Superior vena cava isolation using a pentaspline pulsed-field ablation catheter: feasibility and safety in patients undergoing atrial fibrillation catheter ablation.

AIMS: Superior vena cava (SVC) isolation during atrial fibrillation (AF) catheter ablation is limited by the risk of collateral damage to the sinus node and/or the phrenic nerve. Due to its tissue-specificity, we hypothesized the feasibility and safety of pulsed-field ablation (PFA)-based SVC isolation. METHODS AND RESULTS: A hundred and five consecutive patients undergoing PFA-based AF catheter ablation were prospectively included. After pulmonary vein isolation (± posterior wall isolation and electrical cardioversion), SVC isolation was performed using a standardized workflow. Acute SVC isolation was achieved in 105/105 (100%) patients after 6 ± 1 applications. Transient phrenic nerve stunning occurred in 67/105 (64%) patients but without phenic nerve palsy at the end of the procedure and at hospital discharge. Transient high degree sinus node dysfunction occurred in 5/105 (4.7%) patients, with no recurrence at the end of the procedure and until discharge. At the 3-month follow-up visit, no complication occurred. CONCLUSION: SVC isolation using a pentaspline PFA catheter is feasible and safe.

Definition of left ventricular remodelling following ST-elevation myocardial infarction: a systematic review of cardiac magnetic resonance studies in the past decade.

An increase in left ventricular volumes between baseline and follow-up imaging is the main criteria for the quantification of left ventricular remodelling (LVR) after ST-elevation myocardial infarction (STEMI), but without consensual definition. We aimed to review the criteria used for the definition of LVR based on cardiac magnetic resonance imaging (CMR) in STEMI patients. A systematic literature search was conducted using MEDLINE and the Cochrane Library from January 2010 to August 2019. Thirty-seven studies involving 4209 patients were included. Among these studies, 30 (81%) used a cut-off value for defining LVR, with a pooled LVR prevalence estimate of 22.8%, 95% CI [19.4-26.7%] and a major between-study heterogeneity (I2 = 82%). The seven remaining studies (19%) defined LVR as a continuous variable. The definition of LVR using CMR following STEMI is highly variable, among studies including highly selected patients. A 20% increase or a 15% increase in left ventricular volumes between a baseline and a follow-up CMR imaging were the two most common criterion (13 [35%] and 9 [24%] studies, respectively). The most frequent LVR criterion was a 20% increase in end-diastolic volumes or a 15% increase in end-systolic volumes. A composite cut-off value of a 12 to 15% increase in end-systolic volume and a 12 to 20% increase in end-diastolic volume using a follow-up CMR imaging 3 months after STEMI might be proposed as a consensual cut-off for defining adverse LVR for future large-sized, prospective studies with serial CMR imaging and long-term follow-up in unselected patients.

A telemonitoring programme in patients with heart failure in France: a cost-utility analysis.

BACKGROUND: Certain telemedicine programmes for heart failure (HF) have been shown to reduce all-cause mortality and heart failure-related hospitalisations, but their cost-effectiveness remains controversial. The SCAD programme is a home-based interactive telemonitoring service for HF, which is one of the largest and longest-running telemonitoring programmes for HF in France. The objective of this cost-utility analysis was to evaluate the cost-effectiveness of the SCAD programme with respect to standard hospital-based care in patients with HF. METHODS: A Markov model simulating hospitalisations and mortality in patients with HF was constructed to estimate outcomes and costs. The model included six distinct health states (three 'not hospitalised' states, two 'hospitalisation for heart failure' states, both depending on the number of previous hospitalisations, and one death state). The model lifetime in the base case was 10 years. Model inputs were based on published literature. Outputs (costs and QALYs) were compared between SCAD participants and standard care. Deterministic and probabilistic sensitivity analyses were performed to assess uncertainty in the input parameters of the model. RESULTS: The number of quality-adjusted life years (QALYs) was 3.75 in the standard care setting and 4.41 in the SCAD setting. This corresponds to a gain in QALYs provided by the SCAD programme of 0.65 over the 10 years lifetime of the model. The estimated total cost was €30,932 in the standard care setting and €35,177 in the SCAD setting, with an incremental cost of €4245. The incremental cost-effectiveness ratio (ICER) for the SCAD programme over standard care was estimated at €4579/QALY. In the deterministic sensitivity analysis, the variables that had the most impact on the ICER were HF management costs. The likelihood of the SCAD programme being considered cost-effective was 90% at a willingness-to-pay threshold of €11,800. CONCLUSIONS: Enrolment of patients into the SCAD programme is highly cost-effective. Extension of the programme to other hospitals and more patients would have a limited budget impact but provide important clinical benefits. This finding should also be taken into account in new public health policies aimed at encouraging a shift from inpatient to ambulatory care.

