Anomalous left coronary artery from the pulmonary artery (ALCAPA) in adult patients - a multimodality imaging approach.

Purpose: Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital ano-maly of the origin of the coronary arteries. The prevalence of this anomaly in the adult patient population is low, and therefore there is virtually no original research on this topic. Reports are limited to case reports. Material and methods: We evaluated 16,264 computed tomography (CT) exams (cardiac and chest) performed in our heart imaging department between 2015 and 2022 on a dual-source 128-slice CT scanner (SOMATOM Definition Flash, Siemens Healthineers, Forchheim, Germany) and established a retrospective registry of adult patients (> 18 years old) with ALCAPA. The study included 7 cases. Next, we collected clinical and echocardiographic data, which could be assessed retrospectively. Results: We found 7 cases of ALCAPA in adult patients (0.043%). Three of them were female, and 4 were male. The age varied between 20 and 60 years. Echocardiographic findings, as well as the clinical course, varied widely. Conclusions: ALCAPA is an extremely rare anomaly, which nonetheless must be taken into clinical consideration. This lesion may be fatal during infancy. Data regarding adult patients is scarce. Multicentre registries are needed to establish a more detailed clinical profile of adults with this anomaly.

Major aortopulmonary collateral arteries: clinical, echocardiographic, and radiologic characteristics.

Purpose: Major aortopulmonary collateral arteries (MAPCAs) are rare congenital anomalies with significant clinical implications, often associated with congenital heart diseases like tetralogy of Fallot (TOF) and pulmonary atresia (PA). This study aimed to investigate the clinical, echocardiographic, and radiologic characteristics of MAPCAs in patients with congenital heart diseases admitted to our clinic between 2016 and 2023. Material and methods: A retrospective analysis of 46 cases was conducted using chest computed tomography exams performed on a dual-source 128-slice CT scanner. Clinical data and radiologic characteristics were collected and analysed. Results: The study revealed a strong correlation between congenital heart diseases and the presence of MAPCAs, with TOF, PA, and ventricular septal defect (VSD) being the most common, and it indicated that these collaterals may exist with non-diagnosed congenital heart disease. Tricuspid regurgitation and aortic insufficiency were the predominant echocardiographic findings. Radiologically, MAPCAs primarily originated from the descending aorta (type II) in 85% of cases, and their sizes ranged from ≤ 3 mm to > 10 mm, with an average of 5 mm. Conclusions: This study provides comprehensive insights into the clinical and radiologic aspects of MAPCAs in patients with congenital heart diseases. The findings emphasise the importance of early detection and intervention for better managing of these complex conditions and the need for further research.

Upgrade from implantable cardioverter-defibrillator vs. de novo implantation of cardiac resynchronization therapy: long-term outcomes.

AIMS: To assess and compare long-term mortality and predictors thereof in de novo cardiac resynchronization therapy defibrillators (CRT-D) vs. upgrade from an implantable cardioverter-defibrillator (ICD) to CRT-D. METHODS AND RESULTS: Study population consisted of 595 consecutive patients with CRT-D implanted between 2002 and 2015 in a tertiary care, university hospital, in a densely inhabited, urban region of Poland [480 subjects (84.3%) with CRT-D de novo implantation; 115 patients (15.7%) upgraded from ICD to CRT-D]. In a median observation of 1692 days (range 457-3067), all-cause mortality for de novo CRT-D vs. CRT-D upgrade was 35.5% vs. 43.5%, respectively (P = 0.045). On multivariable regression analysis including all CRT recipients, the previously implanted ICD was an independent predictor for death [hazard ratio (HR) 1.58, 95% confidence interval (CI) 1.10-2.29, P = 0.02]. For those, who were upgraded from ICD to CRT-D, the independent predictors for all-cause death were as follows: creatinine level (HR 1.01, 95% CI 1.00-1.02, P = 0.01), left ventricular end-systolic diameter (HR 1.07, 95% CI 1.02-1.11, P = 0.002), New York Heart Association (NYHA) IV class at baseline (HR 2.36, 95% CI 1.00-5.53, P = 0.049) and cardiac device-related infective endocarditis during follow-up (HR 2.42, 95% CI 1.02-5.75, P = 0.046). A new CRT scale (Creatinine ≥150 µmol/L; Remodelling, left ventricular end-systolic ≥59 mm; Threshold for NYHA, NYHA = IV) showed high prediction for mortality in CRT-D upgrades (AUC 0.70, 95% CI 0.59-0.80, P = 0.0007). CONCLUSION: All-cause mortality in patients upgraded from ICD is significantly higher compared with de novo CRT-D implantations and reaches almost 45% within 4.5 years. A new CRT scale (Creatinine; Remodelling; Threshold for NYHA) has been proposed to help survival prediction following CRT upgrade.

