Therapy duration and improvement of ventricular function in de novo heart failure: the Heart Failure Optimization study.

BACKGROUND AND AIMS: In patients with de novo heart failure with reduced ejection fraction (HFrEF), improvement of left ventricular ejection fraction (LVEF) is expected to occur when started on guideline-recommended medical therapy. However, improvement may not be completed within 90 days. METHODS: Patients with HFrEF and LVEF ≤ 35% prescribed a wearable cardioverter-defibrillator between 2017 and 2022 from 68 sites were enrolled, starting with a registry phase for 3 months and followed by a study phase up to 1 year. The primary endpoints were LVEF improvement > 35% between Days 90 and 180 following guideline-recommended medical therapy initiation and the percentage of target dose reached at Days 90 and 180. RESULTS: A total of 598 patients with de novo HFrEF [59 years (interquartile range 51-68), 27% female] entered the study phase. During the first 180 days, a significant increase in dosage of beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists was observed (P < .001). At Day 90, 46% [95% confidence interval (CI) 41%-50%] of study phase patients had LVEF improvement > 35%; 46% (95% CI 40%-52%) of those with persistently low LVEF at Day 90 had LVEF improvement > 35% by Day 180, increasing the total rate of improvement > 35% to 68% (95% CI 63%-72%). In 392 patients followed for 360 days, improvement > 35% was observed in 77% (95% CI 72%-81%) of the patients. Until Day 90, sustained ventricular tachyarrhythmias were observed in 24 wearable cardioverter-defibrillator carriers (1.8%). After 90 days, no sustained ventricular tachyarrhythmia occurred in wearable cardioverter-defibrillator carriers. CONCLUSIONS: Continuous optimization of guideline-recommended medical therapy for at least 180 days in HFrEF is associated with additional LVEF improvement > 35%, allowing for better decision-making regarding preventive implantable cardioverter-defibrillator therapy.

A novel, evidence-based, comprehensive clinical decision support system improves outcomes for patients with traumatic rib fractures.

BACKGROUND: Traumatic rib fractures are associated with high morbidity and mortality. Clinical decision support systems (CDSS) have been shown to improve adherence to evidence-based (EB) practice and improve clinical outcomes. The objective of this study was to investigate if a rib fracture CDSS reduced hospital length of stay (LOS), 90-day and 1-year mortality, unplanned ICU transfer, and the need for mechanical ventilation. The independent association of two process measures, an admission EB order set and a pain-inspiratory-cough score early warning system, with LOS were investigated. METHODS: The CDSS was scaled across nine US trauma centers. Following multiple imputation, multivariable regression models were fit to evaluate the association of the CDSS on primary and secondary outcomes. As a sensitivity analysis, propensity score matching was also performed to confirm regression findings. RESULTS: Overall, 3,279 patients met inclusion criteria. Rates of EB practices increased following implementation. On risk-adjusted analysis, in-hospital LOS preintervention versus postintervention was unchanged (incidence rate ratio [IRR], 1.06; 95% confidence interval [CI], 0.97-1.15, p = 0.2) but unplanned transfer to the ICU was reduced (odds ratio, 0.28; 95% CI, 0.09-0.84, p = 0.024), as was 1-year mortality (hazard ratio, 0.6; 95% CI, 0.4-0.89, p = 0.01). Provider utilization of the admission order bundle was 45.3%. Utilization was associated with significantly reduced LOS (IRR, 0.87; 95% CI, 0.77-0.98; p = 0.019). The early warning system triggered on 34.4% of patients; however, was not associated with a significant reduction in hospital LOS (IRR, 0.76; 95% CI, 0.55-1.06; p = 0.1). CONCLUSION: A novel, user-centered, comprehensive CDSS improves adherence to EB practice and is associated with a significant reduction in unplanned ICU admissions and possibly mortality, but not hospital LOS. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Cross-Channel Constraints on Resonant Antikaon-Nucleon Scattering.

