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1.
Can J Cardiol ; 2019 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-31492494

RESUMO

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has revolutionized the management of severe aortic stenosis. The development of a new-onset complete left bundle branch block (LBBB) is, however, a frequent complication. The objective of the present study was to assess the impact of a new-onset LBBB after TAVI on the evolution of left ventricular ejection fraction (LVEF). METHODS: Forty consecutive patients were included after the development of a new-onset LBBB after TAVI and were matched for age and LVEF with 40 patients implanted during the same period who did not develop an LBBB. The primary endpoint was evolution of the LVEF measured by echocardiography before implantation and between 6 and 12 months after TAVI. RESULTS: The development of an LBBB was associated with a 5-point decrease in LVEF [-12.5; 2.5], contrary to the non-LBBB group (1.5 [-6.5; 9.5], P = 0.007) at 8 months, with the persistence of the LBBB (n = 23) exacerbating this decrease (-7 [-13; 2], P = 0.009). When left ventricular dysfunction (LVEF < 50%) was present before TAVI, the appearance of an LBBB was associated with a reduction in LVEF (-2 [-8; 2]) contrary to the non-LBBB group (20 [9; 22], P = 0.02). CONCLUSIONS: The appearance of a new-onset LBBB after TAVI has a pejorative impact on left ventricular systolic function, particularly in patients with an initial LVEF < 50%, due to a lack of recovery of the latter, thereby potentially affecting their prognosis.

2.
JACC Clin Electrophysiol ; 5(8): 944-954, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31439296

RESUMO

OBJECTIVES: This study aimed to evaluate incidence, clinical significance, and predictors of early ventricular arrhythmias (VAs) in left ventricular assist device (LVAD) recipients. BACKGROUND: LVAD implantation is increasingly used in patients with end-stage heart failure. Early VAs may occur during the 30-day post-operative period, but many questions remain unanswered regarding their incidence and clinical impact. METHODS: This observational study was conducted in 19 centers between 2006 and 2016. Early VAs were defined as sustained ventricular tachycardia and/or ventricular fibrillation occurring <30 days post-LVAD implantation and requiring appropriate implantable cardioverter-defibrillator therapy, external electrical shock, or medical therapy. RESULTS: A total of 652 patients (median age: 59.8 years; left ventricular ejection fraction: 20.7 ± 7.4%; HeartMate 2: 72.8%; HeartWare: 19.5%; Jarvik 2000: 7.7%) were included in the analysis. Early VAs occurred in 162 patients (24.8%), most frequently during the first week after LVAD implantation. Multivariable analysis identified history of VAs prior to LVAD and any combined surgery with LVAD as 2 predictors of early VAs. The occurrence of early VAs with electrical storm was the strongest predictor of 30-day post-operative mortality, associated with a 7-fold increase of 30-day mortality. However, in patients discharged alive from hospital, occurrence of early VAs did not influence long-term survival. CONCLUSIONS: Early VAs are common after LVAD implantation and increase 30-day post-operative mortality, without affecting long-term survival. Further studies will be needed to analyze whether pre- or pre-operative ablation of VAs may improve post-operative outcomes. (Determination of Risk Factors of Ventricular Arrhythmias After Implantation of Continuous Flow Left Ventricular Assist Device With Continuous Flow Left Ventricular Assist Device [ASSIST-ICD]; NCT02873169).

3.
Europace ; 21(9): 1400-1409, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31177270

RESUMO

AIMS: There is currently no reliable tool to quantify the risks of ventricular fibrillation or sudden cardiac arrest (VF/SCA) in patients with spontaneous Brugada type 1 pattern (BrT1). Previous studies showed that electrocardiographic (ECG) markers of depolarization or repolarization disorders might indicate elevated risk. We aimed to design a VF/SCA risk prediction model based on ECG analyses for adult patients with spontaneous BrT1. METHODS AND RESULTS: This retrospective multicentre international study analysed ECG data from 115 patients (mean age 45.1 ± 12.8 years, 105 males) with spontaneous BrT1. Of these, 45 patients had experienced VF/SCA and 70 patients did not experience VF/SCA. Among 10 ECG markers, a univariate analysis showed significant associations between VF/SCA and maximum corrected Tpeak-Tend intervals ≥100 ms in precordial leads (LMaxTpec) (P < 0.001), BrT1 in a peripheral lead (pT1) (P = 0.004), early repolarization in inferolateral leads (ER) (P < 0.001), and QRS duration ≥120 ms in lead V2 (P = 0.002). The Cox multivariate analysis revealed four predictors of VF/SCA: the LMaxTpec [hazard ratio (HR) 8.3, 95% confidence interval (CI) 2.4-28.5; P < 0.001], LMaxTpec + ER (HR 14.9, 95% CI 4.2-53.1; P < 0.001), LMaxTpec + pT1 (HR 17.2, 95% CI 4.1-72; P < 0.001), and LMaxTpec + pT1 + ER (HR 23.5, 95% CI 6-93; P < 0.001). Our multidimensional penalized spline model predicted the 1-year risk of VF/SCA, based on age and these markers. CONCLUSION: LMaxTpec and its association with pT1 and/or ER indicated elevated VF/SCA risk in adult patients with spontaneous BrT1. We successfully developed a simple risk prediction model based on age and these ECG markers.