Left atrial strain quantified after myocardial infarction is associated with early left ventricular remodeling.

BACKGROUND: Left ventricular remodeling (LVR) is common and associated with adverse outcome after ST-elevation myocardial infarction (STEMI). We aimed to investigate the association between left atrial (LA) mechanical function using speckle tracking imaging and early LVR at follow-up in STEMI patients. METHODS: Baseline 3D thoracic echocardiograms were performed within 48 h following admission and at a median follow-up of 7 months after STEMI. A > 20% increase in the left ventricular (LV) end-diastolic volume compared to baseline at follow-up was defined as LVR. LA global longitudinal strain was evaluated for the reservoir, conduit, and contraction (LASct) phases. RESULTS: A total of 121 patients without clinical heart failure (HF) were prospectively included, between June 2015 and October 2018 (age 58.3 ± 12.5 years, male 98 (81%)). Baseline and follow-up LV ejection fraction (LVEF) were 46.8% [41.0, 52.9] and 52.1% [45.8, 57.0] respectively (p < .001). Compared to other patients, those with LVR had significantly lower values of LASct at baseline (-7.4% [-10.1, -6.5] vs. -9.9% [-12.8, -8.1], p < .01), both on univariate and baseline LV volumes-adjusted analyses. Baseline LA strain for reservoir and conduit phases were not associated with significant LVR at follow-up. Intra- and interobserver analysis showed good reproducibility of LA strain. CONCLUSIONS: Baseline LASct may help identifying patients without HF after STEMI who are at higher risk of further early LVR and subsequent HF and who may benefit from more intensive management.

Association Between Use of Anticancer Drugs and Cardiovascular Disease-Related Hospitalization in Metastatic Colorectal Cancer: Insights From a Population-Based Study, the Anticancer Vigilance of Cardiac Events Study.

We aimed to investigate the association between use of anticancer drugs and cardiovascular-related hospitalization (CVRH) among patients with metastatic colorectal cancer (mCRC). A cohort study, the Anticancer Vigilance of Cardiac Events (AVOCETTE) Study, was conducted using data from the digestive tumor registry of a French county, the Département du Calvados. Incident mCRC cases diagnosed between 2008 and 2014 were included. The follow-up end date was December 31, 2016. Data from the county hospital center pharmacy and medical information departments were matched with the registry data. A competing-risks approach was used. Statistical tests were 2-sided. A total of 1,116 mCRC patients were included, and they were administered 12,374 rounds of treatment; fluorouracil, oxaliplatin, irinotecan, and bevacizumab were most common drugs used. A total of 208 CVRH events occurred in 145 patients (13.0%). The International Cancer Survival Standards type 1 standardized incidence was 84.0 CVRH per 1,000 person-years (95% confidence interval: 72.6, 95.5). Anticancer drugs were not associated with a higher incidence of CVRH. Male sex, increasing age, a prior history of CVRH, and a higher Charlson comorbidity index score were associated with a higher incidence of CVRH. CVRH was significantly associated with higher all-cause mortality (multivariable hazard ratio = 1.58, 95% confidence interval: 1.28, 1.95). In this study, anticancer drugs were not associated with a higher incidence of CVRH in mCRC patients.

Vascular entrapment of a multipolar basket catheter (OrionTM ) during catheter ablation.

The IntellaMap OrionTM (Boston Scientific) is a 64-electrode basket catheter allowing for ultrahigh-density mapping of complex cardiac arrhythmias. We report the case of a basket catheter vascular entrapment, requiring surgical removal.

Impaired left atrial function in adults and adolescents with corrected aortic coarctation.