Chiral perturbation theory and its unitarized versions have played an important role in our understanding of the low-energy strong interaction. Yet, so far, such studies typically deal exclusively with perturbative or nonperturbative channels. In this Letter, we report on the first global study of meson-baryon scattering up to one-loop order. It is shown that covariant baryon chiral perturbation theory, including its unitarization for the negative strangeness sector, can describe meson-baryon scattering data remarkably well. This provides a highly nontrivial check on the validity of this important low-energy effective field theory of QCD. We show that the K[over ¯]N related quantities can be better described in comparison with those of lower-order studies, and with reduced uncertainties due to the stringent constraints from the πN and KN phase shifts. In particular, we find that the two-pole structure of Λ(1405) persists up to one-loop order reinforcing the existence of two-pole structures in dynamically generated states.

Pseudo repetitive non-reentrant ventriculoatrial synchrony: Current challenges.

BACKGROUND: We recently described a novel pacemaker-mediated arrhythmia in Abbott cardiac implantable electronic devices (CIED), called pseudo-RNRVAS, that mimics repetitive non-reentrant ventriculoatrial synchrony (RNRVAS), but can appear in patients with ventriculoatrial (VA) block. It is caused by sinus-p-waves, trapped in the post-ventricular atrial refractory period (PVARP), which mimic VA conduction. The p-waves are followed by atrial pacing during the myocardial refractory time, which can trigger atrial fibrillation (AF). Pseudo-RNRVAS and RNRVAS are probably more common than appreciated, but the recognition and differentiation of the two can be challenging because most CIEDs do not recognize and store them. OBJECTIVE: We illustrate practical challenges in the assessment of Pseudo-RNRVAS and provide programming options that proved safe and effective for preventing Pseudo-RNRVAS and reducing the risk for typical RNRVAS. METHODS AND RESULTS: We illustrate in 10 patients the characteristics of Pseudo-RNRVAS and their treatment. The outcome regarding the recurrence of pseudo-RNRVAS after 6 months of follow-up was collected. Inappropriate atrial pacing during pseudo-RNRVAS resulted in AF in six patients. After shortening the PVARP in nine, inactivation/reduction of rate response in four, and reduction of the basic pacing rate in one patient, pseudo-RNRVAS was avoided in eight patients and reduced in one. In one patient AF became permanent. CONCLUSIONS: Pseudo-RNRVAS is a pacemaker-mediated arrhythmia that can appear in patients without VA conduction and may lead to AF. The suggested adjustments of pacing parameters were safe and effective in preventing the arrhythmia.

Closed loop stimulation in patients with chronic heart failure and severe chronotropic incompetence: Responders versus non-responders.

BACKGROUND: Clinical effects of rate-adaptive pacing (RAP) are unpredictable and highly variable among cardiac resynchronization therapy (CRT) patients with chronotropic incompetence. Physiologic sensors such as Closed Loop Stimulation (CLS), measuring intracardiac impedance changes (surrogate for ventricular contractility), may add clinical benefit and help identify predictors of response to RAP. The objective of the present BIOlCREATE study subanalysis was to identify criteria for selection of CRT patients who are likely to respond positively to CLS-based RAP. METHODS: In the randomized, crossover BIO|CREATE study, CRT patients with severe chronotropic incompetence and NYHA class II/III were randomized to CLS with conventional upper sensor rate programming or to no RAP for 1 month, followed by crossover for another month. At 1-month and 2-month follow-ups, patients underwent treadmill-based cardiopulmonary exercise test. Positive CLS response was defined as a ≥ 5% reduction in ventilatory efficiency slope. Eight of 17 patients (47%) were CLS responders. In this subanalysis, we compared responders and non-responders to explore outcomes, mechanisms, and predictors. RESULTS: All cardiopulmonary variables, health-related quality of life, patient activity status, and NT-proBNP concentration showed favorable trend in CLS responders and unfavorable trend in non-responders, underlining the need to find predictors. Following all analyses, we recommend CLS in heart failure patients with improved left ventricular ejection fraction (LVEF >40%, after a ≥ 10-point increase from a CRT-pre-implant value of ≤40%), corresponding to 'HFimpEF' in the universal classification system. CONCLUSION: HFimpEF patients are likely to benefit from CLS-based RAP, in contrast to 'HFrEF' (heart failure with reduced LVEF [≤40%]).