4.
Am Heart J ; 214: 69-76, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31174053

RESUMO

BACKGROUND: Left ventricular assist device (LVAD)-associated infections may be life-threatening and impact patients' outcome. We aimed to identify the characteristics, risk factors, and prognosis of LVAD-associated infections. METHODS: Patients included in the ASSIST-ICD study (19 centers) were enrolled. The main outcome was the occurrence of LVAD-associated infection (driveline infection, pocket infection, or pump/cannula infection) during follow-up. RESULTS: Of the 652 patients enrolled, 201 (30.1%) presented a total of 248 LVAD infections diagnosed 6.5 months after implantation, including 171 (26.2%), 51 (7.8%), and 26 (4.0%) percutaneous driveline infection, pocket infection, or pump/cannula infection, respectively. Patients with infections were aged 58.7 years, and most received HeartMate II (82.1%) or HeartWare (13.4%). Most patients (62%) had implantable cardioverter-defibrillators (ICDs) before LVAD, and 104 (16.0%) had ICD implantation, extraction, or replacement after the LVAD surgery. Main pathogens found among the 248 infections were Staphylococcus aureus (n = 113' 45.4%), Enterobacteriaceae (n = 61; 24.6%), Pseudomonas aeruginosa (n = 34; 13.7%), coagulase-negative staphylococci (n = 13; 5.2%), and Candida species (n = 13; 5.2%). In multivariable analysis, HeartMate II (subhazard ratio, 1.56; 95% CI, 1.03 to 2.36; P = .031) and ICD-related procedures post-LVAD (subhazard ratio, 1.43; 95% CI, 1.03-1.98; P = .031) were significantly associated with LVAD infections. Infections had no detrimental impact on survival. CONCLUSIONS: Left ventricular assist device-associated infections affect one-third of LVAD recipients, mostly related to skin pathogens and gram-negative bacilli, with increased risk with HeartMate II as compared with HeartWare, and in patients who required ICD-related procedures post-LVAD. This is a plea to better select patients needing ICD implantation/replacement after LVAD implantation.

5.
Sci Rep ; 9(1): 6103, 2019 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-30988339

RESUMO

Cardiac fibrosis is associated with heart failure and poor prognosis. Fibrosis biomarkers have been poorly evaluated as a tool to predict cardiac resynchronization therapy (CRT) response generating conflicting results. The present study assessed the predictive value of cardiac fibrosis biomarkers on CRT response. Patients underwent clinical examination, echocardiography and blood fibrosis biomarker evaluation prior to CRT implantation. At six months, a positive response to CRT was defined by a composite endpoint of no death or hospitalization for heart failure, and presence of left ventricular (LV) reverse remodeling (decrease in LV end-systolic volume ≥15%). Sixty patients were included in a multicenter study. At 6 months, 38 were positive responders to CRT and reached the response criteria (63%). Compared to non-responders, CRT responders displayed lower concentration levels of the fibrosis biomarkers procollagen type I C-terminal propeptide [PICP 135[99-166] ng/ml vs. 179[142-226]ng/ml, p = 0.001)] and procollagen type III N-terminal propeptide [PIIINP 5.50[3.66-8.96] ng/ml vs. 8.01[5.01-11.86]ng/ml, p = 0.014)] at baseline. In multivariate analysis, a PICP ≤ 163 ng/ml was associated with a positive CRT response [OR = 7.8(1.3-46.7), p = 0.023] independently of the presence of LBBB, QRS duration, LV lead position or non-ischemic cardiomyopathy. Altogether, the present findings show that a lower degree of cardiac fibrosis is associated with a positive response after CRT implantation. PICP evaluation before CRT implantation could help improve patient selection.