Quality of life in cardiac resynchronization recipients: association with response and impact on outcome.

BACKGROUND: The prognostic impact of improvement in health-related quality of life (QoL) and its relation to response in cardiac resynchronization therapy (CRT) recipients remains unknown. AIM: To assess the correspondence between response to CRT and improvements in QoL and to verify if a change in QoL after pacing influences outcome in CRT patients. METHODS: Ninety-seven participants of the Triple-Site Versus Standard Cardiac Resynchronization Therapy Trial (TRUST CRT) randomized trial, in New York Heart Association class III-IV, QRS width ≥ 120 ms, left ventricular ejection fraction ≤ 35%, and significant mechanical dyssynchrony were included. Subjects filled out the Minnesota-QoL questionnaire prior to and 6 months after CRT with defibrillator (CRT-D) implantation. Data on major adverse cardiac events (MACEs: death, heart failure hospitalization, heart transplant) collected within the next 2.5 years and adjudicated blindly constituted the censoring variables. RESULTS: Within the first 6 months of resynchronization QoL improved in 81%, while worsening in 19% of patients. Clinical response, but not the echocardiographic one, was associated with improved QoL. During subsequent 2.5 years MACEs occurred in 37% of patients (23% died). Subjects without QoL improvement were significantly (both P < 0.05) more prone to experience MACE (61% vs 32%) and die (44% vs 18%) within the follow-up. Unimproved QoL increased the probability of future MACE by 2.7 times (95% confidence intervals [CI]: 1.26-5.83; P = 0.01) and death by 3.2 times (95% CI: 1.23-8.32; P = 0.02) independently from clinical and echocardiographic response. CONCLUSIONS: Clinical response, but not the echocardiographic one, was associated with improved QoL in CRT recipients. These preliminary data suggest that lack of improvement in QoL after CRT was associated with a strongly unfavorable prognosis, regardless of functional or echocardiographic response. Our results merit further studies with a larger number of patients.

3D and 2D left ventricular systolic function imaging-- from ejection fraction to deformation. Cardiac resynchronization therapy--substudy.

INTRODUCTION: 3D echocardiography offers options of left ventricular systolic function analysis. The aims of this study are: to assess the usefulness of 3D echocardiography, to test 3D regional measurements (with area strain) among a spectrum of patients and then to check prospectively the value of 3D echocardiography vs 2D in the assessment of response to resynchronization. METHODS: The first retrospective study group comprises 42 subjects: 23 consecutive patients with left ventricular systolic heart failure and 19 healthy control subjects. The left ventricle was assessed by: 2D-Simpson's biplane, 3D-triplane and -automated volumetric method. Next, 24 patients undergoing cardiac resynchronization therapy were prospectively assessed before and after 6 months. A haemodynamic response criterion of 15% left ventricular end-systolic volume (ESV) reduction was used. RESULTS: The 3D volumetric method was the fastest method for left ventricular ejection fraction assessment (bi-33 vs tri-53 vs145 sec, ANOVA P < 0.001). In heart failure the only strain parameter associated with QRS width was global peak longitudinal strain (r = 0.47, P = 0.023). A high agreement in left ventricular ejection fraction and volumes between methods was observed. The following measures select resynchronization candidates in the heart failure group: (1) 3D global longitudinal strain (AUC-0.756; P = 0.022; the cut-off value > -9.52%; 78% sensitivity, 80% specificity), radial strain (AUC-0.739; P = 0.086; cut-off value 20%; 78% sensitivity, 80% specificity) and area strain (AUC-0.733; P = 0.045; cut-off value > -13.5%; 67% sensitivity, 80% specificity). The agreement between the response assessment by Simpson's biplane and 3D was 78% with a negative predictive value of 100%. The lack of global area strain improvement after cardiac resynchronization therapy has a negative predictive value of 100% in the selection of non-responders. CONCLUSIONS: 3D echocardiography is applicable in the assessment of both preserved and reduced left ventricular ejection fraction. This assessment is fast and requires minimal user intervention. 3D strain may help in cardiac resynchronization therapy candidates and response assessment. After cardiac resynchronization, none of the patients were incorrectly identified as responder to cardiac resynchronization therapy by 3D algorithms compared to 2D Simpson's reference.

