Deep Vein Thrombosis is Common After Cardiac Ablation and Pre-Procedural D-Dimer Could Predict Risk.

PURPOSE: Cardiac catheter ablations are an established treatment for supraventricular tachycardia (SVT) involving prolonged cannulation of the common femoral vein with multiple catheters. This study aimed to identify the risk of deep vein thrombosis (DVT) by studying the frequency of this complication after catheter ablation. METHODS: This was a prospective multi-centre cohort study of patients undergoing cardiac ablation for atrioventricular nodal re-entry tachycardia or right-sided accessory atrioventricular connection. Those taking anticoagulation or antiplatelet therapy prior to the procedure were excluded. Following the procedure, bilateral venous duplex ultrasonography from the popliteal vein to the inferior vena cava for DVT was undertaken at 24 hours and between 10 to 14 days. RESULTS: Eighty (80) patients (mean age 47.6 yrs [SD 13.4] with 67% female) underwent cardiac ablation (median duration 70 mins). Seven (7) patients developed acute DVT in either the femoral or external iliac vein of the intervention leg, giving a frequency of 8.8% (95% CI 3.6-17.2%). No thrombus was seen in the contralateral leg (p=0.023). An elevated D-dimer prior to the procedure was significantly more frequent in patients developing DVT (42.9% vs 4.1%, p=0.0081; OR 17.0). No other patient or procedural characteristics significantly influenced the risk of DVT. CONCLUSION: In patients without peri-procedural anticoagulation catheter ablation precipitated DVT in the catheterised femoral or iliac veins in 8.8% of patients. Peri-procedure prophylactic anticoagulation may be considered for all patients undergoing catheter ablation for SVT. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT03877770.

Contemporary Management of Patent Foramen Ovale: A Multinational Survey on Cardiologists' Perspective.

OBJECTIVES: The purpose of our survey is to analyze the clinical approach used by interventional and imaging cardiologists to diagnose, treat, and follow-up patients with PFO-related left circulation thromboembolism in different parts of the world with particular emphasis on adherence to current guidelines. BACKGROUND: Firm guidelines do not cover many aspects of PFO-related patient care. Consequently, very disparate approaches exist among clinicians in the real-world. METHODS: A 24-item electronic questionnaire was sent directly to experienced cardiology specialists practicing at consultant/attending positions directly involved in PFO closure management in the United States, United Kingdom, Gulf countries, and other countries. There were no unanswered questions. Responses were recorded between October 2019 and July 2020. RESULTS: Seventy-one responses were obtained: 31 from the UK, 19 from the US, 16 from Gulf countries, 2 from Poland, and 1 response from Australia, Italy, and Switzerland. The overall response rate was 76%. Significant differences between regions were noted in the duration of ECG monitoring during the diagnostic process, PFO closure for left circulation thromboembolism other than stroke/transient ischemic attack, and intraoperative use of intracardiac echocardiography. A similar pattern was noted in the lack of routine screening for thrombophilia and the use of the long-term single antiplatelet therapy. CONCLUSIONS: The study shows a vast spectrum of opinions on the optimal approach to PFO closure with significant differences between the US, UK, and Gulf countries. The results stress the need for systematic, high-quality data on the diagnostic work-up and follow-up strategies to inform the standardized approach.

Renal function and the long-term clinical outcomes of cardiac resynchronization therapy with or without defibrillation.