6.
Arch Cardiovasc Dis ; 112(3): 162-170, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30655226

RESUMO

BACKGROUND: Immediate improvement in kidney function has been reported after surgical aortic valve replacement or transcatheter aortic valve implantation. Long-term data, however, are not available. AIM: To assess the evolution of kidney function in chronic kidney disease stage 3b-5, 1 year after surgical aortic valve replacement or transcatheter aortic valve implantation. METHODS: All patients with chronic kidney disease stage 3b-5 undergoing surgical aortic valve replacement or transcatheter aortic valve implantation for aortic stenosis in a single centre were included. Kidney function was assessed 1 year postprocedure. Improvement or deterioration in estimated glomerular filtration rate was defined by an increase or decrease of 5mL/min/1.73 m2, respectively. RESULTS: Overall, 127 procedures were analysed (54 surgical aortic valve replacements and 73 transcatheter aortic valve implantations). Kidney function improved in 51% of patients at 1 year (45% of the surgical aortic valve replacement group versus 57% of the transcatheter aortic valve implantation group; P=0.21), and deteriorated in only 14% of patients at 1 year (18% of the surgical aortic valve replacement group versus 10% of the transcatheter aortic valve implantation group; P=0.22). Almost a quarter of patients (23%) had an improvement in estimated glomerular filtration rate of>15mL/min/1.73 m2, and this was consistent at later follow-up. Few patients went onto chronic dialysis at 1 year (three after surgical aortic valve replacement and one after transcatheter aortic valve implantation). Acute kidney injury was an independent prognostic factor for long-term deterioration in kidney function (odds ratio 2.1, 95% confidence interval 1.4-3.6; P=0.006). CONCLUSION: Aortic valve replacement, whether by surgical aortic valve replacement or transcatheter aortic valve implantation, improved estimated glomerular filtration rate at 1 year in more than half of patients with chronic kidney disease stage 3b-5.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Taxa de Filtração Glomerular , Implante de Prótese de Valva Cardíaca , Rim/fisiopatologia , Insuficiência Renal Crônica/fisiopatologia , Substituição da Valva Aórtica Transcateter , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Masculino , Recuperação de Função Fisiológica , Sistema de Registros , Insuficiência Renal Crônica/diagnóstico , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento
7.
ESC Heart Fail ; 2018 Nov 20.
Artigo em Inglês | MEDLINE | ID: mdl-30460754

RESUMO

AIMS: Myocardial fibrosis plays a key role in the development of adverse left ventricular remodelling after myocardial infarction (MI). This study aimed to determine whether the circulating levels of BNP, collagen peptides, and galectin-3 are associated with diastolic function evolution (both deterioration and improvement) at 1 year after an anterior MI. METHODS AND RESULTS: The REVE-2 is a prospective multicentre study including 246 patients with a first anterior Q-wave MI. Echocardiographic assessment was performed at hospital discharge and ±1 year after MI. BNP, galectin-3, and collagen peptides were measured ±1 month after MI. Left ventricular diastolic dysfunction (DD) was defined according to the presence of at least two criteria of echocardiographic parameters: septal e' < 8 cm/s, lateral e' < 10 cm/s, and left atrial volume ≥ 34 mL/m2 . At baseline, 87 (35.4%) patients had normal diastolic function and 159 (64.6%) patients had DD. Follow-up of 61 patients among the 87 patients with normal diastolic function at baseline showed that 22 patients (36%) developed DD at 1 year post-MI. The circulating levels of amino-terminal propeptide of type III procollagen > 6 mg/L [odds ratio (OR) = 5.29; 95% confidence interval (CI) = 1.05-26.66; P = 0.044], galectin-3 > 13 µg/L (OR = 5.99; 95% CI = 1.18-30.45; P = 0.031), and BNP > 82 ng/L (OR = 10.25; 95% CI = 2.36-44.50; P = 0.002) quantified at 1 month post-MI were independently associated with 1 year DD. Follow-up of the 137 patients with DD at baseline among the 159 patients showed that 36 patients (26%) had a normalized diastolic function at 1 year post-MI. Patients with a BNP > 82 ng/L were less likely to improve diastolic function (OR = 0.06; 95% CI = 0.01-0.28; P = 0.0003). CONCLUSIONS: The present study suggests that circulating levels of amino-terminal propeptide of type III procollagen, galectin-3, and BNP may be independently associated with new-onset DD in post-MI patients.