A randomized trial of non-fasting vs. fasting for cardiac implantable electronic device procedures (Fast-CIED Study).

AIMS: Data on safety and efficacy of a non-fasting strategy in minimal invasive cardiac procedures are lacking. We assessed a non-fasting strategy compared with a fasting strategy regarding patient's well-being and safety in elective cardiac implantable electronic device (CIED) procedures. METHODS AND RESULTS: In this randomized, single-blinded clinical trial, 201 patients (non-fasting = 100, fasting = 101) with a mean age of 72.0 ± 11.6 years (66.7% male) were assigned to a non-fasting strategy (solids/fluids allowed up to 1 h) or a fasting strategy (at least 6 h no solids and 2 h no fluids) before the procedure and analysed on an intention-to-treat basis. The co-primary outcomes were patients' well-being scores (based on numeric rating scale, 0-10) and incidence of intra-procedural food-related adverse events, including vomiting, perioperative pulmonary aspiration, and emergency intubation. Renal, haematological, and metabolic blood parameters and 30-day follow-up data were gathered. The summed pre-procedural patients' well-being score was significantly lower in the non-fasting group [non-fasting: 13.1 ± 9.6 vs. fasting: 16.5 ± 11.4, 95% confidence interval (CI) of mean difference (MD) -6.35 to -0.46, P = 0.029], which was mainly driven by significantly lower scores for hunger and tiredness in the non-fasting group (non-fasting vs. fasting; hunger: 0.9 ± 1.9 vs. 3.1 ± 3.2, 95% CI of MD -2.86 to -1.42, P < 0.001; tiredness: 1.6 ± 2.3 vs. 2.6 ± 2.7, 95% CI of MD -1.68 to -0.29, P = 0.023). No intra-procedural food-related adverse events were observed. Relevant blood parameters and 30-day follow-up did not show significant differences. CONCLUSION: These results showed that a non-fasting strategy is beneficial to a fasting one regarding patient's well-being and comparable in terms of safety for CIED procedures (NCT04389697).

Tributary effects on the ecological responses of a regulated river to experimental floods.

Rivers regulated by dams display several ecosystem alterations due to modified flow and sediment regimes. Downstream from a dam, ecosystem degradation occurs because of reduced disturbance, mostly derived from limitations on flow variability and sediment supply. In the last decade, most flow restoration/dam impact mitigation was oriented towards the development of environmental flows. Flow variability (and consequent disturbance) can be reintroduced by releasing artificial high flows (experimental floods). Flow-sediment interactions during experimental floods represent strong ecosystem drivers, influencing nutrient dynamics, and metabolic and functional properties. In river networks, sediment and water inputs from tributaries generate points of discontinuity that can drive major changes in environmental conditions, affecting habitat structure and determining functional differences between upstream and downstream. However, despite the relevance for management, flow/sediment relations during environmental flows - and more importantly during experimental floods - remain poorly understood, mostly due to the lack of empirical evidence. In this study, we examined how a major tributary (source of water and sediments) modified the physical habitat template of a regulated river, thereby influencing ecological and geomorphological responses to experimental floods. Methods combined high-resolution drone mapping techniques with a wide range of biological samples collected in field surveys before, during, and after experimental floods in an alpine river. Data were used to quantify changes in relevant functional and structural ecosystem properties, relating ecological responses to geomorphological dynamics. Results highlight the importance of tributaries in restoring ecosystem properties lost after damming, enhancing the resilience of the system. In addition, we observed that disturbance legacy played a fundamental role in determining ecological conditions of a river prior to experimental floods, thus confirming that considering flow variability and sediment availability is crucial in adaptive dam management and environmental flows design.

