Complications of cardiac resynchronization therapy implantation: De novo implants versus upgrades.

BACKGROUND: Cardiac resynchronization therapy (CRT) is a well-established treatment of patients with advanced heart failure and electrical dyssynchrony. Implantation of those devices is in some cases associated with intervention on a formerly implanted system. The aim of this analysis was to compare the rate and type of complications of de novo implants and upgrades to CRT-D. METHODS: Retrospective data were collected from medical records, including 326 patients treated with CRT-D between 2015 and 2020. The following data were analyzed: procedure data including complications, demographics, co-morbidities, pharmacotherapy, and laboratory tests. The primary endpoint of the study was all-cause mortality. RESULTS: A total of 326 procedure were included, of which 53% (n = 172) were de novo implants and 47% (n = 154) were upgrades. The groups did not differ in the incidence of complications: in the de novo group: 25.5% (n = 44); in the upgrade group: 30.5% (n = 47), p = 0.78. The incidence of complications was also similar in respect of the following: early (p = 0.98) and late (p = 0.45), infectious (p = 0.38) and non-infectious (p = 0.82), surgical (p = 0.38) and device or lead related (p = 0.6). The most common complication in the upgrade group was pocket hematoma (n = 9, 5.8%) and in the de novo group pneumothorax (n = 8, 4.7%). CONCLUSIONS: Upgrade procedures of are not associated with a higher percentage of complications than de novo implantations of CRT-D. Previously implanted cardiac implantable electronic device should not limit the implantation of CRT-Ds.

Follow-up and characteristics of recipients of cardiac resynchronization therapy with and without a defibrillator.

BACKGROUND: Cardiac resynchronization therapy defibrillator (CRT-D) and pacemaker (CRT-P) are treatment options for patients with advanced heart failure and electrical dyssynchrony. Current guidelines provide only factors favoring, not specific recommendations as to implant CRT-D or CRT-P. This analysis aimed to compare and contrast populations of CRT-D and CRT-P recipients. METHODS: Retrospective data were collected from medical records, including 231 patients treated with either CRT-D or CRT-P between 2015 and 2019. Following data were analyzed demographics, co-morbidities, pharmacotherapy, laboratory tests, and data related to the procedure of implantation. The primary endpoint of the study was all-cause mortality. RESULTS: A total of 231 patients were included (mean age [standard deviation, SD], 64.1 [12.3] years, 76% male), of these, 13.6% (n = 32) with CRT-P and 86.4% (n = 199) with CRT-D. Mean New York Heart Association (NYHA) class did not differ between the groups: 2.23 (0.9) in CRT-P and 2.35 (0.6) in CRT-D group (P = 0.42). Mean left ventricular ejection fraction was lower in patients eligible for CRT-D: 27.1% vs. 38% (P < 0.001). Patients were followed for a median (interquartile range [IQR]) of 29 (13-44) months and survival in the CRT-P group was 84%, in CRT-D - 82% (P = 0.74). Patients in the CRT-P group were older, and more often after atrioventricular node ablation. The CRT-P group had tendency towards higher Charlton Comorbidity Index, reaching a mean of 4.66 (1.5) points vs. 3.96 (1.5) points in CRT-D (P = 0.06). CONCLUSIONS: Populations with CRT-P and CRT-D differ in terms of comorbidities; however, they have similar survival. Further studies are required to identify a group of patients, who derive a benefit from adding a defibrillator.

Shortening baroreflex delay in hypertrophic cardiomyopathy patients -- an unknown effect of ß-blockers.