8.
JACC Clin Electrophysiol ; 4(9): 1166-1175, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30236390

RESUMO

OBJECTIVES: This study aimed to evaluate the incidence, clinical impact, and predictors of late ventricular arrhythmias (VAs) in left ventricular assist device (LVAD) recipients aiming to clarify implantable cardioverter-defibrillator (ICD) indications. BACKGROUND: The arrhythmic risk and need for ICD in patients implanted with an LVAD are not very well known. METHODS: This observational study was conducted in 19 centers between 2006 and 2016. Late VAs were defined as sustained ventricular tachycardia or fibrillation occurring >30 days post-LVAD implantation, without acute reversible cause and requiring appropriate ICD therapy, external electrical shock, or medical therapy. RESULTS: Among 659 LVAD recipients, 494 (median 58.9 years of age; mean left ventricular ejection fraction 20.7 ± 7.4%; 73.1% HeartMate II, 18.6% HeartWare, 8.3% Jarvik 2000) were discharged alive from hospital and included in the final analysis. Late VAs occurred in 133 (26.9%) patients. Multivariable analysis identified 6 independent predictors of late VAs: VAs before LVAD implantation, atrial fibrillation before LVAD implantation, idiopathic etiology of the cardiomyopathy, heart failure duration >12 months, early VAs (<30 days post-LVAD), and no angiotensin-converting enzyme inhibitors during follow-up. The "VT-LVAD score" was created, identifying 4 risk groups: low (score 0 to 1), intermediate (score 2 to 4), high (score 5 to 6), and very high (score 7 to 10). The rates of VAs at 1 year were 0.0%, 8.0%, 31.0% and 55.0%, respectively. CONCLUSIONS: Late VAs are common after LVAD implantation. The VT-LVAD score may help to identify patients at risk of late VAs and guide ICD indications in previously nonimplanted patients. (Determination of Risk Factors of Ventricular Arrhythmias [VAs] after implantation of continuous flow left ventricular assist device with continuous flow left ventricular assist device [CF-LVAD] [ASSIST-ICD]; NCT02873169).

10.
Int J Cardiol ; 270: 143-148, 2018 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-29895424

RESUMO

BACKGROUND: Electrocardiographic mapping (ECM) expresses electrical substrate through magnitude and direction of the activation delay vector (ADV). We investigated to what extent the response to cardiac resynchronization therapy (CRT) is determined by baseline ADV and by ADV modification through CRT and optimization of left ventricular (LV) pacing site. METHODS: ECM was performed in 79 heart failure patients (4 RBBB, 12 QRS < 120 ms, 23 non-specific conduction delay [NICD] and 40 left bundle branch block [LBBB]). 67 patients (QRS ≥ 120 ms) underwent CRT implantation and in 26 patients multiple LV pacing site optimization was performed. ADV was calculated from locations/depolarization times of 2000 virtual epicardial electrodes derived from ECM. Acute response was defined as ≥10% LVdP/dtmax increase, chronic response by composite clinical score at 6 months. RESULTS: During intrinsic conduction, ADV direction was similar in patients with QRS < 120 ms, NICD and LBBB, pointing towards the LV free wall, while ADV magnitude was larger in LBBB (117 ±â€¯25 ms) than in NICD (70 ±â€¯29 ms, P < 0.05) and QRS < 120 ms (52 ±â€¯14 ms, P < 0.05). Intrinsic ADV accurately predicted the acute (AUC = 0.93) and chronic (AUC = 0.90) response to CRT. ADV change by CRT only moderately predicted response (highest AUC = 0.76). LV pacing site optimization had limited effects: +3 ±â€¯4% LVdP/dtmax when compared to conventional basolateral LV pacing. CONCLUSION: The baseline electrical substrate, adequately measured by ADV amplitude, strongly determines acute and chronic CRT response, while the extent of its modification by conventional CRT or by varying LV pacing sites has limited effects.