Microbial communities in floodplain ecosystems in relation to altered flow regimes and experimental flooding.

River floodplains are spatially diverse ecosystems that respond quickly to flow variations and disturbance. However, it remains unclear how flow alteration and hydrological disturbance impacts the structure and biodiversity of complex microbial communities in these ecosystems. Here, we examined the spatial and seasonal dynamics of microbial communities in aquatic (benthic) and terrestrial habitats of three hydrologically contrasting (natural flow, residual flow, hydropeaking flow) floodplain systems. Microbial communities (alpha and beta diversity) differed more among floodplain habitats than between riverine floodplains. Microbial communities in all systems displayed congruent seasonal effects. In the residual and hydropeaking systems, an experimental flood was released from a reservoir to mimic a natural high flow event causing hydromorphological disturbance. The experimental flood caused a temporary shift in microbial communities by releasing microbes from the reservoir as well as redistributing communities among floodplain habitats. The flood-mediated shift in community structures had only a transient impact as pelagic bacteria did not persist within floodplain habitats over time after the flood. More frequent pulse disturbances might lead to an alternate structure of bacterial communities in floodplains over time.

Impact of closed loop stimulation on prognostic cardiopulmonary variables in patients with chronic heart failure and severe chronotropic incompetence: a pilot, randomized, crossover study.

AIMS: Clinical effects of rate-adaptive pacing in heart failure patients with chronotropic incompetence (CI) undergoing cardiac resynchronization therapy (CRT) remain unclear. Closed loop stimulation (CLS) is a new rate-adaptive sensor in CRT devices. We evaluated the effectiveness of CLS in CRT patients with severe CI, focusing primarily on key prognostic variables assessed by cardiopulmonary exercise (CPX) testing. METHODS AND RESULTS: In the randomized, crossover, multicentre BIO|CREATE study, 20 CRT patients with severe CI and NYHA Class II/III (60%/40%) were randomized 1:1 to the sequence DDD-40 mode to DDD-CLS mode, or the sequence DDD-CLS mode to DDD-40 mode (1 month in each mode). Patients underwent symptom-limited treadmill-based CPX test in each mode. An improvement (decrease) of the ventilatory efficiency (VE) slope of ≥5% during CLS was regarded as positive response to CLS. Seventeen patients with full data sets had a mean intra-individual VE slope change of -1.8 ± 3.0 (-4.1%) with CLS (P = 0.23). Eight patients (47%) were CLS responders, with a -6.1 ± 2.7 (-16.4%) slope change (P = 0.029). Compared to non-responders, CLS responders had a higher left ventricular (LV) ejection fraction (46 ± 3 vs. 36 ± 9%; P = 0.0070), smaller end-diastolic LV volume (121 ± 34 vs. 181 ± 41 mL; P = 0.0085), smaller end-systolic LV volume (65 ± 23 vs. 114 ± 39 mL; P = 0.0076), and were predominantly in NYHA Class II (P = 0.0498). CONCLUSION: The data of the present pilot study are compatible with the notion that CLS activation may improve VE slope in CRT patients with severe CI and less advanced heart failure. Further research is needed to determine the long-term clinical outcomes of CLS.

Novel Pacemaker-Mediated Arrhythmia Without Ventriculoatrial Conduction Can Induce Atrial Fibrillation.

