Survival in New York Heart Association class IV heart failure patients treated with cardiac resynchronization therapy compared with patients on optimal pharmacological treatment.

AIMS: Although the benefit of cardiac resynchronization therapy (CRT) in selected patients with heart failure is well established, its effect on mortality in New York Heart Association (NYHA) class IV patients remains unclear. Our study evaluated the effect of CRT on urgent transplant-free survival in NYHA class IV patients treated with CRT, compared with medication-only treatment. METHODS AND RESULTS: Forty NYHA class IV patients treated with CRT (80% men, 62.5% ischaemic, mean age of 65) were matched 1:1 by age, gender and aetiology of cardiomyopathy with patients treated with optimal medical therapy (OPT group). No significant differences were found between the groups in left ventricular diastolic diameter (71 +/- 6 vs. 73 +/- 9 mm), left ventricular systolic diameter (58 +/- 7 vs. 61 +/- 11 mm), and left ventricular ejection fraction (23 +/- 5 vs. 22 +/- 6%). Mean follow-up was 13.2 +/- 9.5 months for the CRT group and 17.3 +/- 11.6 months for the OPT group. Time to all-cause death or urgent transplantation [hazard ratios (HR), 1.29; 95% CI: 0.59-2.83; P = 0.52] or to cardiovascular death or urgent transplantation (HR, 1.53; 95% CI: 0.64-3.67; P = 0.34) was not reduced significantly in patients treated with CRT. CONCLUSION: In this study, CRT did not significantly improve survival of NYHA class IV heart failure patients compared with pharmacological therapy.

Six-minute walking test predicts long-term cardiac death in patients who received cardiac resynchronization therapy.

AIMS: Cardiac resynchronization therapy (CRT) has been proven to be effective in patients suffering from chronic heart failure (CHF) associated with electrical dyssynchrony. However, long-term predictors of mortality in that subset have not been extensively investigated. The aim of this study was to establish baseline long-term predictors of cardiovascular mortality in CHF patients treated with CRT. METHODS AND RESULTS: A total of 188 consecutive patients with moderate to severe CHF who had undergone a successful CRT implant were evaluated. Baseline measurements included clinical history, a 6-min walking test (6MWT), and echocardiographic parameters. Patients with cardiac or non-cardiac diseases limiting their ability to perform a 6MWT were excluded, with the final count totalling 155 patients [82% men, mean age 69 +/- 8 years, New York Heart Association (NYHA) functional class: II 22%, III 73.5%, IV 4.5%]. A total of 24 patients (15.5%) died of cardiovascular causes and one patient underwent heart transplantation during a mean follow-up of 24.4 +/- 18.1 months. Univariate analysis showed that NYHA class, distance walked in the 6MWT, left atrial diameter, digoxine and left ventricle (LV) ejection fraction were all significantly related to rates of mortality. Multivariate Cox regression after adjustment for the presence of a defibrillator showed that the LV ejection fraction [HR 0.91 (95% CI: 0.84-0.98) P = 0.008] and 6MWT distance <225 m [HR 5.6 (95% CI: 1.2-25.3) P = 0.026] were independent predictors of cardiovascular mortality. CONCLUSION: Baseline functional capacity, measured by the 6MWT distance, and LV ejection fraction are independent predictors of mortality in moderate to severe CHF patients, despite CRT. A 6MWT distance walked of <225 m identifies patients at high risk of cardiovascular death at mid-long term.

Characterization of focal right atrial appendage tachycardia.

AIMS: Though right atrial appendage tachycardia (RAAT) has been described, no studies to date have focused on its clinical characterization. The aim of the present study was to analyze its clinical, electrocardiographic (ECG), and electrophysiologic (EP) characteristics and the results of radiofrequency ablation (RFA) in RAAT. METHODS AND RESULTS: Out of 186 consecutive patients undergoing RFA for AT, 15 (8%) had focal RAAT. Mapping was performed using conventional catheters or a 3D electroanatomic mapping system. Patients with RAAT were more likely to be male (66 vs. 38%; P= 0.013) and younger (32 +/- 12.6 vs. 55 +/- 13.2 years; P < 0.001) than patients with AT originating elsewhere. They were also more likely to have dyspnea (27 vs. 7.6%; P = 0.03), incessant tachycardia (53 vs. 16%; P < 0.001), and left ventricular systolic dysfunction (27 vs. 5%; P = 0.018). RFA was effective in all patients (100 vs. 75%; P = 0.022) and no recurrences (0 vs. 8%; P = 0.31) were observed during a mean follow-up of 37 +/- 36 months. A specific ECG pattern was identified, consisting of negative P-waves in leads V1-V2 and a transition to positivity in the rest of the precordial leads. This ECG pattern correctly identified RAAT with a sensitivity of 100%, a specificity of 98%, a positive predictive value of 88%, and a negative predictive value of 100%. CONCLUSION: Right atrial appendage tachycardia is more prevalent in young male patients and is commonly associated with tachycardiomyopathy. RFA is effective over long-term follow-up. A characteristic ECG pattern identifies RAAT with a very high sensitivity and specificity.