11.
Int J Clin Pharmacol Ther ; 56(8): 347-357, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29792395

RESUMO

OBJECTIVE: The aim of this study was to assess the adherence of general practitioners (GPs) to guidelines in patients with heart failure with reduced ejection fraction (HFrEF) and to describe GPs' prescribing behavior regarding patients with heart failure with preserved ejection fraction (HFpEF). MATERIALS AND METHODS: Cross-sectional study as part of the ETIC trial. Five classes of drugs were described: angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs); ß-blockers (BBs); mineralocorticoid receptor antagonists (MRAs); diuretics (thiazide or loop diuretics); and digoxin. RESULTS: 178 patients were studied: their mean age was 73.5 years (± 10.6). Of the 128 patients with HFpEF, 81.3% received ACEIs or ARBs, 63.3% received BBs, 13.3% received MRAs, 75.8% received diuretics, and 12.5% received digoxin. Of the 50 patients with HFrEF, 84% received ACEIs or ARBs, 74% received BBs, 20% received MRAs, 76% received diuretics, and 2% received digoxin. 25% of the patients were given a drug in accordance with the recommendations for drug class but not a drug authorized for the HFrEF indication. Among the patients with HFrEF who were treated in accordance with the recommendations, target doses were achieved in 1/3 given ACEIs/ARBs, 1/4 given BBs, and 1/2 given MRAs. Only 6% of the patients had a perfect Global Adherence Indicator-3 (GAI-3) with all target doses achieved. CONCLUSION: Several drugs were prescribed even though they were not recommended, and few patients were treated optimally. It seems to be necessary to develop a pragmatic tool to help GPs and cardiologists in optimizing treatment.
.


Assuntos
Insuficiência Cardíaca/terapia , Atenção Primária à Saúde , Idoso , Idoso de 80 Anos ou mais , Cardiologistas , Fármacos Cardiovasculares/uso terapêutico , Estudos Transversais , Uso de Medicamentos , Feminino , Clínicos Gerais , Fidelidade a Diretrizes , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Volume Sistólico , Resultado do Tratamento
12.
Heart Rhythm ; 15(5): 642-650, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29709229

RESUMO

BACKGROUND: The subcutaneous implantable cardioverter-defibrillator (S-ICD) remains a new technology requiring accurate assessment of the various aspects of its functioning. Isolated cases of delayed sensing of ventricular arrhythmia have been described. OBJECTIVE: The purpose of this multicenter study was to assess the quality of sensing during induced ventricular fibrillation (VF). METHODS: One hundred thirty-seven patients underwent induction of VF at the end of the S-ICD implantation. RESULTS: VF induction was successful in 133 patients (97%). Mean time to first therapy was 16.2 ± 3.1 seconds, with a substantial range from 12.5 to 27.0 seconds. Four different detection profiles were arbitrarily defined: (1) optimal detection (n = 39 [29%]); (2) undersensing with moderate prolongation of time to therapy (<18 seconds; n = 68 [51%]); (3) undersensing with significant prolongation of the time to therapy (>18 seconds; n = 19 [14%]); and (4) absence of therapy or prolonged time to therapy related to noise oversensing (n = 7 [6%]). In some of the patients in the last group, despite induction of VF the initial counter was never filled, the device did not charge the capacitors, and the shock was not delivered because of a sustained diagnosis of noise (n = 5). A manual shock by the device or an external shock had to be delivered to restore the sinus rhythm. CONCLUSION: Our study demonstrated a marked sensing delay leading to prolonged time to therapy in a large number of S-ICD patients. A few worrisome cases of noise oversensing inhibiting the therapies were detected. These results support the need for systematic intraoperative defibrillation testing.

14.
Clin Nutr ; 2018 Mar 02.
Artigo em Inglês | MEDLINE | ID: mdl-29525512

RESUMO

BACKGROUND & AIMS: There is an increase in the number of patients worldwide with cardiac implantable electronic devices (CIEDs). Current medical practice guidelines warn against performing bioimpedance analysis (BIA) in this group of patients in order to avoid any electromagnetic interference. These recommendations restrict using the BIA in patients undergoing heart failure or with nutrition disorders in whom BIA could be of major interest in detecting peripheral congestion and to help guide treatment. The present study was conducted to evaluate whether BIA caused electromagnetic interference in patients having CIEDs. METHODS: Patient enrollment was conducted during routine face-to-face consultations for scheduled CIEDs interrogations. Device battery voltage, lead impedance, pacing thresholds and device electrograms were recorded before and after each BIA measurement to detect any electromagnetic interference or oversensing. RESULTS: A total of 200 patients were enrolled. During BIA, no significant changes in battery voltage, lead impedance or pacing thresholds were detected, nor were there any inappropriate over- or undersensing observed in intracardiac electrograms. Furthermore, 6- and 12-month follow-up did not reveal any changes in CIEDs. CONCLUSIONS: This study shows no interference in patients equipped with CIEDs and suggests that BIA can be securely performed in these patients. Trial registered under the identifier NCT03045822.

