Balloon valvuloplasty as destination therapy in elderly with severe aortic stenosis: a cardiac catheterization study.

BACKGROUND: In the current era of transcatheter aortic valve replacement, there is renewed interest in balloon aortic valvuloplasty (BAV) and invasive hemodynamic evaluation of aortic stenosis (AS). The current report aimed to study the invasive hemodynamics of severe AS patients treated with BAV as destination therapy and to identify factors associated with better hemodynamic outcome and prognosis. METHODS: From 2009 to 2012, 63 high risk elderly patients were treated with BAV as destination therapy for symptomatic severe AS and were all prospectively included in the study. Their hemodynamics were invasively evaluated during catheterization, pre- and post-BAV at the same session. All Post-BAV patients were regularly followed-up. RESULTS: The patients (82 ± 6 years, 52% male) had post-BAV aortic valve area index (AVAi) significantly increased and mean pressure gradient (MPG) significantly reduced. During the follow-up of 0.9 (maximum 3.3) years, those with post-BAV AVAi < 0.6 cm(2)/m(2) compared with the AVAi ≥ 0.6 cm(2)/m(2) group had significantly higher mortality (60% vs. 28%, log-rank P = 0.02), even after adjusting for age, gender, atrial fibrillation, chronic kidney disease, diabetes mellitus, coronary artery disease and EuroSCORE [HR: 5.58, 95% confidence interval (CI): 1.62-19.20, P = 0.006]. The only independent predictor of moderate AS post-BAV was the pre-BAV AVAi increase by 0.1cm(2)/m(2) (OR: 3.81, 95% CI: 1.33-10.89, P = 0.01). Pre-BAV AVAi ≥ 0.39 cm(2)/m(2) could predict with sensitivity 84% and specificity 70% the post-BAV hemodynamic outcome. CONCLUSIONS: BAV as destination therapy for severe AS offered immediate and significant hemodynamic improvement. The survival was significantly better when a moderate degree of AS was present.

Clinical profile and therapeutic management of patients with atrial fibrillation in Greece: results from the Registry of Atrial Fibrillation to Investigate New Guidelines (RAFTING).

INTRODUCTION: Atrial fibrillation (AF) is the most common arrhythmia with significant morbidity, including a 5-fold increase in stroke risk. The management of AF, including antithrombotic therapy (AT), varies considerably among countries. Representative data concerning AF features and management in Greece are generally lacking. METHODS: The Registry of Atrial Fibrillation To Investigate New Guidelines (RAFTING) is a country-wide prospective observational study of AF in Greece that enrolled consecutive patients with a diagnosis of AF in emergency departments of 31 hospitals of different types according to the population's geographical distribution. RESULTS: RAFTING enrolled 1127 patients, 51% females, aged 71 ± 12 years. Paroxysmal AF was present in 54% of patients and newly diagnosed AF in 28%; 68% of patients with a previous AF history had undergone a median of 4 cardioversions. A high rate of comorbidities was present, including arterial hypertension in 75% and heart failure in 40%. The median CHADS2 and CHA2DS2VASc scores were 2 and 3, respectively; AT had been prescribed in 87% of non-newly diagnosed patients, with warfarin being prescribed in 56% of them. Among all patients on warfarin, INR values were within therapeutic range in 34% of cases during inhospital measurement. Hospital admission occurred in 82% of cases, with in-hospital mortality 0.8%. CONCLUSIONS: RAFTING provides updated insights into the current features and management of AF in Greece. The majority of patients have a sufficiently high risk to warrant oral anticoagulation and further attempts to comply with the existing guidelines are warranted.

Patients with hypertrophic cardiomyopathy at risk for paroxysmal atrial fibrillation: advanced echocardiographic evaluation of the left atrium combined with non-invasive P-wave analysis.

AIMS: The maintenance of sinus rhythm is crucial for the functional capacity of patients with hypertrophic cardiomyopathy (HCM). Using a multimodality approach, we attempted to identify potential predictors of paroxysmal atrial fibrillation (PAF) in HCM patients. METHODS AND RESULTS: Thirty HCM patients (17 males, mean age 57.9 ± 13.6) with at least one documented PAF episode and 32 age- and sex-matched HCM control patients as well as 25 healthy volunteers were studied in sinus rhythm. Study subjects underwent 2D echocardiography including a colour Doppler myocardial imaging evaluation of the left atrium (LA). Additionally, an orthogonal electrocardiogram was acquired; P-wave duration, maximum, and mean energies were calculated for each subject at each orthogonal lead and the composite vector axis using the Morlet wavelet analysis. Compared with HCM controls, in HCM-PAF patients, LA antero-posterior diameter was significantly enlarged (LADAP: 46.1 ± 5.9 vs. 40.0 ± 4.7 mm, P < 0.001), peak strain rate of the LA lateral wall in the reservoir phase was significantly decreased (LAT peak SR-S: 1.93 ± 0.51 vs. 2.55 ± 0.83 s(-1), P < 0.01), and P-wave duration in the Z-lead was significantly prolonged (P-durZ: 106.9 ± 24.6 vs. 86.2 ± 14.3 ms, P < 0.001). Cut-off values and areas under the curve (AUCs) for individual parameters were 42.0 mm, 2.32 s(-1), and 98.8 ms and 0.81, 0.74, and 0.78, respectively. A multivariable model combining LADAP, LAT peak SR-S and P-durZ had an AUC of 0.90, a sensitivity of 0.87, and a specificity of 0.91 for identifying PAF patients. CONCLUSION: P-wave duration combined with LA antero-posterior diameter and myocardial deformation indices resulted in a higher power for discriminating HCM-PAF patients, when compared with individual parameters derived from either wavelet analysis or 2D echocardiography.