Many response criteria are poor predictors of outcomes after cardiac resynchronization therapy: validation using data from the randomized trial.

AIMS: The aim of the study was to assess the predictive value for outcomes of various response criteria currently used in patients undergoing cardiac resynchronization therapy (CRT). METHODS AND RESULTS: Data from TRUST CRT randomized trial in patients with New York Heart Association (NYHA) III-IV class, QRS ≥ 120 ms, ejection fraction ≤ 35%, and mechanical dyssynchrony was analysed. Ninety-seven subjects who survived 6 months after implantation of CRT-defibrillator were classified as responders or non-responders depending on 15 criteria used in most of the previous trials. Blindly adjudicated data on major adverse cardiac events (MACEs) within 1 year after classification were used to calculate the predictive value of response criteria. After adjustment for baseline confounding variables only eight criteria were significantly predictive for future MACEs. Sensitivity and specificity ranged substantially for clinical (32-94% and 26-63%) and echocardiographic criteria (40-93% and 22-70%, respectively). The most powerful clinical predictor was >a NYHA class reduction ≥ 1 [adjusted relative risk (RR) 4.41 for non-responders; 95% confidence interval (CI) 1.75-11.04, P = 0.002], while the strongest echocardiographic predictor was a reduction in the left ventricular end-systolic index by > 15% (RR 3.49; 95% CI 1.59-7.64, P = 0.002). A combination of these two criteria did not improve the predictive value of a single parameter. Both criteria showed multiple significant interactions with baseline patients' characteristics. CONCLUSION: Only some of the commonly used response criteria predict outcome in patients undergoing CRT. The predictive value varies substantially across different criteria, with a higher sensitivity observed for the clinical parameters and a higher specificity observed for echocardiographic parameters. Combining various criteria adds little to their prognostic value. The predictive accuracy of various criteria can be different in various subgroups due to multiple interactions with baseline characteristics. CLINICALTRIALS. GOV IDENTIFIER: NCT00814840.

Anomalous Origin of Left Circumflex Artery from the Right Sinus of Valsalva in Cardiac Computed Tomography in a Group of 16,680 Patients-Radiologic and Clinical Characteristics.