This study examined the left atrial (LA) function using two-dimensional (2D) strain analysis after aortic coarctation (CoA) repair, as well as relationships between LA function and patient characteristics, especially aortic arch anatomy. 56 patients (34 males, age: 31 ± 16 years) with CoA repair (46 post 'end-to-end anastomosis/subclavian flap') and 56 controls were studied. 2D strain imaging was performed to assess left ventricular (LV) and LA functions including peak-positive LA strain, early and late diastolic LA strains, and global longitudinal (LV-GLS) and circumferential (LV-GCS) strains. LA dysfunction (LAD) was defined as a peak-positive LA strain value lower than the mean value of the control group minus 2 SDs. Peak-positive LA strain, early and late diastolic LA strains, and LV-GLS were significantly lower in the CoA group while LV-GCS did not differ. No significant correlation was found between LA strain and either current age, age at initial repair, or blood pressure; Ea and LV-GLS were moderately correlated to peak-positive LA strain (r = 0.49, p < 0.001 and r = - 0.55, p < 0.001, respectively). 23 CoA patients (41%) presented LAD (abnormal peak-positive LA strain < 25%). Among patients who underwent end-to-end anastomosis/subclavian flap, those with a non-romanesque aortic arch anatomy exhibited a significantly lower peak-positive LA strain. Ischemic stroke and atrial arrhythmia were more frequent in CoA patients with LAD. Our findings suggest that LAD may be prevalent late after CoA repair. Postoperative aortic arch anatomy may impact peak-positive LA strain.

Clinical outcomes after primary prevention defibrillator implantation are better predicted when the left ventricular ejection fraction is assessed by cardiovascular magnetic resonance.

BACKGROUND: The left ventricular ejection fraction (LVEF) is the key selection criterion for an implanted cardioverter defibrillator (ICD) in primary prevention of sudden cardiac death. LVEF is usually assessed by two-dimensional echocardiography, but cardiovascular magnetic resonance (CMR) imaging is increasingly used. The aim of our study was to evaluate whether LVEF assessment using CMR imaging (CMR-LVEF) or two-dimensional echocardiography (2D echo-LVEF) may predict differently the occurrence of clinical outcomes. METHODS: In this retrospective study, we reviewed patients referred for primary prevention ICD implantation to Caen University Hospital from 2005 to 2014. We included 173 patients with either ischemic (n = 120) or dilated cardiomyopathy (n = 53) and who had undergone pre-ICD CMR imaging. The primary composite end point was the time to death from any cause or first appropriate device therapy. RESULTS: The mean CMR-LVEF was significantly lower than the mean 2D echo-LVEF (24% ± 6 vs 28% ± 6, respectively; p < 0.001). CMR-LVEF was a better independent predictive factor for the occurrence of the primary composite endpoint with a cut-off value of 22% (Hazard Ratio [HR] = 2.22; 95% CI [1.34-3.69]; p = 0.002) than 2D echo-LVEF with a cut-off value of 26% (HR = 1.61; 95% CI [0.99-2.61]; p = 0.056). Combination of the presence of scar with CMR-LVEF< 22% improved the predictive value for the occurrence of the primary outcome (HR = 2.58; 95% CI [1.54-4.30]; p < 0.001). The overall survival was higher among patients with CMR-LVEF≥22% than among patients with CMR-LVEF< 22% (p = 0.026), whereas 2D echo-LVEF was not associated with death. CONCLUSIONS: CMR-LVEF is better associated with clinical outcomes than 2D echo-LVEF in primary prevention using an ICD. Scar identification further improved the outcome prediction. The combination of CMR imaging and echocardiography should be encouraged in addition to other risk markers to better select patients.

Prevalence and significance of fragmented QRS complex in lead V1 on the surface electrocardiogram of healthy athletes.