BACKGROUND AND AIMS: Patients with moderate-to-severe chronic kidney disease (CKD) are underrepresented in clinical trials of cardiac resynchronization therapy (CRT)-defibrillation (CRT-D) or CRT-pacing (CRT-P). We sought to determine whether outcomes after CRT-D are better than after CRT-P over a wide spectrum of CKD. METHODS AND RESULTS: Clinical events were quantified in relation to preimplant estimated glomerular filtration rate (eGFR) after CRT-D (n = 410 [39.2%]) or CRT-P (n = 636 [60.8%]) implantation. Over a follow-up period of 3.7 years (median, interquartile range: 2.1-5.7), the eGFR < 60 group (n = 598) had a higher risk of total mortality (adjusted hazard ratio [aHR]: 1.28; P = 0.017), total mortality or heart failure (HF) hospitalization (aHR: 1.32; P = 0.004), total mortality or hospitalization for major adverse cardiac events (MACEs, aHR: 1.34; P = 0.002), and cardiac mortality (aHR: 1.33; P = 0.036), compared to the eGFR ≥ 60 group (n = 448), after covariate adjustment. In analyses of CRT-D versus CRT-P, CRT-D was associated with a lower risk of total mortality (eGFR ≥ 60 HR: 0.65; P = 0.028; eGFR < 60 HR: 0.64, P = 0.002), total mortality or HF hospitalization (eGFR ≥ 60 aHR: 0.66; P = 0.021; eGFR < 60 aHR: 0.69, P = 0.007), total mortality or hospitalization for MACEs (eGFR ≥ 60 aHR: 0.70; P = 0.039; eGFR < 60 aHR: 0.69, P = 0.005), and cardiac mortality (eGFR ≥ 60 aHR: 0.60; P = 0.026; eGFR < 60 aHR: 0.55; P = 0.003). CONCLUSION: In CRT recipients, moderate CKD is associated with a higher mortality and morbidity compared to normal renal function or mild CKD. Despite less favorable absolute outcomes, patients with moderate CKD had better outcomes after CRT-D than after CRT-P.

Long-term clinical outcomes of cardiac resynchronization therapy with or without defibrillation: impact of the aetiology of cardiomyopathy.

Aims: There is a continuing debate as to whether cardiac resynchronization therapy-defibrillation (CRT-D) is superior to CRT-pacing (CRT-P), particularly in patients with non-ischaemic cardiomyopathy (NICM). We sought to quantify the clinical outcomes after primary prevention of CRT-D and CRT-P and identify whether these differed according to the aetiology of cardiomyopathy. Methods and results: Analyses were undertaken in the total study population of patients treated with CRT-D (n = 551) or CRT-P (n = 999) and in propensity-matched samples. Device choice was governed by the clinical guidelines in the United Kingdom. In univariable analyses of the total study population, for a maximum follow-up of 16 years (median 4.7 years, interquartile range 2.4-7.1), CRT-D was associated with a lower total mortality [hazard ratio (HR) 0.72] and the composite endpoints of total mortality or heart failure (HF) hospitalization (HR 0.72) and total mortality or hospitalization for major adverse cardiac events (MACE; HR 0.71) (all P < 0.001). After propensity matching (n = 796), CRT-D was associated with a lower total mortality (HR 0.72) and the composite endpoints (all P < 0.01). When further stratified according to aetiology, CRT-D was associated with a lower total mortality (HR 0.62), total mortality or HF hospitalization (HR 0.63), and total mortality or hospitalization for MACE (HR 0.59) (all P < 0.001) in patients with ischaemic cardiomyopathy (ICM). There were no differences in outcomes between CRT-D and CRT-P in patients with NICM. Conclusion: In this study of real-world clinical practice, CRT-D was superior to CRT-P with respect to total mortality and composite endpoints, independent of known confounders. The benefit of CRT-D was evident in ICM but not in NICM.

Refractory hypertensive emergency associated with complete heart block resolved after permanent pacemaker implantation: A case report.

Severe hypertension sometimes improves with treatment of bradycardia but this phenomenon is under-reported. Here, an elderly gentleman with complete heart block and a hypertensive emergency was refractory to medical therapies and blood pressure only improved following pacemaker implantation. We discuss the possible mechanisms relating to heart rate and artificial pacing.

Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance.