15.
Am J Cardiol ; 121(6): 725-730, 2018 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-29402420

RESUMO

Prognosis of heart failure with reduced ejection fraction (HFrEF) is improved by drug optimization according to guidelines; however, little is known regarding such optimization in HFrEF patients with an implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT). This study aimed to describe implementation of this optimized strategy and its impact in patients implanted with an ICD/CRT. Using a 1/97th representative sample of the French national health-care insurance system claims database, a retrospective cohort study was conducted including HFrEF patients implanted with ICD or CRT between January 2009 and December 2014. HFrEF treatments were analyzed before and after ICD/CRT implantation. Heart failure (HF) hospitalization and survival were examined at 1, 3, and 5 years: 378 patients (135 CRT, 243 ICD) with a mean age of 68 ± 13 years were included. Mean follow-up was 23 months [11-42]. At baseline, 36% of patients had no or only 1 HFrEF drug among ß-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and mineralocorticoid receptor antagonists, whereas 26% of patients received an optimal treatment (all 3 classes). At 3 months after ICD/CRT implantation, the prescription rate of HFrEF drugs was higher than baseline but returned to preimplantation levels at the end of follow-up. HF hospitalization rate was higher in the nonoptimized patient group (28% vs 14%, p = 0.001). Optimal HFrEF treatment was associated with better survival (hazard ratio = 0.59 [0.4-0.86], p = 0.006). In conclusion, HFrEF drugs are underprescribed before and after ICD/CRT implantation despite the demonstration that HFrEF drug optimization also reduces death and HF hospitalization in this population.

16.
Circ J ; 82(3): 783-790, 2018 Feb 23.
Artigo em Inglês | MEDLINE | ID: mdl-29199266

RESUMO

BACKGROUND: Spontaneous reanalyzed coronary thrombus (SRCT) has been reported in autopsy series, but little is known about SRCT, and it is potentially under-diagnosed in clinical practice.Methods and Results:SRCT identified on OCT were included in a French multicenter series, the Lotus Root French Registry. A total of 34 SRCT were identified on OCT in 33 patients (23 male; median age, 56 years; IQR, 52-65 years); 23/33 patients (70%) presented with angina pectoris and/or dyspnea. Three angiographic aspects were distinguished retrospectively: braided, pseudo-dissected, and hazy. Stenosis severity on quantitative coronary analysis varied between 11% and 100% (median, 45%), whereas the reduction in lumen area on OCT varied between 20% and 92% (median, 68%). A typical "lotus root" aspect was confirmed on OCT, consisting of multiple circular concave-edged channels of varying size, numbering between 3 and 12 depending on the slice, separated by smooth-edged septa of high luminosity without posterior attenuation. OCT also served to guide treatment, with stenting in 91% of cases. During the 17-month follow-up 91% of patients had excellent evolution. One death and 3 ACS events occurred. CONCLUSIONS: In this large SRCT cohort, angiography had limited diagnostic value whereas OCT could be used to define disease characteristics and guide treatment of lesions inducing angina pectoris and/or silent myocardial ischemia. OCT-guided management was associated with good prognosis.

17.
Artigo em Inglês | MEDLINE | ID: mdl-28630171

RESUMO

BACKGROUND: In contrast to patients with left bundle branch block (LBBB), heart failure patients with narrow QRS and nonspecific intraventricular conduction delay (NICD) display a relatively limited response to cardiac resynchronization therapy. We sought to compare left ventricular (LV) activation patterns in heart failure patients with narrow QRS and NICD to patients with LBBB using high-density electroanatomic activation maps. METHODS AND RESULTS: Fifty-two heart failure patients (narrow QRS [n=18], LBBB [n=11], NICD [n=23]) underwent 3-dimensional electroanatomic mapping with a high density of mapping points (387±349 LV). Adjunctive scar imaging was available in 37 (71%) patients and was analyzed in relation to activation maps. LBBB patients typically demonstrated (1) a single LV breakthrough at the septum (38±15 ms post-QRS onset); (2) prolonged right-to-left transseptal activation with absence of direct LV Purkinje activity; (3) homogeneous propagation within the LV cavity; and (4) latest activation at the basal lateral LV. In comparison, both NICD and narrow QRS patients demonstrated (1) multiple LV breakthroughs along the posterior or anterior fascicles: narrow QRS versus LBBB, 5±2 versus 1±1; P=0.0004; NICD versus LBBB, 4±2 versus 1±1; P=0.001); (2) evidence of early/pre-QRS LV electrograms with Purkinje potentials; (3) rapid propagation in narrow QRS patients and more heterogeneous propagation in NICD patients; and (4) presence of limited areas of late activation associated with LV scar with high interindividual heterogeneity. CONCLUSIONS: In contrast to LBBB patients, narrow QRS and NICD patients are characterized by distinct mechanisms of LV activation, which may predict poor response to cardiac resynchronization therapy.