AIMS: Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular hypertrophy and impaired diastolic and systolic function. Abnormal sympathetic-parasympathetic balance is a potential stimulus for left ventricular hypertrophy in HCM patients. ß-Blockers are routinely used in HCM for their strong negative inotropic effect; however, these drugs also influence the sympathetic-parasympathetic balance. This study aimed to determine the autonomic control of the cardiovascular system and the autonomic effects of ß-blockers in HCM patients treated or untreated with ß-blockers. METHODS: Among 51 HCM outpatients (18-70 years old; 29 men) there were 19 individuals with no medication and 32 subjects treated with a ß-blocker. Fourteen age- and gender-matched (23-70 years old; nine men) healthy volunteers were enrolled in the control group. Continuous, non-invasive finger blood pressure was recorded during supine rest for 30 min. Autonomic regulation of the cardiovascular system was measured by heart rate variability and spontaneous baroreflex function (cross-correlation sequence method). RESULTS: The mean pulse interval, time domain and spectral measures of heart rate variability and baroreflex sensitivity were comparable between HCM patients, treated or not with ß-blockers, and the control group. However, the delay of the baroreflex was significantly longer in HCM patients who were not treated with ß-blockers [2.0 (1.6-2.3) s] in comparison with HCM patients receiving ß-blockers [1.4 (1.1-1.8) s; P = 0.0072] or control subjects [1.2 (0.8-1.8) s; P = 0.0025]. This delay did not differ between HCM patients treated with ß-blockers and the control group. CONCLUSIONS: Hypertrophic cardiomyopathy not treated with ß-blockers is accompanied by prolonged baroreflex delay. The use of ß-blockers normalizes this delay.

Late proarrhythmia on sotalol therapy triggered by emotional stress.

We present a case of significant QTc prolongation with torsade de pointes in a female patient with a DDD pacemaker, who had been treated with an established dose of sotalol for two years. The most probable trigger factor of this adverse event was a strong emotional stress. The discontinuation of treatment with sotalol resulted in clinical recovery and QTc normalisation.

Leptin and inflammation in patients with chronic heart failure.

BACKGROUND: There is an increasing interest in the role of leptin in cardiovascular pathophysiology, including proinflammatory effects. Many studies have reported elevated leptin levels in non-cachectic patients with chronic heart failure (CHF), however, the role of leptin in CHF remains unclear. AIM: To assess the relationship between leptin levels in patients with CHF and left ventricular (LV) systolic dysfunction in relation to ventilatory response to exercise and hsCRP levels. METHODS: The study group consisted of 41 patients (mean age 50.2 ± 9.3 years) with stable CHF and LV ejection fraction < 45% and eight healthy controls (mean age 43.6 ± 14.7 years). Sixteen (39%) patients had coronary artery disease. All subjects underwent anthropometric measurements (weight, height, and waist circumference), standard echocardiography, and maximal cardiopulmonary exercise treadmill test. Biochemical analysis included the assessment of leptin and hsCRP levels as well as white blood count (WBC) and erythrocyte sedimention rate. RESULTS: Leptin levels, including body mass index (BMI)-adjusted leptin levels, were significantly higher in the CHF patients than in the controls (9.2 ± 7.5 vs 2.9 ± 1.25 ng/mL; p = 0.005). We found significantly higher WBC, neutrophil count, lymphocyte percentage and BNP levels in the CHF group vs controls. There were significant correlations in the CHF group between leptin levels and BMI (r = 0.55; p < 0.05), waist circumference (r = 0.49; p < 0.05), leukocyte count (r = 0.41; p < 0.05), hsCRP levels (r = 0.34; p < 0.05), and peak VO2 (r = -0.34; p < 0.05). Multivariate step forward regression analysis showed that peak VO2 was significantly related with leptin levels. After adding VE/VCO2 slope to the multivariate regression analysis model, only VE/VCO2 slope was independently associated with leptin levels. CONCLUSIONS: There is a significant relationship between serum leptin levels and peak VO2, VE/VCO2 slope and levels of inflammatory markers in patients with CHF.

Oxygen uptake efficiency slope correlates with brain natriuretic peptide in patients with heart failure.