BACKGROUND: Anomalous aortic origin of a coronary artery (AAOCA) is the most prevalent form of coronary anomaly. One variant of AAOCA is the anomalous origin of the left circumflex artery from the right sinus of Valsalva, which can be detected using cardiac computed tomography (CT). However, limited data are available regarding the natural history of this anomaly, its impact on myocardial function, and associated symptoms. METHODS: We conducted a retrospective analysis of 16,680 CT exams (cardiac and chest) performed between 2015 and 2022 at our Heart Imaging Department, utilising a dual-source 128-slice CT scanner (SOMATOM Definition Flash, Siemens Healthineers, Forchheim, Germany). A registry of patients with anomalous origin of the circumflex artery from the right sinus of Valsalva (RCx) was established. The study included 56 cases of RCx (0.33%). Clinical information was obtained from medical records. RCx was defined as a circumflex artery originating from the right sinus of Valsalva (type I or II) or the right coronary artery (type III). Two researchers independently reevaluated each CT exam in our study group to ensure accurate radiologic descriptions and provide additional precise radiologic information regarding the anomaly, including high-risk features. RESULTS: Our study comprised 56 patients, with approximately equal distribution between males (n = 30, 54%) and females (n = 26, 46%), and with a median age of 59 years. Coronary heart disease (CAD) was known in 23% of patients (n = 13), while 11% (n = 6) were obese (defined as a BMI > 30 kg/m2), and 13% (n = 7) were diagnosed with type 2 diabetes. Only 9% of patients (n = 5) were smokers. Dyslipidemia was the most prevalent atherosclerotic risk factor, affecting approximately one third of patients (n = 17, 30%). In 14% (n = 8) of patients, heart failure was observed, while 13% (n = 7) were diagnosed with atrial fibrillation. Type I RCx was the most common subtype, identified in 48% of patients (n = 27) with this anomaly. Type II and Type III were found in 25% (n = 14) and 27% (n = 15) of patients, respectively. CONCLUSIONS: Our findings suggest that RCx is frequently encountered as an incidental finding, and we did not identify a consistent clinical characteristic in all patients with this type of anomaly. Furthermore, no gender predominance was associated with RCx. The natural history of this anomaly and its clinical implications seem benign. Further research is warranted to better understand this anomaly's natural course and clinical implications.

Effect of cardiac resynchronization on gradient reduction in patients with obstructive hypertrophic cardiomyopathy: preliminary study.

BACKGROUND: The purpose of this study was to assess the effectiveness of cardiac resynchronization therapy (CRT) in terms of outflow tract gradient reduction and functional improvement in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) requiring implantable cardioverter-defibrillator (ICD) implantation. METHODS: Eleven consecutive symptomatic HOCM patients with a significant (≥40 mmHg) gradient and indications for ICD, but without indications for resynchronization, underwent CRT-D implantation. Nine of them (four female, median age of 50 years) in whom the procedure succeeded were screened for New York Heart Association (NYHA) class, outflow gradient, mechanical dyssynchrony, QRS-width change, and 6-minute walking distance (6MWD) and peak oxygen consumption (VO(2)peak) improvement after 6 months and remotely. RESULTS: After 6 months of pacing, NYHA class decreased (median 1 vs 2, respectively); peak (33 vs 84 mmHg) and mean (13 vs 38 mmHg) outflow tract gradients were reduced; and QRS width (143 vs 105 ms), intraventricular dyssynchrony (35 vs 55 ms), and VO(2)peak (19.5 vs 14.2 mL/kg/min) increased significantly (all P < 0.05) compared to baseline. In six of nine patients (67%), the peak gradient was reduced >50% and reached <40 mmHg. After a median of 36 months, the outflow gradient decreased even more (8 mmHg) and was significantly (P < 0.05) lower than after 6 months of CRT. CONCLUSIONS: These preliminary data suggest that CRT seems to be an effective method of reducing the outflow tract gradient and improving the functional status of symptomatic HOCM patients requiring ICD implantation. Our findings need to be confirmed by more extensive studies.

Clinical manifestations of device-related infective endocarditis in cardiac resynchronization therapy recipients.

INTRODUCTION: The aim of the study was to analyse microbiological characteristics and clinical manifestations of cardiac device-related infective endocarditis (CDRIE) in cardiac resynchronization therapy (CRT) recipients, and to compare the diagnostic value of modified Duke (MDC) versus modified Duke lead criteria (MDLC; including to MDC local infection and pulmonary infection or embolism as major criteria). MATERIAL AND METHODS: The study population comprised 765 consecutive CRT patients from a high-volume, tertiary care centre from 2002 to 2015. All patients were screened for CDRIE. RESULTS: During a median follow-up of 1692 days (range: 457-3067) 5.36% of patients (n = 41) developed CDRIE, which was accompanied by CRT pocket infection in 17.1% (n = 7) and recurrent pulmonary infection or pulmonary embolism in 29.3% (n = 12). Fever was present in 95.1% of patients (n = 39), whereas blood cultures were positive in 65.9% (n = 27). Staphylococcus was the most prevalent pathogen in 59.3% (n = 16), Gram-negative bacteria in 25.9% (n = 7). Transoesophageal echocardiography showed intracardiac vegetations in 73.2% of patients (n = 30). Non-different pathogen types with the most common methicillin-sensitive Staphylococcus aureus were observed for early versus late CDRIE (endocarditis ≤ 6 vs. > 6 months from CRT or other device-related procedure). All 3 inflammatory markers (C-reactive protein, white blood cells, procalcitonin) were normal in 4.9% of patients (n = 2). MDC versus MDLC indicated definite CDRIE in 48.8% versus 80.5%, respectively (p = 0.003). CONCLUSIONS: Fever is the most common symptom of CRT-related CDRIE, and transoesophageal echocardiography allows vegetations to be visualised in nearly 3/4 of patients with CDRIE. Although the most common pathogens were Staphylococci, Gram-negative bacteria accounted for a quarter of CDRIE. Modified Duke lead criteria proved superior to MDC.

