACKGROUND: Automatic atrioventricular search hysteresis (AVSH) is designed to reduce the cumulative percentage of potentially deleterious right ventricular apical pacing (VP%) in dual-chamber pacemakers. We investigated whether minimizing VP% by AVSH can, in turn, reduce ventricular wall stretching/stress, as assessed by plasma concentrations of the amino-terminal fragment of the pro-B-type natriuretic peptide (NT-proBNP). METHODS: After dual-chamber pacemaker implantation in 81 patients (age: 69 ± 11 years; males: 55.6%), the fixed atrioventricular delay of 225 ms was programmed and AVSH was turned off for 1 month. The patients were thereafter randomly assigned to standard AVSH for 1 month, followed by an enhanced AVSH for another month, or vice versa. At the 1-, 2-, and 3-month follow-ups, VP% values were retrieved from the pacemaker memory, and venous blood samples were taken for NT-proBNP measurements. RESULTS: Both standard and enhanced AVSH reduced the median VP% value from 38.5% (for the fixed atrioventricular delay) to 2.1% (P < 0.001). However, plasma NT-proBNP concentrations for the fixed atrioventricular delay (median, 253 pg/mL), standard AVSH (225 pg/mL), and enhanced AVSH (276 pg/mL) did not differ significantly on the intrapatient basis (paired Wilcoxon tests) between any pair of these modalities. CONCLUSION: Minimizing ventricular pacing by AVSH during 1 month had no influence on plasma NT-proBNP levels (i.e., ventricular wall stretching/stress) compared with a constant, moderately prolonged atrioventricular delay.