BACKGROUND: Myocardial scarring at the LV pacing site leads to incomplete resynchronization and a suboptimal symptomatic response to CRT. We sought to determine whether the use of late gadolinium cardiovascular magnetic resonance (LGE-CMR) to guide left ventricular (LV) lead deployment influences the long-term outcome of cardiac resynchronization therapy (CRT). METHODS: 559 patients with heart failure (age 70.4 ± 10.7 yrs [mean ± SD]) due to ischemic or non-ischemic cardiomyopathy underwent CRT. Implantations were either guided (+CMR) or not guided (-CMR) by LGE-CMR prior to implantation. Fluoroscopy and LGE-CMR were used to localize the LV lead tip and and myocardial scarring retrospectively. Clinical events were assessed in three groups: +CMR and pacing scar (+CMR+S); CMR and not pacing scar (+CMR-S), and; LV pacing not guided by CMR (-CMR). RESULTS: Over a maximum follow-up of 9.1 yrs, +CMR+S had the highest risk of cardiovascular death (HR: 6.34), cardiovascular death or hospitalizations for heart failure (HR: 5.57) and death from any cause or hospitalizations for major adverse cardiovascular events (HR: 4.74) (all P < 0.0001), compared with +CMR-S. An intermediate risk of meeting these endpoints was observed for -CMR, with HRs of 1.51 (P = 0.0726), 1.61 (P = 0.0169) and 1.87 (p = 0.0005), respectively. The +CMR+S group had the highest risk of death from pump failure (HR: 5.40, p < 0.0001) and sudden cardiac death (HR: 4.40, p = 0.0218), in relation to the +CMR-S group. CONCLUSIONS: Compared with a conventional implantation approach, the use of LGE-CMR to guide LV lead deployment away from scarred myocardium results in a better clinical outcome after CRT. Pacing scarred myocardium was associated with the worst outcome, in terms of both pump failure and sudden cardiac death.

Female gender is associated with a better outcome after cardiac resynchronization therapy.

BACKGROUND: Some studies have suggested that women respond differently to cardiac resynchronization therapy (CRT). We sought to determine whether female gender influences long-term clinical outcome, symptomatic response as well as echocardiographic response after CRT. METHODS AND RESULTS: A total of 550 patients (age 70.4 ± 10.7 yrs [mean ± standard deviation]) were followed up for a maximum of 9.1 years (median: 36.2 months) after CRT-pacing (CRT-P) or CRT-defibrillation (CRT-D) device implantation. Outcome measure included mortality as well as unplanned hospitalizations for heart failure or major adverse cardiovascular events (MACE). Female gender predicted survival from cardiovascular death (hazard ratio [HR]: 0.52, P = 0.0051), death from any cause (HR: 0.52, P = 0.0022), the composite endpoints of cardiovascular death /heart failure hospitalizations (HR: 0.56, P = 0.0036) and death from any cause/hospitalizations for MACE (HR: 0.67, P = 0.0214). Female gender predicted death from pump failure (HR: 0.55, P = 0.0330) but not sudden cardiac death. Amongst the 322 patients with follow-up echocardiography, left ventricular (LV) reverse remodelling (≥ 15% reduction in LV end-systolic volume) was more pronounced in women (62% vs 44%, P = 0.0051). In multivariable Cox proportional hazards analyses, the association between female gender and cardiovascular survival was independent of age, LV ejection fraction, atrial rhythm, QRS duration, CRT device type, New York Heart Association (NYHA) class, and LV reverse remodelling (adjusted HR: 0.48, P = 0.0086). At one year, the symptomatic response rate (improvement by ≥ 1 NYHA classes or ≥ 25% increase in walking distance) was 78% for both women and men. CONCLUSIONS: Female gender is independently associated with a lower mortality and morbidity after CRT.

Fluoroscopic left ventricular lead position and the long-term clinical outcome of cardiac resynchronization therapy.