Optimal medical therapy in patients with stable coronary artery disease in Poland: the ISCHEMIA trial experience.

Introduction: Optimal medical therapy (OMT) is the cornerstone of treatment for stable coronary disease with the ISCHEMIA trial showing similar outcomes using OMT with or without an initial invasive approach. Objectives: To describe OMT goal attainment in Polish ISCHEMIA participants compared with other countries. Patients and methods: Among 5179 trial participants, 333 were randomized in Poland. The median follow-up was 3.2 years. OMT targets were: not smoking, high-intensity statin therapy, low-density lipoprotein cholesterol (LDL-C) of less than 70 mg/dl, systolic blood pressure of less than 140 mm Hg, aspirin therapy, and ACEI / ARB, and ß-blocker therapy if indicated. Results: Compared with 36 other countries, at randomization, patients in Poland were older (67 [62­75] y vs 65 [58­71] y); P <⁠0.001), more often female (30% vs 22%; P = 0.002), with a longer history of angina (3 [1­9] y vs 1 [0­3] y; P <⁠0.001), and there were more cases of prior myocardial infarction (32% vs 18%; P <⁠0.01) and revascularization (PCI, 40% vs 19%; CABG, 11% vs 3%; P <⁠0.001 for both). The number of OMT goals attained increased from baseline to follow-up visits (5 [4­5] vs 6 [5­6]; P <⁠0.001) in Poland and other countries alike (P = 0.89 vs P = 0.14). In Poland, significant improvements were achieved regarding high-intensity statin therapy (27% vs 50%), LDL-C <⁠70 mg/dl (29% vs 65%), and systolic blood pressure of less than 140 mm Hg (63% vs 81%) (P <⁠0.001 for all), whereas not-smoking (89% vs 89%), aspirin (90% vs 88%), ACEI / ARB (93% vs 95%), and ß-blocker therapy (94% vs 90%) remained high. Conclusions: With regular surveillance and contemporary medical therapy, high OMT goal attainment was achievable among the participants of the ISCHEMIA trial in Poland relative to other countries. There is still room for improvement in LDL-C and blood pressure management.

Assessment of apical rocking: a new, integrative approach for selection of candidates for cardiac resynchronization therapy.

AIMS: Current attempts of improving patient selection in cardiac resynchronization therapy (CRT) are mainly based on echocardiographic timing of myocardial velocity peaks. Regional myocardial function is neglected. Apical transverse motion (ATM) is a new parameter to quantify apical rocking as an integrative surrogate of both temporal and functional inhomogeneities within the left ventricle. In this study, we tested the predictive value of apical rocking for response to CRT. METHODS AND RESULTS: Sixty-nine patients eligible for CRT were assessed by echocardiography before and 11 ± 5 months after pacemaker implantation. Response was defined as left ventricular (LV) end-systolic volume decrease >15%. Rocking was quantified (ATM) and visually assessed by four blinded readers. Predictive value for CRT response of both assessments was compared with conventional dyssynchrony parameters. ATM in the four-chamber view plane differentiated best between responders and non-responders (2.2 ± 1.5 vs. 0.06 ± 1.9 mm, P< 0.0001). Quantified ATM predicted reverse remodelling with a sensitivity, specificity, and accuracy of 75, 96, and 83% whereas visual rocking assessment resulted in 89, 75, and 83%, respectively. The accuracy of conventional parameters was significantly lower. CONCLUSION: Apical rocking is a new marker to assess LV dyssynchrony and predict CRT response. It is superior to conventional parameters. Even its simple visual assessment may be sufficiently accurate in the clinical setting.