BACKGROUND: Cardiopulmonary exercise testing is a well-established tool for clinical and prognostic assessment of patients with chronic heart failure (CHF). Recently, a new parameter of this examination--oxygen uptake efficiency slope (OUES)--has been described and proposed as a new prognostic factor in patients with CHF. Brain natriuretic peptide (BNP) is an established prognostic factor in CHF. The purpose of the study was to assess OUES in patients with CHF in relation to other cardiopulmonary parameters and BNP levels. METHODS: The study group consisted of 42 patients with CHF and left ventricular ejection fraction (LVEF) < 45% (mean age 50.2 +/- 9.3 years, mean ejection fraction 26.1 +/- 8.1% and NYHA functional class - 2.5 +/- 0.8) and eight healthy controls (age 43.6 +/- 14.7 years). Coronary artery disease was diagnosed in 16 patients (38%). All underwent maximal cardiopulmonary exercise treadmill test. BNP level was measured using Abbott AxSYM Immunoassay system. RESULTS: There were significant (p < 0.001) differences between the patients and controls in BNP levels (350 +/- 520 vs 14 +/- 19 pg/mL), OUES (1.7 +/- 0.4 vs 2.7 +/- 0.5), peak VO(2) (17.1 +/- +/- 5.1 vs 36.9 +/- 4.9 mL/kg/min), O(2) pulse (10.9 +/- 3.3 vs 15.9 +/- 2.7) and VE/VCO(2) slope (35.7 +/- 7.8 vs 25.7 +/- 2.7). In patients, OUES was significantly (p < 0.001) correlated with LVEF (r = 0.54), BNP levels (r = -0.49), peak VO(2) (r = 0.80), VO(2) AT (r = 0.65) and VE/VCO(2) slope (r = -0.59). BNP was independently related to OUES in multivariate regression analysis. CONCLUSIONS: Oxygen uptake efficiency slope is significantly reduced in patients with CHF and correlates with peak VO(2) and other parameters of cardiopulmonary exercise treadmill test. It is not related to age. BNP is an independent marker of OUES in patients with CHF.

[Fascicular tachycardia - a rare case of ventricular tachycardia]. / Czestoskurcz wiazkowy - rzadka forma czestoskurczu komorowego.

It is described a case of an 18 years old woman admitted to the hospital with tachycardia 160/min. Drugs routinely used for supraventricular arrhythmias and cardioversion were ineffective. Patient were transferred to the reference center. Based on careful ECG examination diagnosis was established as fascicular tachycardia. Verapamil given intravenously stopped tachycardia immediately. Location of reentry circuit within left ventricle and differential diagnosis of fascicular tachycardia as well as ECG features are described in discussion.

[Myocarditis--the first symptom of adult Still's disease]. / Zapalenie miesnia sercowego jako pierwszy objaw choroby Stilla u doroslych.

Myocardial involvement during the course of adult Still's disease is very rare. We present a case of a 34-year-old man admitted with fever, tachycardia, weakness and chest discomfort. The electrocardiogram showed non-specific diffuse ST-T changes, troponin level was slightly elevated and echocardiography did not reveal any abnormalities. After ruling out other relevant diseases, the adult Still's disease was diagnosed.

[Twiddler syndrome: a rare complication of ICD implantation]. / Twiddler syndrome - rzadkie powiklanie wszczepienia kardiowertera-defibrylatora.

Twiddler syndrome is a rare complication after pacemaker or ICD implantation. We present a case of a man who experienced 7 inappropriate ICD shocks because of this complication. Treatment included total system removal and new device implantation on the right side.

Impaired glucose tolerance worsens exercise capacity and ventilatory response to exercise in patients with chronic heart failure.

BACKGROUND: There is increasing evidence for the importance of peripheral abnormalities in the pathogenesis and progression of heart failure (HF). Recently, glucose and insulin metabolism abnormalities have been intensively investigated in patients with HF. AIM: To investigate whether coexistence of impaired glucose tolerance (IGT) may decrease exercise tolerance and influence ventilatory response to exercise in patients with systolic HF. METHODS: Maximal cardiopulmonary exercise test with evaluation of peak VO2 and VE/VCO2 slope and oral glucose tolerance test were performed in 64 clinically stable patients with HF and LVEF <45%. RESULTS: Impaired glucose tolerance was diagnosed in 26 (41%) patients and normal glucose tolerance (NGT) in 38 (59%) patients. There were no significant differences in baseline clinical characteristics or LVEF between groups. There were significant differences in peak VO2 between IGT and NGT (15.4+/-4.1 vs. 18.7+/-4.2 ml/kg/min respectively; p=0.003) and VE/VCO2 slope (35.7+/-7.3 vs. 31.8+/-5.7 respectively; p=0.02). The IGT was independently related to peak VO2 and VE/VCO2 slope in multivariate regression analysis. CONCLUSION: The IGT is associated with worse exercise capacity and ventilatory response to exercise in patients with HF.

Cytokines and heart rate variability in patients with chronic heart failure.