AIMS: Limited data exist concerning fragmented QRS complexes (fQRSs) on the surface electrocardiogram (ECG) of apparently healthy athletes. We aimed to study the prevalence and significance of fQRS in lead V1 (fQRSV1), representing right ventricular (RV) activation, regarding training-induced RV morphological remodelling. METHODS AND RESULTS: Between January 2017 and August 2019, 434 consecutive non-sedentary subjects underwent preparticipation cardiovascular screening, including a 12-lead ECG. Three hundred and ninety-three apparently healthy subjects were included, 119 of them were athletes (defined as performing ≥8 h/week for the last 6 months) and 274 were non-athletes. All athletes underwent two-dimensional transthoracic echocardiography. Fragmented QRS complex in lead V1 pattern was defined as a narrow (<120 ms) and quadriphasic QRS complex in lead V1. Fragmented QRS complex in lead V1 was more frequent in athletes compared with non-athletes (22% vs. 5.1%, P < 0.001) and was independently associated with the athlete status [adjusted odds ratio (aOR) = 4.693, 95% confidence interval (95% CI) 2.299-9.583; P < 0.001], the endurance category (aOR = 2.522, 95% CI 1.176-5.408; P = 0.017), and age (aOR = 0.962, 95% CI 0.934-0.989; P = 0.007) in multivariate analysis. In the subgroup of athletes, fQRSV1 was independently associated with mean RV outflow tract diameter (aOR = 1.458, 95% CI 1.105-1.923; P = 0.008) and age (aOR = 0.941, 95% CI 0.894-0.989; P = 0.017) in multivariate analysis. CONCLUSION: Fragmented QRS complex in lead V1 is a newly described, frequent, ECG pattern in young and apparently healthy athletes and is associated with training-induced RV remodelling.

Atrial fibrillation detection by the subcutaneous defibrillator: real-world clinical performances and implications from a multicentre study.

AIMS: No data exist concerning the clinical performances of the subcutaneous implantable cardioverter-defibrillator (S-ICD) atrial fibrillation (AF) detection algorithm. We aimed to study the performances and implications of the latter in a 'real-world' setting. METHODS AND RESULTS: Between July 2017 and August 2019, 155 consecutive S-ICD recipients were included. Endpoint of the study was the incidence of de novo or recurrent AF using a combined on-site and remote-monitoring follow-up approach. After a mean follow-up of 13 ± 8 months, 2531 AF alerts were generated for 55 patients. A blinded analysis of the 1950 subcutaneous electrocardiograms available was performed. Among them 47% were true AF, 23% were premature atrial contractions or non-sustained AF, 29% were premature ventricular contractions or non-sustained ventricular tachycardia, and 1% were misdetection. Fourteen percent (21/155) patients had at least one correct diagnosis of AF by the S-ICD algorithm. One patient presented symptomatic paroxysmal AF not diagnosed by the S-ICD algorithm (false negative patient). Patient-based sensitivity, specificity, positive, and negative predictive values were respectively 95%, 74%, 38%, and 99%. Among patients with at least one correct diagnosis of AF, 38% (8/21) had subsequent clinical implications (anticoagulation initiation or rhythm control therapies). CONCLUSION: The S-ICD AF detection algorithm yields a high sensitivity for AF diagnosis. Low specificity and positive predictive value contribute to a high remote monitoring-notification workload and underline the necessity of a manual analysis. Atrial fibrillation diagnosis by the S-ICD AF detection algorithm might lead to significant therapeutic adjustments.

Serum neprilysin levels are associated with myocardial stunning after ST-elevation myocardial infarction.