Apical transverse motion as surrogate parameter to determine regional left ventricular function inhomogeneities: a new, integrative approach to left ventricular asynchrony assessment.

AIMS: Left ventricular (LV) asynchrony assessment is mostly based on delays between regional myocardial velocity peaks. Regional function is barely considered. We propose apical transverse motion (ATM) as a new parameter integrating both temporal and functional information, which was tested in different conduction delays. METHODS AND RESULTS: We examined 67 patients, 11 patients with post-infarct ischaemic left bundle branch blocks (iLBBB) and 25 patients with non-ischaemic left bundle branch block (nLBBB), 12 patients with right bundle branch block (RBBB), and 19 normal healthy volunteers (NORM). Longitudinal colour tissue Doppler data were used to calculate the total transverse apex motion (ATM), the transverse motion in the four-chamber view plane alone (ATM(4CV)) as well as regional myocardial deformation and conventional LV asynchrony parameters. Median ATM was 1.8 mm in NORM, 1.5 mm in RBBB (P = 0.999), 2.4 mm in iLBBB (P = 0.183), and 4.3 mm in nLBBB (P < 0.001 vs. NORM and RSB). ATM(4CV) behaved similarly, showed a good correlation with regional deformation data, and distinguished well between NORM and LBBB (AUC = 0.87). CONCLUSION: Apical transverse motion is a new and simple parameter integrating information on both regional and temporal function inhomogeneities of the LV. It has a potential role in assessing LV asynchrony in the clinical context.

The impact of the aortic cusps fusion pattern and valve disease severity on the aortic wall mechanics in patients with bicuspid aortic valve.

The ascending aorta dilatation in the bicuspid aortic valve (BAV) patients is often attributed to congenital abnormalities of the aortic wall, but it may be related to hemodynamic disturbances in the course of BAV disease. At present, ascending aortic diameter is used as almost sole but weak predictor of aortic dissection and rupture in BAV. We examined the association between aortic wall mechanics and severity of aortic valve disease including different cusps fusion patterns using conventional echocardiography and tissue Doppler imaging (TDI). We prospectively studied 106 BAV patients: 72 with right-left (R-L) coronary cusp fusion were matched 1:1 to 34 patients with right-noncoronary (R-N) cusp fusion obtaining 34 pairs of patients. Peak systolic radial velocity and acceleration of the ascending aortic wall, measured by TDI, were used as an index of hemodynamic stress imposed on the aorta. Paired analysis showed higher aortic wall radial velocity (4.71 ± 1.61 cm/s vs. 3.33 ± 1.44 cm/s, p = 0.001) and acceleration (1.08 ± 0.46 m/s2 vs. 0.80 ± 0.34 m/s2, p = 0.015) in-R-L compared to R-N fusion. Pearson correlation showed association of ascending tubular aortic diameter with age (r = 0.258, p = 0.012), weight (r = 0.323, p = 0.001), peak aortic valve gradient (r = 0.386, p = 0.0001), aortic root diameter (r = 0.439, p < 0.0001), and R-N fusion pattern (r = 0.209, p = 0.043). Aortic root diameter was related to male gender (r = 0.296, p = 0.003), weight (r = 0.381, p = 0.0001), ascending aortic diameter (r = 0.439, p < 0.0001), and severity of aortic regurgitation (r = 0.337, p = 0.0009). Regional differences in aortic wall motion between different BAV cusp fusion patterns and association of aortic diameters with the severity of aortic valve disease, both suggest a deleterious hemodynamic impact of cusp fusion patterns and aortic valve dysfunction on ascending aortic wall. Assessment of aortic hemodynamic by TDI is feasible and could be potentially used to improve prediction of acute aortic complications, thus helping to establish optimal timing of aortic surgery in BAV patients.