Cardiovascular implantable electronic devices can initiate and sustain pacemaker-mediated arrhythmias. Endless loop tachycardia and repetitive non-re-entrant ventriculoatrial synchrony (RNRVAS) are well-described examples of pacemaker-mediated arrhythmias. However, such arrhythmias only occur in the presence of ventriculoatrial conduction. We identified a novel pacemaker-mediated arrhythmia that closely mimics RNRVAS but in the absence of ventriculoatrial conduction. We identified these arrhythmias in 9 patients, all with a St. Jude Medical/Abbott device, recorded as inappropriate mode-switch episodes by a device algorithm that includes paced events in the atrial counter. This report describes the mechanism, discusses clinical implications, and outlines programming options to eliminate this pseudo-RNRVAS.

Predictors of rhythm outcomes after cardiac resynchronization therapy in atrial fibrillation patients: When should we use an atrial lead?

BACKGROUND: Cardiac resynchronization therapy (CRT) is widely used in atrial fibrillation (AF) patients and could impact rhythm stability. HYPOTHESIS: We aimed to identify predictors of sinus rhythm (SR) stability or AF progression in a real-word cohort of CRT-AF patients. METHODS: From 330 consecutive implantable cardioverter-defibrillator implantations due to ischemic or dilated cardiomyopathy, 65 (20%) patients with AF history (paroxysmal, n = 32) underwent a CRT implantation with an atrial electrode and were regularly followed every 4-6 months. Rhythm restoration was attempted for most AF patients based on symptoms, biventricular pacing (BP), and lack of thrombi. RESULTS: After 33 months, 18 (28%) patients progressed to permanent mode switch (MS≥99%) and 20 (31%) patients had stable SR (MS < 1%). Logistic regression showed that history of persistent AF (OR: 8.01, 95%CI: 2.0-31.7, p = .003) is associated with higher risk of permanent MS. In persistent AF patients, a bigger left atrium (OR: 1.2 per mm, 95%CI: 1.03-1.4, p = .025) and older age (OR: 1.15 per life-year, 95%CI: 1.01-1.3, p = .032) were predictors of future permanent MS. Paroxysmal AF at implantation (OR: 5.96, 95%CI: 1.6-21.9, p = .007) and increased BP (OR: 1.4 per 1%, 95%CI: 1.05-1.89, p = .02) were associated with stable SR. In persistent AF patients, stable SR correlated with higher BP (98 ± 2 vs. 92 ± 8%, p < .001). CONCLUSION: In patients with AF undergoing CRT implantation, persistent AF, LA dilatation and advanced age relate to future permanent MS (AF), whereas high BP promotes SR stability. These findings could facilitate the management of CRT-AF patients and guide therapy in order to maximize its effect on rhythm.

Clinical utility of cardiovascular magnetic resonance imaging in patients with implantable cardioverter defibrillators presenting with electrical instability or worsening heart failure symptoms.

BACKGROUND: Data on the usefulness of cardiovascular magnetic resonance (CMR) imaging for clinical decision making in patients with an implanted cardioverter defibrillator (ICD) are scarce. The present study determined the impact of CMR imaging on diagnostic stratification and treatment decisions in ICD patients presenting with electrical instability or progressive heart failure symptoms. METHODS: 212 consecutive ICD patients underwent 1.5 T CMR combining diagnostic imaging modules tailored to the individual clinical indication (ventricular function assessment, myocardial tissue characterization, adenosine stress-perfusion, 3D-contrast-enhanced angiography); four CMR examinations (4/212, 2%) were excluded due to non-diagnostic CMR image quality. The resultant change in diagnosis or clinical management was determined in the overall population and compared between ICD patients for primary (115/208, 55%) or secondary prevention (93/208, 45%). Referral indication consisted of documented ventricular tachycardia, inadequate device therapy or progressive heart failure symptoms. RESULTS: Overall, CMR imaging data changed diagnosis in 40% (83/208) with a significant difference between primary versus secondary prevention ICD patients (37/115, 32% versus 46/93, 49%, respectively; p = 0.01). The information gain from CMR led to an overall change in treatment in 21% (43/208) with a similar distribution in primary versus secondary prevention ICD patients (25/115,22% versus 18/93,19%, p = 0.67). The effect on treatment change was highest in patients initially scheduled for ventricular tachycardia ablation procedure (18/141, 13%) with revision of the treatment plan to medical therapy or coronary revascularization. CONCLUSIONS: CMR imaging in ICD patients presenting with electrical instability or worsening heart failure symptoms provided diagnostic or management-changing information in a considerable proportion (40% and 21%, respectively).