Ibutilide for the Cardioversion of Paroxysmal Atrial Fibrillation during Radiofrequency Ablation of Supraventricular Tachycardias.

Direct current electrical cardioversion (DC-ECV) is the preferred treatment for the termination of paroxysmal atrial fibrillation (AF) that occurs during radiofrequency ablation (RFA) of supraventricular tachycardias (SVT). Intravenous Ibutilide may be an alternative option in this setting. Thirty-four out of 386 patients who underwent SVT-RFA presented paroxysmal AF during the procedure and were randomized into receiving ibutilide or DC-ECV. Ibutilide infusion successfully cardioverted 16 out of 17 patients (94%) within 17.37 ± 7.87 min. DC-ECV was successful in all patients (100%) within 17.29 ± 3.04 min. Efficacy and total time to cardioversion did not differ between the study groups. No adverse events were observed. RFA was successfully performed in 16 patients (94%) in the ibutilide arm and in all patients (100%) in the DC-ECV arm, p = NS. In conclusion, ibutilide is a safe and effective alternative treatment for restoring sinus rhythm in cases of paroxysmal AF complicating SVT-RFA.

Chronotropic incompetence and its relation to exercise intolerance in hypertrophic cardiomyopathy.

BACKGROUND: Diminished functional capacity is common in hypertrophic cardiomyopathy (HCM), although the underlying mechanisms are complicated. We studied the prevalence of chronotropic incompetence and its relation to exercise intolerance in patients with HCM. METHODS: Cardiopulmonary exercise testing was performed in 68 patients with HCM (age 44.8 ± 14.6 years, 45 males). Chronotropic incompetence was defined by chronotropic index (heart rate reserve)/(220-age-resting heart rate) and exercise capacity was assessed by peak oxygen consumption (peak Vo(2)). RESULTS: Chronotropic incompetence was present in 50% of the patients and was associated with higher NYHA class, history of atrial fibrillation, higher fibrosis burden on cardiac MRI, and treatment with ß-blockers, amiodarone and warfarin. On univariate analysis, male gender, age, NYHA class, maximal wall thickness, left atrial diameter, peak early diastolic myocardial velocity of the lateral mitral annulus, history of atrial fibrillation, presence of left ventricular outflow tract obstruction (LVOTO) at rest, and treatment with beta-blockers were related to peak Vo(2). Peak heart rate during exercise, heart rate reserve, chronotropic index, and peak systolic blood pressure were also related to peak Vo(2). On multivariate analysis male gender, atrial fibrillation, presence of LVOTO and heart rate reserve were independent predictors of exercise capacity (R(2) = 76.7%). A cutoff of 62 bpm for the heart rate reserve showed a negative predictive value of 100% in predicting patients with a peak Vo(2) <80%. CONCLUSIONS: Blunted heart rate response to exercise is common in HCM and represents an important determinant of exercise capacity.

Practice patterns of cardiologists, general practitioners, and internists for managing supraventricular tachycardias in Greece.

OBJECTIVES: Supraventricular tachycardias (SVT) often lead to emergency room and primary care visits. Not only cardiologists, but also general practitioners (GPs) and internists are involved to an increasing extent in the acute and long-term management of SVT. We aimed to explore the differences between practice patterns of cardiologists and noncardiologists with regard to SVT management in Greece. METHODS: A cross-sectional questionnaire survey was conducted among 250 cardiologists and 250 GPs/internists from various areas across Greece. RESULTS: A response rate of 61.8% was obtained. Vagal maneuvers were the initial therapeutic approach for SVT termination; however, 22% of noncardiologists would rather start with an antiarrhythmic drug. Adenosine was the most popular drug for SVT termination, but the GPs/internists would use it less often than the cardiologists (67 vs. 86%, P<0.001). The GPs/internists would keep the patient for at least 24 h or more after SVT termination, while 48% of the cardiologists would discharge the patient within the first 3 h. Noncardiologists would more often suggest a 24-h Holter recording than the cardiologists (73 vs. 55%, P<0.005). With regard to the long-term management of SVT, the GPs/internists would prescribe antiarrhythmic drugs earlier than the cardiologists, and seem to be less familiar with the indications for the electrophysiological testing and ablation. CONCLUSION: Significant differences in practice patterns exist in Greece with regard to SVT management between cardiologists and noncardiologists. The GPs/internists seem to rely more on antiarrhythmic drugs and tend to underestimate the role of ablation therapy for the long-term management of SVT.