The association of mechanical dyssynchrony and resynchronization therapy with survival in heart failure with a wide QRS complex: a two-world study.

Setting up a randomized trial to assess the association of mechanical dyssynchrony (MD) and the success of cardiac resynchronization therapy (CRT) in heart failure with a wide QRS complex is ethically challenging. We therefore investigated this association in a retrospective cohort study observing different treatment strategies which were chosen based on the availability of health care resources. The survival of 500 patients from six Western European centers treated with CRT was compared to their 137 Eastern European counterparts not treated with CRT, with regard to the presence of MD. MD was visually assessed and was defined as the presence of apical rocking and/or septal flash. Patients were followed for a mean of 26 ± 8 months for the occurrence of death of any cause. As compared with medical therapy alone, CRT was associated with a more favorable survival (hazard ratio (HR), 0.53; 95% confidence interval (CI) 0.35-0.79; P = 0.002). Patients with MD treated by CRT had better survival than patients belonging to all other groups-they showed 72%, 66% and 56% reduction in all-cause mortality, respectively, compared to patients with MD not treated by CRT (HR 0.28; 95% CI 0.17-0.44), patients without MD treated by CRT (HR 0.34; 95% CI 0.22-0.52) and patients without MD not treated by CRT (HR 0.44; 95% CI 0.25-0.76). Patients with wide QRS complex who are treated with CRT have a significantly better survival when MD is present.

Effects of cardiac resynchronization therapy on heart rate turbulence.

BACKGROUND: Cardiac resynchronization therapy (CRT) improves the clinical status of patients with heart failure (HF), though its effects on heart rate turbulence (HRT) are unknown. METHODS: We measured HRT indices in 58 recipients of CRT systems (mean age = 56 +/- 9 years, 41 men) in New York Heart Association HF functional class III-IV, and with a left ventricular (LV) ejection fraction < or =35%. At 6 months of follow-up, 42 patients were responders and 13 nonresponders to CRT, and three patients died suddenly. The HRT indices turbulence onset (TO%) and turbulence slope (TS ms/RR interval) were calculated from digital 24-hour electrocardiogram before and after 6 months of CRT. TO > or = 0% and TS < or = 2.5 ms/RR interval were considered abnormal. RESULTS: Mean TO in the entire population was 0.4 +/- 1.5 before CRT, and decreased to -0.8 +/- 7.0 during the 6 months of CRT (ns). TS increased significantly from 2.0 +/- 1.7 at baseline, to 3.9 +/- 3.1 (P < 0.05), and a significantly lower proportion of patients had abnormal HRT indices at 6 months. In contrast to the significant increase observed in responders, not significant change in TS was observed among the nonresponders. CONCLUSIONS: During 6 months of CRT, improvements in HRT indices and a decrease in the proportion of patients with abnormal HRT were observed. CRT may have beneficial effects on baroreflex sensitivity.

Comparison of transesophageal and intracardiac echocardiography in guiding percutaneous left atrial appendage closure with an Amplatzer Amulet device.

INTRODUCTION: Percutaneous occlusion of the left atrial appendage (LAAO) is becoming an extensively used method of stroke prevention in individuals with contraindications to oral anticoagulants. Transesophageal echocardiography (TOE) is the gold standard for LAAO guiding, but intracardiac echocardiography (ICE) appears to be a potential alternative. AIM: To compare the LAAO procedure guided by TOE or ICE with respect to procedural success and safety. MATERIAL AND METHODS: TOE-guided LAAO was performed in 12 patients and ICE-guided LAAO in 11 patients. ICE was performed using an 8F AcuNav probe and the ACUSON SC2000 system. For LAAO the Amplatzer Amulet was used. After 1 month TOE was performed. RESULTS: Procedural success was achieved in all patients in TOE and ICE groups. There was 1 complication (groin hematoma). The procedure time was significantly longer in the TOE group (43 to 80 min; median: 54 min) compared to the ICE group (28 to 67 min; median: 45 min), (p = 0.02) The time needed to puncture the interatrial septum and time needed to remove the sheath did not differ between groups. Fluoroscopic time was insignificantly longer in the ICE group (9.91 ±4.01s) compared to the TOE group (7.69 ±3.21s), and a significantly larger contrast media volume was used in the ICE group (30.00 ±6.67 ml vs. 40.45 ±23.18 ml, p = 0.03). There were no statistically significant differences in the results between TOE and ICE groups in follow-up assessments. CONCLUSIONS: LAAO using the Amplatzer Amulet may be successfully and safely guided by ICE. ICE offered shorter procedure time and similar results irrespectively of left atrial appendage anatomy compared to TOE guidance.