BACKGROUND: Left ventricular remodeling following ST-elevation myocardial infarction (STEMI) is associated with poor outcome, including heart failure (HF). Neprilysin inhibition leads to improved outcome in patients with altered left ventricular ejection fraction (LVEF). METHODS: We aimed to assess the association between serum levels of neprilysin and left ventricular (LV) volumes, function and remodeling in STEMI patients with successful myocardial reperfusion and no clinical sign of HF. Sixty-eight patients were admitted for STEMI and had both plasma neprilysin measurement at baseline and 3D transthoracic echocardiogram at baseline and after a median follow-up of 7 months. We compared 3 groups: a group with a low-level of plasma neprilysin (< 125 pg/mL, i.e. the lower limit of detection of the assay) and the two other groups were defined as being below or above the median value of the remaining samples. RESULTS: Median age was 58.5 ± 12.8 years and 56 (82.4%) were men. Median LVEF was 45.0 ± 8.5%. Baseline characteristics were comparable between groups (low-level of neprilysin group [≤125 pg/mL, n = 38], medium-level of neprilysin group [126-450 pg/mL, n = 15] and a high-level group [> 450 pg/mL, n = 15]). At baseline there was a non-significant trend towards lower end-diastolic volume (p = 0.07) but significantly lower LVEF in the high neprilysin group (46.4 ± 8.3%, 47.1 ± 8.1% and 39.1 ± 6.9%, p < 0.01). At follow-up, the magnitude of LVEF increase was significantly more important in the high neprilysin group compared to the other groups (p = 0.022 for relative change in LVEF and 6.6 ± 7.3%, 3.6 ± 9.0% and 11.3 ± 8.4%, p = 0.031 for absolute change in LVEF) resulting in similar LVEF levels at follow-up between all groups (53.0 ± 8.9%, 50.6 ± 9.7% and 50.4 ± 9.9%, p = 0.55). CONCLUSIONS: Initial high neprilysin levels may identify patients with stunned myocardium early after STEMI, with a recovery of contractility leading to improved LVEF at follow-up. Future studies will have to assess the role of neprilysin in the setting of STEMI and the potential benefit of its blockade.

Echocardiographic evidence of left ventricular untwisting-filling interplay.

BACKGROUND: Left ventricular untwisting generates an early diastolic intraventricular pressure gradient (DIVPG) than can be quantified by echocardiography. We sought to confirm the quantitative relationship between peak untwisting rate and peak DIVPG in a large adult population. METHODS: From our echocardiographic database, we retrieved all the echocardiograms with a normal left ventricular ejection fraction, for whom color Doppler M-Mode interrogation of mitral inflow was available, and left ventricular untwisting rate was measurable using speckle tracking. Standard indices of left ventricular early diastolic function were assessed by Doppler (peaks E, e' and Vp) and speckle tracking (peak strain rate Esr). Load dependency of DIVPG and untwisting rate was evaluated using a passive leg raising maneuver. RESULTS: We included 154 subjects, aged between 18 to 77 years old, 63% were male. Test-retest reliability for color Doppler-derived DIVPG measurements was good, the intraclass correlation coefficients were 0.97 [0.91-0.99] and 0.97 [0.67-0.99] for intra- and inter-observer reproducibility, respectively. Peak DIVPG was positively correlated with peak untwisting rate (r = 0.73, P <  0.001). On multivariate analysis, peak DIVPG was the only diastolic parameter that was independently associated with untwisting rate. Age and gender were the clinical predictive factors for peak untwisting rate, whereas only age was independently associated with peak DIVPG. Untwisting rate and DIVPG were both load-dependent, without affecting their relationship. CONCLUSIONS: Color Doppler-derived peak DIVPG was quantitatively and independently associated with peak untwisting rate. It thus provides a reliable flow-based index of early left ventricular diastolic function.

Direct measurement of cardiac stiffness using echocardiographic shearwave imaging during open-chest surgery: A pilot study in human.

PURPOSE: Cardiac stiffness is a marker of diastolic function with a strong prognostic significance in many heart diseases that is not measurable in clinical practice. This study investigates whether elastometry, a surrogate for organ stiffness, is measurable in the heart using ShearWave Imaging. METHODS: In 33 anesthetized patients scheduled for cardiac surgery, ShearWave imaging was acquired epicardially using a dedicated ultrasound machine on the left ventricle parallel to the left anterior descending coronary artery in a loaded heart following the last cardiac beat. Cardiac elastometry was measured offline using the Young modulus with customized software. RESULTS: Overall, the ejection fraction was 61 ± 10%. E/A and E/e' ratios were 1.0 ± 0.5 and 10.5 ± 4.1, respectively. Cardiac elastometry averaged 15.3 ± 5.3 kPa with a median of 18 kPa. Patients with high elastometry >18 kPa were older (P = .04), had thicker (P = .02) but smaller LV (P = .004), had larger left atria (P = .05) and a higher BNP level (P = .04). We distinguished three different transmural elastometry patterns: higher epicardial, higher endocardial, or uniformly distributed elastometry. CONCLUSION: Elastometry measurement was feasible for the human heart. This surrogate for cardiac stiffness dichotomized patients with low and high elastometry, and provided three different phenotypes of transmural elastometry with link to diastolic function.