BACKGROUND: To determine the effects of left ventricular (LV) lead tip position on the long-term outcome of cardiac resynchronization therapy (CRT). SETTING: Cardiac device therapy center. PATIENTS: Five hundred and fifty-six patients (age 70.4 ± 10.7 years [mean ± standard deviation]). INTERVENTIONS: CRT-pacing or CRT-defibrillation device implantation. MAIN OUTCOME MEASURES: Cardiovascular mortality and events over a maximum follow-up period of 9.1 years. RESULTS: Hazard ratios (HRs [95% 785]797) for cardiovascular mortality, adjusted for age, gender, QRS duration, heart failure etiology, New York Heart Association class, and presence of diabetes and atrial fibrillation, were derived for LV lead tip positions in terms of veins, circumferential, and longitudinal positions with respect to the LV chamber. For vein position, these were 1.07 (0.74-1.56) for anterolateral vein position and 1.24 (0.79-1.95) for the middle cardiac vein, compared with a posterolateral vein. For circumferential lead tip position, HRs were 1.56 (0.73-3.34) for anterolateral and 1.57 (0.76-3.25) for lateral, compared with posterior positions. For longitudinal lead tip positions, HRs were 1.02 (0.72-1.46) for basal and 1.21 (0.68-2.17) for apical, compared with mid-ventricular positions. The risk of meeting the composite endpoints of cardiovascular death or hospitalizations for heart failure and death from any cause or hospitalizations for major adverse cardiovascular events was similar among the various LV lead tip positions. CONCLUSIONS: The position of the LV lead over the LV free wall, assessed by fluoroscopy, has no influence over the long-term outcome of CRT.

UBLED AF (Uninterrupted BLackpool EDoxaban vs Warfarin vs Rivaroxaban in Atrial Fibrillation/Flutter ablation) Study.

AIM: Catheter ablation in patients with atrial fibrillation (AF)/atrial flutter carries a risk of thromboembolism and major bleeding. In light of recent prospective trial data on the safety and efficacy of uninterrupted edoxaban in patients undergoing AF/flutter ablation, real-world Data was aimed for validation. METHODS: A total of 228 patients who underwent AF/atrial flutter ablation over 14 months at our centre were retrospectively analyzed. All patients received uninterrupted oral anticoagulation for at least 4 weeks prior to ablation and 3 months post-ablation. Both bleeding and thromboembolic events were assessed at 24 hours comparing patients on warfarin, rivaroxaban and edoxaban. RESULTS: Mean age of patients were 68.5 +/- 8 years in the warfarin group ( N =86), 63.4 +/- 10.6 years; in the edoxaban group ( N =63) and 62.3 +/- 11.6 years in the rivaroxaban group ( N =79). CHADSVASc scores were 2.43 +/- 1.34, 1.68 +/- 1.34 and 1.64 +/- 1.38 respectively. The mean left atrial sizes were 42.7 +/- 6.8 mm, 42.0 +/- 6 mm and 41.1 +/- 6.5 mm respectively. The study endpoint was death, acute thromboembolism or major bleeding. There was 1 pericardial effusion (1.2%) in the warfarin group, 1 pericardial effusion and 1 transient ischaemic attack (2.5%) in the rivaroxaban group and 1 pericardial effusion needing drainage (1.6%) in the edoxaban group. There were no significant differences in the study endpoints between groups. CONCLUSION: This real-world study demonstrated no significant difference in safety and efficacy between uninterrupted edoxaban, warfarin and rivaroxaban in patients undergoing AF/flutter ablation.

A 59-Year-Old Woman with Familial Brugada Syndrome and the c.664C>T Variant of the Sodium Voltage-Gated Channel Alpha Subunit 5 (SCN5A) Gene, Accompanied by Congenital Absence of the Right Coronary Artery, Patent Foramen Ovale, and Ischemic Stroke.

BACKGROUND Brugada syndrome is a rare inherited channelopathy that can lead to sudden cardiac death. The discovery of new variants of variable penetrance along with the current guidance for cascade family screening can be expected to lead to an increase in identified asymptomatic carriers of potentially causative mutations of channelopathies. A single coronary artery is a rare congenital anomaly of the coronary anatomy. We present a rare case of a 59-year-old woman with a family history of Brugada syndrome with the c.664C>T variant of the SCN5A gene, congenital absence of the right coronary artery, and patent foramen ovale. CASE REPORT We present a case of a patient with a family history of Brugada syndrome who tested positive for the SCN5A variant. The patient had no previous history of syncope or aborted sudden cardiac death. The patient had no features suggestive of Brugada type I ECG. An electrophysiology study was offered but the patient declined. She also complained of angina, and work-up with computed tomography coronary angiography revealed a congenital absence of the right coronary artery with no significant stenosis of the single left coronary artery. In the followup period, she suffered a stroke and was diagnosed with patent foramen ovale (PFO). She has been referred for PFO closure. CONCLUSIONS A rare case is reported of familial Brugada syndrome with absence of the right coronary artery and patent foramen ovale, which may have combined to increase this patient's risk for ischemic stroke.