Outcome in patients undergoing upgrade to cardiac resynchronization therapy: predictors of outcome after upgrade to CRT.

The advantages of upgrade to cardiac resynchronisation therapy (CRT) have not been explored as carefully as the outcomes of de novo CRT implantations. Furthermore selection criteria for patients with the potential to benefit the most from this therapy are unknown. Therefore, we analyzed the long term outcome and its predictors in a real-world cohort receiving a CRT upgrade from previous pacemaker (PM) and defibrillator devices (ICD). We analyzed 86 patients (mean age 68 ± 9 years; 89% male) undergoing CRT upgrade procedures. Response to CRT as well as long term patient outcome was analyzed. NYHA class improved in majority of the patients during short term period (61%), and this trend remained constant during long term follow-up (54%). The observed all-cause mortality was 54% with mean survival of 49 ± 4 months. 11 patients underwent left ventricular assist device implantation or heart transplantation. In the multivariate analysis, only kidney function assessed by GFR (HR 0.97; 95% CI 0.95-0.99; p = 0.009) and LVEF (HR 0.92; 95% CI 0.87-0.97; p = 0.002) remain predictors for mortality. Patients who undergo an upgrade procedure to CRT demonstrate a significant response rate assessed by improvement in NYHA class, with initial baseline parameters such as LVEF and kidney function remaining significant predictors for mortality.

Deep sedation for transvenous lead extraction: a large single-centre experience.

AIMS: Transvenous lead extraction for cardiac implantable electronic devices (CIED) is of growing importance. Nevertheless, the optimal anaesthetic approach, general anaesthesia vs. deep sedation (DS), remains unresolved. We describe our tertiary centre experience of the feasibility and safety of DS. METHODS AND RESULTS: Extraction procedures were performed in the electrophysiology (EP) laboratory by two experienced electrophysiologists. We used intravenous Fentanyl, Midazolam, and Propofol for DS. A stepwise approach with locking stylets, dilator sheaths, and mechanical sheaths via subclavian, femoral, or internal jugular venous access was utilized. Patient characteristics and procedural data were collected. Logistic regression models were used to identify parameters associated with sedation-related complications. Extraction of 476 leads (dwelling time/patient 88 ± 49 months, 30% ICD leads) was performed in 220 patients (64 ± 17 years, 80% male). Deep sedation was initiated with bolus administration of Fentanyl, Midazolam, and Propofol; mean doses 0.34 ± 0.12 µg/kg, 24.3 ± 6.8 µg/kg, and 0.26 ± 0.13 mg/kg, respectively. Deep sedation was maintained with continuous Propofol infusion (initial dose 3.7 ± 1.1 mg/kg/h; subsequently increased to 4.7 ± 1.2 mg/kg/h with 3.9 ± 2.6 adjustments) and boluses of Midazolam and Fentanyl as indicated. Sedation-related episodes of hypotension, requiring vasopressors, and hypoxia, requiring additional airway management, occurred in 25 (11.4%) and 5 (2.3%) patients, respectively. These were managed without adverse consequences. Five patients (2.3%) experienced major intraprocedural complications; there were no procedure-related deaths. All of our logistic regression models indicated intraprocedural support was associated with administration higher Fentanyl doses. CONCLUSION: Transvenous lead extraction under DS in the EP laboratory is a safe procedure with high success rates when performed by experienced staff.

Cardiovascular magnetic resonance imaging in patients with cardiac implantable electronic devices: a device-dependent imaging strategy for improved image quality.