Assessment of mechanical dyssynchrony can improve the prognostic value of guideline-based patient selection for cardiac resynchronization therapy.

Aim: To determine if incorporation of assessment of mechanical dyssynchrony could improve the prognostic value of patient selection based on current guidelines. Methods and results: Echocardiography was performed in 1060 patients before and 12 ± 6 months after cardiac resynchronization therapy (CRT) implantation. Mechanical dyssynchrony, defined as the presence of apical rocking or septal flash was visually assessed at the baseline examination. Response was defined as ≥15% reduction in left ventricular end-systolic volume at follow-up. Patients were followed for a median of 59 months (interquartile range 37-86 months) for the occurrence of death of any cause. Applying the latest European guidelines retrospectively, 63.4% of the patients had been implanted with a Class I recommendation, 18.2% with Class IIa, 9.4% with Class IIb, and in 9% no clear therapy recommendation was present. Response rates were 65% in Class I, 50% in IIa, 38% in IIb patients, and 40% in patients without a clear guideline-based recommendation. Assessment of mechanical dyssynchrony improved response rates to 77% in Class I, 75% in IIa, 62% in IIb, and 69% in patients without a guideline-based recommendation. Non-significant difference in survival among guideline recommendation classes was found (Log-rank P = 0.2). Presence of mechanical dyssynchrony predicted long-term outcome better than guideline Classes I, IIa, IIb (Log-rank P < 0.0001, 0.006, 0.004, respectively) and in patients with no guideline recommendation (P = 0.02). Comparable results were observed using the latest American Guidelines. Conclusion: Our data suggest that current guideline criteria for CRT candidate selection could be improved by incorporating assessment of mechanical asynchrony.

Sex-specific difference in outcome after cardiac resynchronization therapy.

AIMS: Observation of better outcome in women after cardiac resynchronization therapy (CRT) has led to controversies about a potential sex-specific response. In this study, we investigated to which extent this sex-specific difference in CRT outcome could be explained by differences in baseline characteristics between both sexes. METHODS AND RESULTS: We retrospectively analysed data from a multicentre registry of 1058 patients who received CRT. Patients were examined by echocardiography before and 12 ± 6 months after implantation. Response was defined as ≥15% reduction of left ventricular end-systolic volume at follow-up. Patient's characteristics at baseline, including New York Heart Association class, ejection fraction, QRS width and morphology, ischaemic aetiology of cardiomyopathy (ICM), number of scarred segments, age at implantation, atrial fibrillation, and mechanical dyssynchrony (Dyss) were analysed. Patients were followed for a median duration of 59 months. Primary end point was all-cause mortality. Women (24% of the population) had less ICM (23% vs. 49%, P < 0.0001), less scarred segments (0.4 ± 1.3 vs. 1.0 ± 2.1, P < 0.0001), more left bundle branch block (LBBB; 87% vs. 80%, P = 0.01), and more Dyss at baseline (78% vs. 57%, P < 0.0001). Without matching baseline differences, women showed better survival (log rank P < 0.0001). After matching, survival was similar (log rank P = 0.58). In multivariable analysis, female sex was no independent predictor of neither volumetric response (P = 0.06) nor survival (P = 0.31). CONCLUSION: Our data suggest that the repeatedly observed better outcome in women after CRT is mainly due to the lower rate ICM and smaller scars. When comparing patients with similar baseline characteristics, the response of both sexes to CRT is similar.