Assuntos
Arritmias Cardíacas/diagnóstico , Bloqueio de Ramo/diagnóstico , Eletrocardiografia , Técnicas Eletrofisiológicas Cardíacas , Sistema de Condução Cardíaco/fisiopatologia , Insuficiência Cardíaca/complicações , Ventrículos do Coração/fisiopatologia , Disfunção Ventricular Esquerda/diagnóstico , Função Ventricular Esquerda , Potenciais de Ação , Adulto , Idoso , Arritmias Cardíacas/etiologia , Arritmias Cardíacas/fisiopatologia , Arritmias Cardíacas/terapia , Bloqueio de Ramo/fisiopatologia , Terapia de Ressincronização Cardíaca , Mapeamento Epicárdico , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Frequência Cardíaca , Ventrículos do Coração/diagnóstico por imagem , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Seleção de Pacientes , Valor Preditivo dos Testes , Volume Sistólico , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/terapia
18.
Heart Rhythm ; 14(7): 1008-1015, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28323174

RESUMO

BACKGROUND: The SecureSense right ventricular (RV) lead noise discrimination algorithm is designed to detect lead fracture and other types of oversensing in order to decrease inappropriate therapy. OBJECTIVE: We studied the real-life accuracy of the SecureSense algorithm in implantable cardioverter-defibrillator (ICD) patients followed by remote monitoring across multiple centers. METHODS: Across 3 French centers, we studied 486 patients with a St Jude Medical device who were followed by remote monitoring and who had the SecureSense algorithm activated. We reviewed ≤10 of the most recent remote monitoring-transmitted electrograms of nonsustained oversensing, RV lead noise, and ventricular tachycardia/ventricular fibrillation that received therapy. RESULTS: SecureSense inhibited 22 inappropriate therapies (lead dysfunction in 10 cases, P-wave oversensing in 12 cases). A total of 57 patients (12%) sent ≥1 nonsustained oversensing episode (total of 393 episodes) with multiple etiologies: noise on the near-field channel (38%), oversensing of T waves during ventricular pacing (33%), oversensing of the sinus P wave (12%), and oversensing of the paced P wave (6%). Two episodes (0.5%) of nonsustained VT were undersensed by the far-field channel. Of 336 analyzed episodes of ventricular tachyarrhythmia, 15 episodes (4%) in 4 patients were related to oversensing of intrinsic P waves in 11 episodes or oversensing of external noise due to electrical cautery for the remaining 4 episodes. CONCLUSION: Of ICD patients equipped with SecureSense, 12% developed episodes of oversensing. The SecureSense algorithm prevented inappropriate ICD therapies with accurate diagnosis of oversensing (caused by lead dysfunction or oversensing of physiological signals). P-wave oversensing in integrated bipolar leads, electrical cautery, and electromagnetic interference are prone to be missed by SecureSense.


Assuntos
Desfibriladores Implantáveis/efeitos adversos , Erros de Diagnóstico/prevenção & controle , Cardioversão Elétrica , Eletrocardiografia Ambulatorial , Taquicardia Ventricular , Fibrilação Ventricular , Idoso , Algoritmos , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/métodos , Eletrocardiografia Ambulatorial/efeitos adversos , Eletrocardiografia Ambulatorial/métodos , Falha de Equipamento , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Tecnologia de Sensoriamento Remoto/efeitos adversos , Tecnologia de Sensoriamento Remoto/métodos , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/terapia , Fibrilação Ventricular/diagnóstico , Fibrilação Ventricular/terapia
19.
EuroIntervention ; 13(4): 397-406, 2017 Jul 20.
Artigo em Inglês | MEDLINE | ID: mdl-28067196