Aims: To prospectively determine evaluability of routine cardiovascular magnetic resonance (CMR) diagnostic modules in a referral population of implanted rhythm device all-comers, and to establish a device-dependent CMR imaging strategy to achieve optimal image quality. Methods and results: One hundred and twenty-eight patients with cardiac implantable electronic devices [insertable cardiac monitoring system, n = 14; implantable loop-recorder, n = 21; pacemaker, n = 31; implantable cardioverter-defibrillator (ICD), n = 50; and cardiac resynchronization therapy defibrillator (CRT-D), n = 12] underwent clinically indicated CMR at 1.5 T. CMR protocols were tailored to the clinical indication and consisted of cine, perfusion, T1-/T2-weighted, late-gadolinium enhancement (LGE), 3D angiographic, and post-contrast cine spoiled gradient echo (SGE) scans. Image quality was determined using a 4-grade visual score per myocardial segment. Segmental evaluability was strongly influenced by device type and location with the highest proportion of non-diagnostic images encountered in the presence of ICD/CRT-D systems. Cine steady-state free-precession (SSFP) imaging was found to be mostly non-diagnostic in ICD/CRT-D patients, but a significant improvement of image quality was demonstrated when using SGE sequences with a further incremental improvement post-contrast resulting in an overall four-fold higher likelihood of achieving good image quality. LGE scans were found to be non-diagnostic in about one-third of left-ventricular segments of ICD/CRT-D patients but were artefact-free in > 94% for all other device types. Conclusion: Device type and location constitute the main independent predictors of CMR image quality and thus, need to be considered during protocol adaptation. Most notably, post-contrast SGE cine imaging proved superior to conventionally used SSFP sequences. Thus, following the proposed device-dependent CMR imaging strategy, diagnostic image quality can be achieved in the majority of device patients.

Long-Term Impact of Right Ventricular Pacing on Left Ventricular Systolic Function in Pacemaker Recipients With Preserved Ejection Fraction: Results From a Large Single-Center Registry.

BACKGROUND: There is limited evidence of long-term impact of right ventricular pacing on left ventricular (LV) systolic function in pacemaker recipients with preserved LV ejection fraction (LVEF). The objective of the study was to evaluate the outcome and echocardiographic course of baseline preserved LVEF in a large cohort of pacemaker recipients with respect to pacing indication and degree of right ventricular pacing. METHODS AND RESULTS: We enrolled 991 patients (73±10 years, 54% male) with baseline normal (>55%) LVEF (n=791) or mildly reduced (41-55%) LVEF (n=200) who had paired echocardiographic data on LV systolic function recorded at implantation and last follow-up. According to pacing indication, patients were divided into atrioventricular block group A (n=500) and sinus node disease group B (n=491). Main outcome measures were all-cause mortality and deterioration of LV function ≥2 LVEF categories at last follow-up. Patients were followed for an average of 44 months. Death from any cause occurred in 166 (17%), and deterioration of LV function ≥2 LVEF categories in 56 (6%) patients. There was no significant difference in outcome between group A and group B either in patients with normal LVEF or in those with mildly reduced LVEF. Mean percentage of right ventricular pacing was not predictive of outcome. CONCLUSIONS: In a large cohort of pacemaker recipients with predominantly normal LVEF, clinically relevant LV dysfunction develops rather infrequently. No significant difference in all-cause mortality and development of severe LV dysfunction is observed between patients with atrioventricular block and sinus node disease. Accordingly, de novo biventricular pacing cannot be recommended for patients with preserved LVEF.

Perioperative management of antithrombotic treatment during implantation or revision of cardiac implantable electronic devices: the European Snapshot Survey on Procedural Routines for Electronic Device Implantation (ESS-PREDI).

