Risk stratification of ventricular arrhythmias in repaired tetralogy of Fallot.

INTRODUCTION AND OBJECTIVES: Risk stratification of ventricular arrhythmias in patients with repaired tetralogy of Fallot (rTOF) remains unresolved. We aimed to identify right ventricular (RV) electrophysiological parameters potentially associated with a higher risk of ventricular arrhythmias in patients with rTOF. METHODS: We included all consecutive patients with rTOF who underwent RV electroanatomical mapping at a single tertiary center. We used logistic regression modeling to identify those variables associated with an increased risk of clinical or induced ventricular tachycardia (VT), or clinical VT exclusively. RESULTS: Twenty-one of the 56 patients included had clinical or induced VT. A high-frequency of premature ventricular contractions/nonsustained VT (OR, 11.34; 95%CI, 1.50-85.97; P=.019), an HV interval > 55 ms (OR, 21.20; 95%CI, 3.12-144.14; P=.002), and RV activation time (ms) (OR [per 10ms intervals], 1.34; 95%CI, 1.02-1.75; P=.035) proved to be associated with clinical or induced VT. The model including this information had good discrimination ability, with an area under the curve of 0.884 (95%CI, 0.79-0.97; P <.001). When considering only clinical VT as the outcome of interest, only an HV interval > 55ms (OR, 9.65; 95%CI, 1.41-66.14; P=.021) and high-frequency of premature ventricular contractions/nonsustained VT (OR, 13.14; 95%CI, 1.95-88.54; P=.008) were independently associated (area under the curve of 0.836 [95%CI, 0.663-1.000; P=.002]). CONCLUSIONS: High-frequency of premature ventricular contractions/nonsustained VT, an HV interval> 55ms and RV activation time are factors associated with an increased risk of ventricular arrhythmias in patients with rTOF.

Substrate characterization of the right ventricle in repaired tetralogy of Fallot using late enhancement cardiac magnetic resonance.

BACKGROUND: Three-dimensional (3D) substrate characterization by high-resolution late gadolinium enhancement cardiac magnetic resonance (LE-CMR) is useful for guiding ventricular tachycardia ablation of the left ventricle in ischemic heart disease. OBJECTIVE: The purpose of this study was to validate the substrate characterization and 3D reconstruction of LE-CMR images of the right ventricle (RV) in patients with repaired tetralogy of Fallot (rTOF) and to identify the algorithm that best fits with electroanatomic mapping (EAM). METHODS: RV LE-CMR images were compared with RV EAM in 10 patients with rTOF. RV LE-CMR images were postprocessed and analyzed to identify fibrotic tissue on 3D color maps. The 3D RV substrate reconstructions were created using an adjustable percentage of the maximum voxel signal intensity (MSI) of the scar region to define the threshold between core, transitional zone (TZ), and healthy tissue. Extensions of the core and TZ areas were compared with the scar (<0.5 mV) and low-voltage (0.5-1.5 mV) areas obtained by RV EAM. Agreement on anatomic isthmi identification was quantified. RESULTS: The best match between core and scar was obtained at 65% MSI cutoff (mean areas 17.4 ± 9.9 cm2 vs 16.9 ± 10.0 cm2, respectively; r = 0.954; P <.001). Agreement on anatomic isthmi identification was best at 60% MSI cutoff, which identified 95% of isthmi and achieved a total fit in 90% of patients. CONCLUSION: This study demonstrates that characterization of the RV substrate by postprocessing LE-CMR images in rTOF patients is feasible and validates the technique against RV EAM, which could help in planning target ablation.

Cardiac resynchronization therapy is associated with a reduction in ICD therapies as it improves ventricular function.

BACKGROUND: Repeated implantable cardioverter-defibrillator (ICD) therapies cause myocardial damage and, thus, an increased risk of arrhythmias and mortality. HYPOTHESIS: Cardiac resynchronization therapy-defibrillator (CRT-D) reduces the number of appropriate therapies in patients with left ventricular dysfunction (left ventricular ejection fraction [LVEF] <50%). METHODS: The retrospective study involved 175 consecutive patients (mean age, 64.6 ±10.4 years; 86.9% males) with reduced LVEF of 27.9% ±7.6% treated with an ICD (56.6%) or CRT-D (43.4%), according to standard indications, between January 2009 and July 2014. Devices were placed for either primary (54.3%) or secondary prevention (45.7%). Mean follow-up was 2.5 ±1.5 years. Predictors of first appropriate therapy were assessed using Cox regression analysis. RESULTS: Forty-four (25.1%) patients received ≥1 appropriate therapy. Although patients treated with CRT-D had lower LVEF and poorer New York Heart Association class, CRT-D patients with LVEF improvement >35% at the end of follow-up had a significantly lower risk of receiving a first appropriate therapy relative to those with an ICD (adjusted hazard ratio: 0.24, 95% confidence interval: 0.07-0.83, P = 0.025), independently of ischemic cardiomyopathy, baseline LVEF, and secondary prevention. There were no differences in mortality between the ICD and the CRT-D groups. CONCLUSIONS: Although patients receiving CRT-D had a worse clinical profile, they received fewer device therapies in comparison with those receiving an ICD. This reduction is associated with a significant improvement in LVEF.

A risk score to predict the absence of left ventricular reverse remodeling: Implications for the timing of ICD implantation in primary prevention.