Mental Health Outcomes Among British Healthcare Workers-Lessons From the First Wave of the Covid-19 Pandemic.

OBJECTIVE: To ascertain the level of psychological distress, using validated psychology tools, among British National healthcare workers (HCW) during the first wave of the Covid-19 crisis. METHODS: A multi-centre, anonymized, all-comer staff survey across 3 hospitals in Lancashire, England during the Covid-19 first wave (April to June 2020), consisting of Patient Health Questionnaire (PHQ-9), Perceived Stress Scale-10 (PSS-10), Generalized Anxiety Disorder-7 (GAD-7), and Impact of Events Scale (IES-6). RESULTS: Among 1113 HCW, median (IQR) PHQ-9, GAD-7, PSS-10, and IES-6 score was 7 (3 to 11), 6 (3 to 11), 19 (13 to 24), and 9 (5 to 14), respectively. Potential predictors of higher levels of psychological distress included living alone, disabled dependents, history of depression/anxiety, and being female. CONCLUSIONS: The study indicates a high prevalence of psychological distress during the acute Covid-19 period among HCW, identifies groups at risk and areas of future research.

Coronovirus Disease-2019 (COVID-19) Pandemic and Cardiac Electrophysiology: Guidance Protocol From a UK Tertiary Cardiac Center.

Since December 2019, the coronovirus disease-2019 (COVID-19) pandemic has resulted in more than 2,160,000 positive cases and more than 145,000 deaths until April 18, 2020. The pressure to the health services worldwide has been unprecedented. The redeployment of staff and resources to treat more efficiently COVID-19 cases along with the need to reduce disease transmission has affected the field of electrophysiology among many others. Amendments to clinical pathways are obligatory in this perspective to continue to provide the necessary health services to the people who need them, although at the same time, infection control and prevention are not compromised by inadvertent disease transmission or unnecessary use of resources. We aim to provide a guide of the logistic aspects of electrophysiology procedures derived from our tertiary cardiac center during the current COVID-19 pandemic.

Late perforation of a defibrillator lead managed by percutaneous, intravenous extraction.

We report the case of a patient with ischaemic cardiomyopathy who underwent cardiac resynchronization therapy with defibrillator back-up. He re-presented 3 weeks later with chest pain, having received two shocks. We describe a case of late perforation with the Riata lead causing inappropriate shocks.

Long-term effects of upgrading from right ventricular pacing to cardiac resynchronization therapy in patients with heart failure.

AIMS: To determine the effects of upgrading from right ventricular (RV) pacing to cardiac resynchronization therapy (CRT) in patients with heart failure. METHODS AND RESULTS: Patients with heart failure [age 67.3 +/- 9.6 years (mean +/- SD), NYHA class III or IV, left ventricular ejection fraction (LVEF) or= 120 ms] underwent de novo CRT (n = 336) or upgrading from RV pacing [n = 58; VVIR in 24, DDDR in 34] to CRT. The endpoint of death from any cause or major cardiovascular events, cardiovascular death or hospitalization for heart failure, and cardiovascular death or death from any cause was determined after a maximum follow-up of 7.7 years. No differences emerged between the de novo CRT and the upgrade-to-CRT groups with respect to any of the clinical endpoints. The de novo CRT and upgrade-to-CRT groups derived similar improvements in NYHA class [-1.2 vs. -1.3 (mean), both P < 0.0001), 6 min walking distance [75.9 (P < 0.0001) vs. 46.4 (P = 0.0205) m], and quality of life scores [-25.2 vs. -18.7 (both P < 0.0001)] 1 year after implantation. Response rates using a combined clinical score (>or=1 NYHA classes or >or=25% increase in 6 min walking distance plus survival with freedom from heart failure hospitalizations for 1 year) were 73.2% and 75.4%, respectively (P = NS). There were reductions in left ventricular end-systolic volume [median of 20.3 mL (P = 0.0012) and 22.7 mL (P = 0.0066), respectively] and improvements in LVEF [median of 2.9% and 9.3%, respectively (both P < 0.0001)]. CONCLUSION: In patients with heart failure who are RV-paced, upgrading to CRT is associated with a similar long-term risk of mortality and morbidity to patients undergoing de novo CRT. Symptomatic improvements and degree of reverse remodelling are also comparable.