Right Ventricular Strain Impairment in Adults and Adolescents with Repaired Aortic Coarctation.

This study examines the function of the right ventricle (RV) using two-dimensional (2D) strain analysis after aortic coarctation (CoA) repair, as well as relationships between potential RV strain abnormalities and patient characteristics. The study examined 39 patients (61% male, age 32 ± 16 years) with CoA repair (33 post end-to-end anastomosis/sub-clavian flap, 6 post stenting/bypass/Teflon patch) and 42 controls. The structure and function of the left ventricle (LV), left atrium (LA), and RV were assessed using 2D standard echocardiography, tissue Doppler imaging, and 2D strain imaging. The characteristics examined included global RV longitudinal strain (RV-GLS), global LV longitudinal strain (LV-GLS), and LA longitudinal strain (LA strain). RV dysfunction was defined by RV-GLS lower than the mean minus 2 standard deviations (SDs) of the control group value. LV mass and mitral E/Ea were significantly higher in the CoA group. Septal Ea, LV-GLS, and LA strain were significantly lower in the CoA group. RV dysfunction (RV-GLS > - 16%) was present in 10 (25.6%) CoA patients. RV-GLS was correlated with lateral Ea, LV-GLS, and LA strain (r = - 0.35, p = 0.02; r = - 0.54, p < 0.001; and r = - 0.44, p = 0.005, respectively). Patients who had a stenting/bypass/Teflon patch as the first initial repair exhibited significantly lower RV-GLS. RV systolic strain abnormalities may occur in patients late after CoA repair. RV strain was correlated with parameters of LV dysfunction. Further large-scale studies are required to confirm these findings and to determine the mechanisms and prognostic implications of RV strain in such patients.

Spironolactone and perioperative atrial fibrillation occurrence in cardiac surgery patients: Rationale and design of the ALDOCURE trial.

BACKGROUND: After artery bypass grafting (CABG), the presence of perioperative AF (POAF) is associated with greater short- and long-term cardiovascular morbidity. Underlying POAF mechanisms are complex and include the presence of an arrhythmogenic substrate, cardiac fibrosis and electrical remodeling. Aldosterone is a key component in this process. We hypothesize that perioperative mineralocorticoid receptor (MR) blockade may decrease the POAF incidence in patients with a left ventricular ejection fraction (LVEF) ≥50% who are referred for CABG with or without aortic valve replacement (AVR). STUDY DESIGN: The ALDOCURE trial (NCT03551548) will be a multicenter, randomized, double-blind, placebo-controlled trial testing the superiority of a low-cost MR antagonist (MRA, spironolactone) on POAF in 1500 adults referred for on-pump elective CABG surgery with or without AVR, without any history of heart failure or atrial arrhythmia. The primary efficacy end point is the occurrence of POAF from randomization to within 5 days after surgery, assessed in a standardized manner. The main secondary efficacy end points include the following: postoperative AF occurring within 5 days after cardiac surgery, perioperative myocardial injury, major cardiovascular events and death occurring within 30 days of surgery, hospital and intensive care unit length of stay, need for readmission, LVEF at discharge and significant ventricular arrhythmias within 5 days after surgery. Safety end points, including blood pressure, serum potassium levels and renal function, will be monitored regularly throughout the trial duration. CONCLUSION: The ALDOCURE trial will assess the effectiveness of spironolactone in addition to standard therapy for reducing POAF in patients undergoing CABG. CLINICAL TRIAL REGISTRATION: NCT03551548.

Comparison between novel and standard high-density 3D electro-anatomical mapping systems for ablation of atrial tachycardia.