BACKGROUND: A prophylactic implantable cardioverter defibrillator (ICD) in patients with heart failure and reduced left ventricular ejection fraction (HFrEF) is only indicated when left ventricular ejection fraction (LVEF) reassessment remains ≤35% after 3-6 months on optimal pharmacological therapy. However, LVEF may not improve during this period and the patient may be exposed to an unnecessary risk of sudden cardiac death. This study aimed to determine the incidence and predictors of the absence of left ventricular reverse remodeling (LVRR) after pharmacological treatment optimization in patients with HFrEF to design a risk score of absence of LVRR. METHODS: Consecutive outpatients with LVEF ≤35% were included in this observational prospective study. Up-titration of angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradine was performed in our Heart Failure (HF) Unit. The absence of LVRR was defined as the persistence of an LVEF ≤35% at the 6-month follow-up. RESULTS: One hundred and twenty patients were included. At the 6-month follow-up, 64%, 76%, 72%, and 7% of patients were at 100% of the target dose of ACE inhibitors/ARBs, beta-blockers, MRAs, and ivabradine, respectively. LVRR was observed in 48% of the patients. Ischemic cardiomyopathy, prolonged HF duration, and larger left ventricular end-diastolic diameter index (LVEDDI) were independent predictors of the absence of LVRR. The risk score based on these predictors showed a c-statistic value of 0.81. CONCLUSIONS: Pharmacological treatment optimization is associated with LVRR in approximately half of cases, reducing potential ICD indications in parallel. However, ischemic cardiomyopathy, prolonged HF duration, and larger LVEDDI predict the absence of LVRR and favor ICD implantation without delay. The risk score based on the former predictors may help the clinician with the timing of ICD implantation.

Infusiones ambulatorias de levosimendán: ¿eficaces y eficientes en la insuficiencia cardiaca avanzada? / Ambulatory levosimendan infusions. Effective and efficient in advanced heart failure?

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Control terapéutico de los factores de riesgo y calidad de vida en los pacientes tratados mediante derivación aortocoronaria / Therapeutic control and quality of life in coronary artery bypass surgery patients

FUNDAMENTO: Describir las medidas de prevención secundaria en los pacientes intervenidos de derivación aortocoronaria en nuestro medio y la calidad de vida relacionada con la salud al año de la intervención. PACIENTES Y MÉTODO: Estudio prospectivo de un año de seguimiento, realizado en hospitales públicos y privados de Cataluña. RESULTADOS: Se incluyeron 710 pacientes cuya edad media era de 63 años. El 74,8 por ciento de las mujeres y el 48,7 por ciento de los varones eran hipertensos, el 70,2 por ciento de las mujeres y el 55 por ciento de los varones tenían hipercolesterolemia, el 42,3 por ciento de las mujeres y el 28,7 por ciento de los varones eran diabéticos y el 31,2 por ciento de los varones y el 2,9 por ciento de las mujeres eran fumadores (p < 0,01). Al año de seguimiento seguían fumando un 7 por ciento de la población, y se observó una reducción significativa de todos los fármacos antianginosos y una mejora significativa de la calidad de vida relacionada con la salud. Entre el ingreso y al año del alta hospitalaria se apreció un aumento significativo de los fármacos hipolipemiantes en los pacientes diagnosticados basalmente de hipercolesterolemia (de un 44 a un 58 por ciento; p < 0,01). CONCLUSIONES: Los pacientes intervenidos de cirugía aortocoronaria mejoran clínicamente al cabo de un año de la intervención, mejorando también la calidad de vida relacionada con la salud. Tanto el porcentaje de fumadores como el grado de tratamiento antihipertensivo e hipolipemiante al final del seguimiento indican un grado de control subóptimo de la prevención secundaria en pacientes de alto riesgo (AU)

Adaptación del cuestionario de calidad de vida postinfarto MacNew QLMI para su uso en la población española / Adaptation of the MacNew QLMI quality of life questionnaire after myocardial infarction to be used in the Spanish population

Fundamento: Los cuestionarios de calidad de vida específicos tienen la ventaja de evaluar aspectos concretos propios de la enfermedad analizada. El objetivo del presente estudio es elaborar una versión española del cuestionario autoadministrado MacNew QLMI para los pacientes que han presentado un infarto de miocardio. Material y método: Se realizaron la traducción y retrotraducción del cuestionario original y se evaluaron su comprensibilidad y facilidad de administración. Posteriormente se llevó a cabo un análisis factorial de componentes principales en 143 pacientes que habían sido dados de alta por un primer infarto de miocardio. Para el estudio de fiabilidad se administró el cuestionario a 50 pacientes con infarto de miocardio en situación estable y se evaluó la reproducibilidad mediante la t de Student y la correlación intraclase, y la consistencia interna mediante el alfa de Cronbach. Resultados: El análisis factorial demostró una estructura de los ítems en tres dimensiones similar a la versión original. Los coeficientes de correlación intraclase fueron de 0,83, 0,87 y 0,83, y las alfas de Cronbach de 0,85, 0,88 y 0,83 para las tres dimensiones: emocional, física y social, respectivamente. Conclusiones: La versión española del cuestionario MacNew QLMI presenta una buena equivalencia con la versión original, buena consistencia interna y buena reproducibilidad, de modo que puede utilizarse en la población española para estudiar su validez. (AU)