Left ventricular non-compaction: clinical features and cardiovascular magnetic resonance imaging.

BACKGROUND: It is apparent that despite lack of family history, patients with the morphological characteristics of left ventricular non-compaction develop arrhythmias, thrombo-embolism and left ventricular dysfunction. METHODS: Forty two patients, aged 48.7 +/- 2.3 yrs (mean +/- SEM) underwent cardiovascular magnetic resonance (CMR) for the quantification of left ventricular volumes and extent of non-compacted (NC) myocardium. The latter was quantified using planimetry on the two-chamber long axis LV view (NC area). The patients included those referred specifically for CMR to investigate suspected cardiomyopathy, and as such is represents a selected group of patients. RESULTS: At presentation, 50% had dyspnoea, 19% chest pain, 14% palpitations and 5% stroke. Pulmonary embolism had occurred in 7% and brachial artery embolism in 2%. The ECG was abnormal in 81% and atrial fibrillation occurred in 29%. Transthoracic echocardiograms showed features of NC in only 10%. On CMR, patients who presented with dyspnoea had greater left ventricular volumes (both p < 0.0001) and a lower left ventricular ejection fraction (LVEF) (p < 0.0001) than age-matched, healthy controls. In patients without dyspnoea (n = 21), NC area correlated positively with end-diastolic volume (r = 0.52, p = 0.0184) and end-systolic volume (r = 0.56, p = 0.0095), and negatively with EF (r = -0.72, p = 0.0001). CONCLUSION: Left ventricular non-compaction is associated with dysrrhythmias, thromboembolic events, chest pain and LV dysfunction. The inverse correlation between NC area and EF suggests that NC contributes to left ventricular dysfunction.

Bradyarrhythmias for the Internist.

In this article, the authors review the different types of sinus node and atrioventricular node diseases that lead to bradyarrhythmias with their associated symptoms, the diagnostic investigations needed to assess the degree of disease, and the therapeutic management, including the indications for permanent pacing.

Long-term effects of cardiac resynchronization therapy in octogenarians: a comparative study with a younger population.

AIMS: Heart failure is a disease of octogenarians. The evidence base for cardiac resynchronization therapy (CRT) has emerged from trials of patients in their 60s. We compared the effectiveness of CRT in octogenerians with younger patients. METHODS AND RESULTS: Patients aged >or=80 years [n = 53, age 83.7 +/- 2.6 years (mean +/- SD)] and <80 years (n = 277, age 66.9 +/- 9.5 years) with ischaemic or non-ischaemic cardiomyopathy (NYHA class III or IV heart failure, left ventricular ejection fraction <35%, QRS >or= 120 ms) underwent CRT. A clinical assessment, including a 6-min walk test, and a quality of life assessment (Minnesota Living with Heart Failure questionnaire) were undertaken at baseline and after CRT. In octogenarians, CRT was associated with similar changes in NYHA class [-1.28 vs. -1.22, P < 0.0001 (P-values refer to changes from baseline)], 6-min walking distance (77.2 vs. 78.6 m, P < 0.0001), and quality of life scores (-20.4 vs. -31.4, P = 0.0084) to <80 year olds. A symptomatic response to CRT (improvement by >or=1 NYHA classes or >or=25% 6-min walking distance) was observed in 80% of <80 year olds and in 81% of octogenarians (P = NS). Using a combined clinical score (CCS; survival for 1 year with no heart failure hospitalizations, and; improvement by >or=1 NYHA classes or >or=25% 6-min walking distance), a response was observed in 201 out of 277 (73%) patients <80 years and in 36 out of 53 (68%) octogenarians (P = NS). After a maximum follow-up of 7.6 years (median 634 days), no group differences emerged with respect to the composite endpoints of cardiovascular death or hospitalization for major cardiovascular events, the composite endpoint of cardiovascular death or heart failure hospitalization, cardiovascular mortality, or total mortality. CONCLUSION: Octogenarians derive similar benefits from CRT to younger patients.