RESUMO

AIMS: The aim of this study was to demonstrate the feasibility and safety of ST-elevation myocardial infarction (STEMI) management in young patients by limiting implantation of durable intracoronary devices (using a bioresorbable stent or medical treatment alone). METHODS AND RESULTS: Patients <50 years old admitted for STEMI with single-vessel disease received a two-stage management strategy. During a second coronary angiography performed between day 2 and day 7, optical frequency domain imaging (OFDI) guided the decision on therapeutic management, i.e., i) in the case of a stenosis greater than 70% or plaque prolapse, implantation of a BVS; or ii) in the other cases, continuation of medical management alone without stenting. All patients underwent systematic angiographic control with OFDI imaging at six months. Among the 653 patients admitted for STEMI, 124 patients were under 50 years old and 45 patients were included. Early management was performed on average at day 3.9 (day 2 - day 7). Thirty-four (34) patients received BVS implantation and 11 were treated medically. Only one major adverse cardiac event (MACE) had occurred at six months. CONCLUSIONS: In a selected younger population, the management of STEMI guided by OFDI and based on the concept of limiting implantation of durable intracoronary devices appears to be a feasible and safe therapeutic option.


Assuntos
Stents Farmacológicos , Everolimo/uso terapêutico , Infarto do Miocárdio/terapia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Implantes Absorvíveis , Adulto , Angiografia Coronária/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/métodos , Tomografia de Coerência Óptica/métodos , Resultado do Tratamento
20.
J Cardiovasc Magn Reson ; 19(1): 2, 2017 Jan 04.
Artigo em Inglês | MEDLINE | ID: mdl-28063459

RESUMO

BACKGROUND: Left ventricular (LV) remodeling following acute myocardial infarction (MI) is difficult to predict at an individual level although a possible interfering role of vascular function has yet to be considered to date. This study aimed to determine the extent to which this LV remodeling is influenced by the concomitant evolution of vascular function and LV loading conditions, as assessed by phase-contrast Cardiovascular Magnetic Resonance (CMR) of the ascending aorta. METHODS: CMR was performed in 121 patients, 2-4 days after reperfusion of a first ST-segment elevation myocardial infarction and 6 months thereafter. LV remodeling was: (i) assessed by the 6-month increase in end-diastolic volume (EDV) and/or ejection fraction (EF) and (ii) correlated with the indexed aortic stroke volume (mL.m-2), determined by a CMR phase-contrast sequence, along with derived functional vascular parameters (total peripheral vascular resistance (TPVR), total arterial compliance index, effective arterial elastance). RESULTS: At 6 months, most patients were under angiotensin enzyme converting inhibitors (86%) and beta-blockers (84%) and, on average, all functional vascular parameters were improved whereas blood pressure levels were not. An increase in EDV only (EDV+/EF-) was documented in 17% of patients at 6 months, in EF only (EDV-/EF+) in 31%, in both EDV and EF (EDV+/EF+) in 12% and neither EDV nor EF (EDV-/EF-) in 40%. The increase in EF was mainly and independently linked to a concomitant decline in TPVR (6-month change in mmHg.min.m2.L-1, EDV-/EF-: +1 ± 8, EDV+/EF-: +3 ± 9, EDV-/EF+: -7 ± 6, EDV+/EF+: -15 ± 20, p < 0.001) while the absence of any EF improvement was associated with high persisting rates of abnormally high TPVR at 6 months (EDV-/EF-: 31%, EDV+/EF-: 38%, EDV-/EF+: 5%, EDV+/EF+: 13%, p = 0.007). By contrast, the 6-month increase in EDV was mainly dependent on cardiac as opposed to vascular parameters and particularly on the presence of microvascular obstruction at baseline (EDV-/EF-: 37%, EDV+/EF-: 76%, EDV-/EF+: 38%, EDV+/EF+: 73%, p = 0.003). CONCLUSION: LV remodeling following reperfused MI is strongly influenced by the variable decrease in systemic vascular resistance under standard care vasodilating medication. The CMR monitoring of vascular resistance may help to tailor these medications for improving vascular resistance and consequently, LV ejection fraction. TRIAL REGISTRATION: NCT01109225 on ClinicalTrials.gov site (April, 2010).


Assuntos
Aorta/diagnóstico por imagem , Hemodinâmica , Imagem Cinética por Ressonância Magnética , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Função Ventricular Esquerda , Remodelação Ventricular , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Aorta/efeitos dos fármacos , Aorta/fisiopatologia , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Recuperação de Função Fisiológica , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Resistência Vascular , Vasodilatação , Vasodilatadores/uso terapêutico , Função Ventricular Esquerda/efeitos dos fármacos , Remodelação Ventricular/efeitos dos fármacos
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