The European Snapshot Survey on Procedural Routines for Electronic Device Implantation (ESS-PREDI) was a prospective European survey of consecutive adults who had undergone implantation/surgical revision of a cardiac implantable electronic device (CIED) on chronic antithrombotic therapy (enrolment March-June 2015). The aim of the survey was to investigate perioperative treatment with oral anticoagulants and antiplatelets in CIED implantation or surgical revision and to determine the incidence of complications, including clinically significant pocket haematomas. Information on antithrombotic therapy before and after surgery and bleeding and thromboembolic complications occurring after the intervention was collected at first follow-up. The study population comprised 723 patients (66.7% men, 76.9% aged ≥66 years). Antithrombotic treatment was continued during surgery in 489 (67.6%) patients; 6 (0.8%) had their treatment definitively stopped; 46 (6.4%) were switched to another antithrombotic therapy. Heparin bridging was used in 55 out of 154 (35.8%) patients when interrupting vitamin K antagonist (VKA) treatment. Non-vitamin K oral anticoagulant (NOAC) treatment was interrupted in 88.7% of patients, with heparin bridging in 25.6%, but accounted for only 25.3% of the oral anticoagulants used. A total of 108 complications were observed in 98 patients. No intracranial haemorrhage or embolic events were observed. Chronic NOAC treatment before surgery was associated with lower rates of minor pocket haematoma (1.4%; P= 0.042) vs. dual antiplatelet therapy (13.0%), VKA (11.4%), VKA + antiplatelet (9.2%), or NOAC + antiplatelet (7.7%). Similar results were observed for bleeding complications (P= 0.028). Perioperative management of patients undergoing CIED implantation/surgical revision while on chronic antithrombotic therapy varies, with evidence of a disparity between guideline recommendations and practice patterns in Europe. Haemorrhagic complications were significantly less frequent in patients treated with NOACs. Despite this, the incidence of severe pocket haematomas was low.

Differences in predictors of implantable cardioverter-defibrillator therapies in patients with ischaemic and non-ischaemic cardiomyopathies.

AIMS: Implantable cardioverter-defibrillators (ICDs) have been shown to reduce mortality in patients with both ischaemic and non-ischaemic cardiomyopathy by terminating life-threatening arrhythmias. However, such arrhythmic events are unequally distributed among different patient subgroups. We aimed to evaluate predictors of appropriate ICD therapies as a step towards risk stratification in a real-world cohort. METHODS AND RESULTS: The prevalence and predictors of appropriate ICD therapies were analysed in 330 consecutive patients (mean age 65 ± 11, 81% male) with implanted ICDs due to ischaemic (n = 204) or dilated (n = 126) cardiomyopathy. During a mean follow-up of 19 ± 9 months, 1545 appropriate ICD therapies (antitachycardia pacing and shocks) were detected in 94 patients (29%). In multivariate analysis applied on the whole cohort, the presence of atrial fibrillation [AF: odds ratio (OR) = 1.906, confidence interval (CI) = 1.143-3.177, P = 0.013] and secondary prevention indication (OR = 1.963, CI = 1.123-3.432, P = 0.018) was associated with ICD therapy. The presence of cardiac resynchronization therapy (CRT) had a protective value (OR = 0.563, CI = 0.327-0.968, P = 0.038). Moreover, the predictors were different depending on the aetiology of the cardiomyopathy: in the ischaemic group, only secondary prevention indication (OR = 2.0, CI = 1.029-3.891, P = 0.041) and the presence of a biventricular system (OR = 0.359, CI = 0.163-0.794, P = 0.011) remained significant, while in the non-ischaemic group, an association with AF was observed (OR = 4.281, CI = 1.632-11.231, P = 0.003). CONCLUSION: The aetiology of cardiomyopathy should be taken into consideration for the therapy of ICD patients. The protective role of CRT devices should be pointed out in ischaemic cardiomyopathy (ICM) and a more rigorous antiarrhythmic treatment should be considered for ICM patients with secondary prevention or for dilated cardiomyopathy patients with AF.