Late gadolinium enhancement-cardiovascular magnetic resonance as a predictor of response to cardiac resynchronization therapy in patients with ischaemic cardiomyopathy.

AIM: To determine whether myocardial scarring, quantified using late gadolinium enhancement-cardiovascular magnetic resonance (LGE-CMR), predicts response to cardiac resynchronization therapy (CRT). METHODS AND RESULTS: A total of 45 patients with ischaemic cardiomyopathy [age 67.1 +/- 10.4 years (mean +/- SD)] underwent assessment of 6 min walking distance (6MWD) and quality of life (QoL) before and after CRT. Scar size (percentage of left ventricular mass), location, and transmurality were assessed prior to CRT using LGE-CMR. Responders (survived for 1 year with no heart failure hospitalizations, and improvement by >or=1 NYHA classes or >or=25% 6MWD) had a higher left ventricular ejection fraction (P = 0.048), smaller scars (<33%) (P = 0.009), and fewer scars with >or=51% transmurality (P = 0.002). Scar size correlated negatively with change in 6MWD (r = -0.54, P < 0.001) and positively with changes in QoL scores (r = 0.35, P = 0.028). Responder rates in patients with <33% scar were higher than in those with >or=33% scar (82 vs. 35%, P < 0.01). Responder rates in patients with scar transmurality <51% were higher than in those with >or=51% (89 vs. 46%, P < 0.01). Among the patients with posterolateral scars, a transmurality value of >or=51% was associated with a particularly poor response rate (23%), compared with scars with <51% transmurality (88%, P < 0.001). In multivariate analyses, both scar size (P = 0.022) and transmurality (P = 0.004) emerged as predictors of response. In patients with posterolateral scars, pacing outside the scar was associated with a better responder rate than pacing over the scar (86 vs. 33%, P = 0.004). CONCLUSIONS: In patients with ischaemic cardiomyopathy, a scar size >or=33%, a transmurality >or=51%, and pacing over a posterolateral scar are associated with a suboptimal response to CRT.

Modelling the economic and health consequences of cardiac resynchronization therapy in the UK.

OBJECTIVE: Clinical evidence supports the use of cardiac resynchronization therapy (CRT) in advanced heart failure, but its cost-effectiveness is still unclear. This analysis assessed the economic and health consequences in the UK of implanting a CRT in patients with NYHA class III-IV heart failure. METHODS: A discrete event simulation of heart failure was used to compare the course over 5 years of 1000 identical pairs of patients -- one receiving both CRT and optimum pharmacologic treatment (OPT), the other OPT alone. All inputs were obtained from the data collected in the CArdiac REsynchronization in Heart Failure (CARE-HF) trial and a hospital in the UK. Direct medical costs (in 2004 pound) from the perspective of the National Health Service were considered. Both costs and benefits were discounted at 3.5%. Sensitivity analyses addressed all model inputs and multivariate analyses were performed by varying key parameters simultaneously. RESULTS: The model predicted 471 deaths and 2263 hospitalizations over 5 years with OPT alone and 348 deaths and 1764 hospitalizations with CRT, equivalent to a 26% reduction in mortality and 22% in hospitalizations, at a discounted cost of pound 11,423 per patient with CRT vs. pound 4,900 with OPT alone. CRT was predicted to increase quality-adjusted survival by 0.43 QALYs per patient, resulting in an incremental cost-effectiveness ratio of pound 15,247 per QALY gained (range: pound 12,531- pound 23,184). Sensitivity analyses revealed that this outcome was most sensitive to time horizon and cost of implantation. CONCLUSION: Based on these 5-year analyses, CRT is expected to yield substantial health benefits at a reasonable cost.