RESUMO
OBJECTIVE: To develop and validate a prognostic risk index of cardiovascular mortality after cardiac resynchronisation therapy (CRT). DESIGN: Prospective cohort study. SETTING: District general hospital. PATIENTS: 148 patients with heart failure (mean age 66.7 (SD 10.4) years), New York Heart Association class III or IV, LVEF <35%) who underwent CRT. INTERVENTIONS: CRT device implantation. MAIN OUTCOME MEASURES: Value of a composite index in predicting cardiovascular mortality, validated internally by bootstrapping. The predictive value of the index was compared to factors that are known to predict mortality in patients with heart failure. RESULTS: All patients underwent assessment of 16 prognostic risk factors, including cardiovascular magnetic resonance (CMR) measures of myocardial scarring (gadolinium-hyperenhancement) and dyssynchrony, before implantation. Clinical events were assessed after a median follow-up of 913 (interquartile range 967) days. At follow-up, 37/148 (25%) of patients died from cardiovascular causes. In Cox proportional hazards analyses, (DSC) Dyssynchrony, posterolateral Scar location (both p<0.0001) and Creatinine (p = 0.0046) emerged as independent predictors of cardiovascular mortality. The DSC index, derived from these variables combined, emerged as a powerful predictor of cardiovascular mortality. Compared to patients with a DSC <3, cardiovascular mortality in patients in the intermediate DSC index (3-5; HR: 11.1 (95% confidence interval (CI) 3.00 to 41.1), p = 0.0003) and high DSC index (> or =5; HR: 30.5 (95% CI 9.15 to 101.8), p<0.0001) were higher. Bootstrap validation confirmed excellent calibration and internal validity of the prediction model. CONCLUSION: The DSC index, derived from a standard CMR scan and plasma creatinine before implantation, is a powerful predictor of cardiovascular mortality after CRT.
Assuntos
Estimulação Cardíaca Artificial/mortalidade , Insuficiência Cardíaca/mortalidade , Índice de Gravidade de Doença , Idoso , Feminino , Insuficiência Cardíaca/patologia , Insuficiência Cardíaca/terapia , Humanos , Imageamento por Ressonância Magnética , Masculino , Estudos Prospectivos , Medição de RiscoRESUMO
OBJECTIVE: To compare the effects of cardiac resynchronisation therapy (CRT) in patients with heart failure (HF) in either atrial fibrillation (AF) or sinus rhythm (SR). DESIGN: Prospective observational study. PATIENTS: 295 consecutive patients with HF (permanent AF in 66, paroxysmal AF in 20, SR in 209; New York Heart Association (NYHA) class III or IV; left ventricular ejection fraction (LVEF)
Assuntos
Fibrilação Atrial/terapia , Estimulação Cardíaca Artificial/métodos , Insuficiência Cardíaca/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/etiologia , Fibrilação Atrial/fisiopatologia , Progressão da Doença , Métodos Epidemiológicos , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/fisiopatologia , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Volume Sistólico , Resultado do Tratamento , UltrassonografiaRESUMO
OBJECTIVES: To determine the effect of a posterolateral (PL) left ventricular scar on mortality and morbidity following cardiac resynchronization therapy (CRT). METHODS: Sixty-two patients with heart failure (age 67.3 +/- 9.6 yrs [mean +/- SD], 45 males, New York Heart Association class [NYHA] class III or IV, left ventricular ejection fraction [LVEF]= 35%, left bundle branch block, QRS > or = 120 ms) underwent late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) for scar imaging. Patients were followed up for 741 (75-1602) days (mean [range]). RESULTS: The presence of a PL scar emerged as an independent predictor of the composite endpoint of cardiovascular death or hospitalization for worsening heart failure (HR: 3.06 [1.63, 7.7, P < 0.0001]) as well as the endpoint of cardiovascular death (HR: 2.63 [1.39, 6.65], P = 0.0016). A transmural PL scar was the strongest predictor of these endpoints (both P < 0.0001). The symptomatic responder rate (improvement by > or =1 NYHA classes or > or =25% in 6-min walking distance) was 83% in the group with non-PL scars, but only 47% in the group with transmural PL scars (P < 0.0001). Pacing over the scar was associated with a higher mortality and morbidity than pacing outside the scar (all P < 0.05). CONCLUSIONS: A PL scar is associated with a worse clinical outcome following CRT, particularly if it is transmural. Pacing scarred left ventricular myocardium carries a greater risk of mortality and morbidity than pacing nonscarred myocardium.
Assuntos
Estimulação Cardíaca Artificial/efeitos adversos , Estimulação Cardíaca Artificial/mortalidade , Ventrículos do Coração/patologia , Idoso , Bloqueio de Ramo/patologia , Cicatriz/patologia , Ecocardiografia , Feminino , Seguimentos , Insuficiência Cardíaca/complicações , Humanos , Imageamento por Ressonância Magnética , Masculino , Marca-Passo Artificial , Volume SistólicoRESUMO
Left ventricular (LV) lead displacement is an early complication of biventricular pacemakers and leads to loss of capture, diaphragmatic pacing, and symptomatic deterioration, requiring a revision procedure. We report a case of late LV lead displacement following a coughing fit and treatment with a lead with a new principle of active fixation.