INTRODUCTION: Heart rate variability (HRV) analysis is a non-invasive method of assessment of the autonomic nervous system's effects on heart function. In chronic heart failure (CHF), decreased HRV correlates with the progression of the disease. It is also known that in CHF increased levels of proinflammatory cytokines are present. Because these molecules are believed to influence the nervous system at both the central and peripheral levels, their potential role in HRV reduction in the course of CHF has been proposed. AIM: The study was designed to verify potential relations between cytokines and HRV parameters in CHF patients. The concept of the study was driven by the recognition of controversies in this field and the paucity of published reports. METHODS: Forty-four patients with CHF and stable NYHA class I-IV symptoms and 15 healthy controls were enrolled in the study. Time-domain HRV analysis was performed based on of 24-hour Holter ECG monitoring. Plasma concentrations of soluble TNFalpha receptors sTNF-RI and sTNF-RII and interleukin 6 (IL-6) were measured using commercially available ELISA kits (Quantikine, RD Systems). RESULTS: In patients with CHF, HRV indices included in the analysis were significantly decreased, and the levels of cytokines increased in comparison with the control group. In the whole study population, both in the CHF patients and the control group, significant negative correlations were observed between sTNF-RI level and long-term HRV indices such as SDNN (r=-0.44; p=0.0006), SDANN (r=-0.44; p=0.0005) and short-time index SDNNI (r=-0.37; p=0.004). Similar negative correlations were found between sTNF-RII level and SDNN (r=-0.35; p=0.007), SDANN (r=-0.34; p=0.01), and SDNNI (r=-0.31; p=0.02), as well as between IL-6 level and SDNN (r=-0.41; p=0.001), SDANN (r=-0.44; p=0.0005) and SDNNI (r=-0.34; p=0.009). CONCLUSIONS: Significant negative correlations between TNF-alpha soluble receptors sTNF-RI, sTNF-RII and IL-6 levels and time-domain HRV parameters were observed in the study. Because the results of investigations conducted so far do not elucidate the cause-effect relationship, further studies are needed to clarify the mechanisms of HRV depression in CHF and the role of cytokines in this severe clinical condition.

[Cardiopulmonary exercise testing and cytokines in chronic heart failure. Comparison of patients with ischaemic and with dilated cardiomyopathy]. / Wyniki testu spiroergometrycznego i wartosci wybranych wskazników odczynu zapalnego u chorych z przewlekla niewydolnoscia serca. Porównanie chorych z kardiomiopatia niedokrwienna i rozstrzeniowa.

Heart failure (HF) is a complex clinical syndrome due to ischaemic heart disease, idiopathic cardiomyopathy, hypertension, valve heart disease and others. It is not clear if the etiology of HF influences decreased in this syndrome exercise tolerance. Controversial is also dependence of cytokine levels on etiology of HF. The aim of the study was to compare exercise capacity and cytokines levels in pts with ischaemic and dilated cardiomyopathy. We analyzed circulating levels of TNF-alpha and its soluble receptors sTNF-RI and sTNF-RII, and interleukin-1beta (IL-1beta), and interleukin-6 (IL-6) in 41 pts with CHF, functional class NYHA I-IV, mean EF--25.2 +/- 7.1%. For determination of cytokines level (using R & D System tests) venous blood was withdrawn after 30 minutes of supine rest. All underwent echocardiography and cardiopulmonary exercise stress testing. Dilated cardiomyopathy (DCM) was diagnosed in 21 pts, ischaemic (ICM) in 20 pts. Pts with DCM were younger then with ICM (48 +/- 6.6 vs 56 +/- 6.6 yrs; p = 0.001). There were no significant differences between groups concerning BMI and EF. There were no significant differences in the level of TNF-alpha and sTNF-RI between groups. There was a trend of increased sTNF-RII in pts with ICM (3179.7 +/- 832.7 vs 2699 +/- 680.1 pg/ml; p = 0,07), IL-1beta (2.55 +/- 2.41 vs 1.49 +/- 1.68 pg/ml; p = 0.087) and IL-6 (6.25 +/- 2.21 vs 4.98 +/- 3.64 pg/ml; p = 0.065), and significant increased ESR (11.2 +/- 9.5 vs 5.5 +/- 4.7 mm/h; p = 0.04). Peak VO2 was reduced in pts with ICM group as compared to those with DCM (14.1 +/- 3.7 vs 18.1 +/- 4.8 ml/kg/min; p = 0.0069). In chronic heart failure circulating levels of cytokines tended to be higher in pts with ischaemic origin of the syndrome. The exercise capacity is lower in ischaemic cardiomyopathy.