Ultra-high-density mapping allows very accurate characterization of circuits/mechanisms in atrial tachycardia (AT). Whether these advantages will translate into a better procedural or long-term clinical outcome is unknown. Sixty consecutive AT ablation procedures using ultra-high-density mapping (Rhythmia™, group 1) were retrospectively compared to 60 consecutive procedures using standard high-density mapping (Carto/NavX™, group 2) (total 209 AT, 79% left AT). A higher number of maps were performed in group 1 (4.8 ± 2.5 vs 3.2 ± 1.7, p = 0.0001) with similar acquisition duration (12 ± 5 vs 13 ± 6 min per map, p = ns), although with a greater number of activation points (10,543 ± 5854 vs 689 ± 1827 per map, p < 0.0001). AT location remained undetermined in 5 AT in group 1 vs 10 (p = 0.1). Mechanism remained undetermined in 5 AT from group 1 vs 11 (p = 0.06). Acute complete success was achieved in 77%, in both groups. At 1-year follow-up, AT recurred in 37% in group 1 vs 50% in group 2 (p = 0.046). There are less long-term recurrences after AT ablation using ultra-high-density mapping system compared to standard high-density 3D mapping, possibly because of a better comprehensive approach of AT mechanisms.

Predictors of clinical outcomes after cardiac resynchronization therapy in patients ≥75 years of age: a retrospective cohort study.

BACKGROUND: Cardiac resynchronization therapy has been shown to benefit selected patients with heart failure and reduced ejection fraction. Older patients have been underrepresented in randomized trials. This study was conducted to determine whether predictive factors for cardiac resynchronization therapy outcomes differ in patients older and younger than 75 years of age. METHODS: Consecutive patients who received a cardiac resynchronization device cardiac resynchronization therapy between 2013 and 2016 in our center were retrospectively included in this cohort study. The primary endpoint was cardiac resynchronization therapy effectiveness, which was defined as survival for one year with both no heart failure hospitalization and improvement by one or more NYHA class. The secondary endpoints were mortality, complications, and device therapies. RESULTS: Among the 243 patients included, 102 were ≥ 75 years old. Cardiac resynchronization therapy effectiveness was observed in 70 patients (50%) < 75 years old and in 48 patients (47%) ≥75 years old (p = 0.69). NYHA class ≥III (OR = 6.02; CI95% [1.33-18.77], p = 0.002) was a predictive factor for cardiac resynchronization therapy effectiveness only in the ≥75-year-old group, while atrial fibrillation was independently negatively associated with the primary endpoint in the < 75-year-old group (OR = 0.28; CI95% [0.13-0.62], p = 0.001). The one-year mortality rate was 14%, with no difference between age groups. Rescue cardiac resynchronization therapy and atrial fibrillation were independent predictive factors for mortality in both age groups. Eighty-two complications occurred in 45 patients (19%), with no difference between groups. Defibrillator use and QRS duration were independent predictive factors for complications in both age groups. There was no difference between groups considering device therapies. CONCLUSION: At one year, cardiac resynchronization therapy response is not compromised by patient age. In older patients, highly symptomatic individuals with NYHA class ≥III have better outcomes after cardiac resynchronization therapy.

Angles between the aortic root and the left ventricle assessed by MDCT are associated with the risk of aortic regurgitation after transcatheter aortic valve replacement.

OBJECTIVES: To evaluate the impact of the angles quantified by multidetector computed tomography (MDCT) between the ascending aorta's long axis and, the left ventricular inflow long axis (LVLA), or the left ventricule outflow tract long axis, and the occurrence of post-transcatheter aortic valve replacement (TAVR) aortic regurgitation (AR). METHODS: We prospectively included 136 consecutive patients who underwent a transfemoral TAVR with a preoperative MDCT. The groups were defined according to AR <2 or ≥2 assessed by echocardiography at 1 month. RESULTS: AR ≥2 identified in 21 patients (15.4%), was associated with increased rates of mortality (p value 0.02) and heart failure (p value 0.001) at 1-year follow-up. The aorta-LVLA angle was significantly higher in patients with AR ≥2 (130.5° ± 8.8° vs. 124.6° ± 9.5°; p = 0.009). On univariate analysis, aorta-LVLA angle was predictive of AR ≥2 [OR 1.07 per degree (1.02-1.13); p = 0.011]. After adjustment on annular calcification extent, the percentage of prosthesis-annular mismatch and the type of prosthesis, the relationship between aorta-LVLA angle and the risk of AR ≥2 remained unchanged. CONCLUSIONS: We showed that increased angulation between the ascending aorta and the LVLA is associated with higher rates of AR post-TAVR independent of other potential correlates.