Clinical Implications of DeviceDetected Atrial Fibrillation in Cardiac Resynchronization Therapy

Background and Objectives@#Atrial fibrillation (AF) is associated with decreased cardiac resynchronization therapy (CRT) benefits compared to sinus rhythm (SR). Effective biventricular (BiV) pacing is a determinant of CRT success, but AF can interfere with adequate BiV pacing and affect clinical outcomes. We investigated the effect of device-detected AF on clinical outcomes and optimal BiV pacing in patients with heart failure (HF) treated with CRT. @*Methods@#We retrospectively analyzed 174 patients who underwent CRT implantation between 2012 and 2019 at a tertiary center. The optimal BiV pacing percentage was defined as ≥98%. Device-detected AF was defined as an atrial high-rate episode ≥180 beats per minute lasting more than 6 minutes during the follow-up period. We stratified the patients without preexisting AF at pre-implantation into device-detected AF and no-AF groups. @*Results@#A total of 120 patients did not show preexisting AF at pre-implantation, and 54 had AF. Among these 120 patients, 19 (15.8%) showed device-detected AF during a median follow-up of 25.1 months. The proportion of optimal BiV pacing was significantly lower in the device-detected AF group than in the no-AF group (42.1% vs. 75.2%, p=0.009). The devicedetected AF group had a higher incidence of HF hospitalization, cardiovascular death, and all-cause death than the no-AF group. The device-detected AF and previous AF groups showed no significant differences regarding the percentage of BiV pacing and clinical outcomes. @*Conclusions@#For HF patients implanted with CRT, device-detected AF was associated with lower optimal BiV pacing and worse clinical outcomes than no-AF.

Treatment of advanced heart failure

The development of medical and device treatment of heart failure (HF) has improved the survival and quality of life in HF patients. However, not all HF patients respond well to these up-to-date HF treatments. We have termed these non-responders as advanced HF patients. The definition, diagnosis, and treatment of advanced HF are discussed in this review article.Current Concepts: After current guideline-directed treatments, advanced HF patients can experience aggravation and decompensation, usually resulting in hospitalization for the symptoms and volume control. Recurrent decompensation or hospitalization can cause a vicious cycle between the heart and other vital organs, such as the kidney and liver. Current and up-to-date guidelines recommend treatments, including heart transplant, left ventricular assist device (LVAD), and hospice care, for advanced HF. Given the limitation of heart transplant donors, LVAD can be used as a bridge to transplant, in addition to destination therapy. Updated LVAD system can reduce pump-related thrombosis, stroke, and bleeding.Discussion and Conclusion: Current guidelines suggest early recognition of advanced HF and referral to advanced HF specialists. Despite advances in the treatments of advanced HF, unmet needs for further improving clinical outcomes and quality of life exist.

In silico screening method for non‑responders to cardiac resynchronization therapy in patients with heart failure: a pilot study

Background@#Cardiac resynchronization therapy (CRT) is an effective treatment option for patients with heart failure (HF) and left ventricular (LV) dyssynchrony. However, the problem of some patients not responding to CRT remains unresolved. This study aimed to propose a novel in silico method for CRT simulation. @*Methods@#Three-dimensional heart geometry was constructed from computed tomography images. The finite ele‑ ment method was used to elucidate the electric wave propagation in the heart. The electric excitation and mechani‑ cal contraction were coupled with vascular hemodynamics by the lumped parameter model. The model parameters for three-dimensional (3D) heart and vascular mechanics were estimated by matching computed variables with measured physiological parameters. CRT effects were simulated in a patient with HF and left bundle branch block (LBBB). LV end-diastolic (LVEDV) and end-systolic volumes (LVESV), LV ejection fraction (LVEF), and CRT responsiveness measured from the in silico simulation model were compared with those from clinical observation. A CRT responder was defined as absolute increase in LVEF ≥ 5% or relative increase in LVEF ≥ 15%. @*Results@#A 68-year-old female with nonischemic HF and LBBB was retrospectively included. The in silico CRT simu‑ lation modeling revealed that changes in LVEDV, LVESV, and LVEF by CRT were from 174 to 173 mL, 116 to 104 mL, and 33 to 40%, respectively. Absolute and relative ΔLVEF were 7% and 18%, respectively, signifying a CRT responder.In clinical observation, echocardiography showed that changes in LVEDV, LVESV, and LVEF by CRT were from 162 to 119 mL, 114 to 69 mL, and 29 to 42%, respectively. Absolute and relative ΔLVESV were 13% and 31%, respectively, also signifying a CRT responder. CRT responsiveness from the in silico CRT simulation model was concordant with that in the clinical observation. @*Conclusion@#This in silico CRT simulation method is a feasible technique to screen for CRT non-responders in patients with HF and LBBB.

Sodium-glucose Co-transporter 2 Inhibitors: a New Path for Heart Failure Treatment

Results from cardiovascular outcome trials (CVOT) with 5 different sodium-glucose cotransporter 2 inhibitors (SGLT2i; empagliflozin, canagliflozin, dapagliflozin, ertugliflozin, sotagliflozin), initially developed for their glucose-lowering effect by blocking tubular glucose reabsorption in kidney, have been shown to decrease the risk of heart failure hospitalization (HFH) across a range of patients with and without atherosclerotic cardiovascular disease in patients with type 2 diabetes mellitus (T2DM). Following these CVOT results, SGLT2i (dapagliflozin, empagliflozin, sotagliflozin) also were reported to reduce HFH and cardiovascular death in patients with heart failure with reduced ejection fraction (HFrEF), regardless of existence or absence of T2DM. Ongoing studies have been conducted to evaluate the clinical benefit of SGLT2i (empagliflozin, dapagliflozin) in patients with heart failure with preserved ejection fraction (HFpEF). Although SGLT2i brought us to the entrance of a new era for prevention of HF incidence and worsening of HF, the search for pivotal mechanism of SGLT2i to improve our pharmacological armamentarium should continue in order to protect every HF patient from fatal progression of HF disease. In this review, we summarized the updated clinical evidences on SGLT2i (rather than basic and translational evidence) for reduction of HF risk in T2DM patients and favorable clinical outcomes in both HFrEF and HFpEF patients.

Nlrp3, Csf3, and Edn1 in Macrophage Response to Saturated Fatty Acids and Modified Low-Density Lipoprotein

Background and Objectives@#The relationship between metabolic stress, inflammation, and cardiovascular disease is being studied steadily. The aim of this study was to evaluate the effect of palmitate (PA) and minimally modified low-density lipoprotein (mmLDL) on macrophages and to identify the associated pathways. @*Methods@#J774 macrophages were incubated with PA or mmLDL and lipopolysaccharide (LPS). Secretion of inflammatory chemokines and the expression of corresponding genes were determined. The phosphorylation of extracellular signal-regulated kinase (ERK) mitogen-activated protein kinase was also assessed. RNA sequencing of macrophages was performed to identify the genes regulated by PA or mmLDL. Some of the genes regulated by the 2 agents were validated by knocking down the cells using small interfering RNA. @*Results@#PA or mmLDL promoted the secretion of interleukin (IL)-6 and IL-1β in LPSstimulated macrophages, and this was accompanied by higher phosphorylation of ERK. RNA sequencing revealed dozens of genes that were regulated in this process, such as Csf3 and Edn1, which were affected by PA and mmLDL, respectively. These agents also increased Nlrp3 expression. The effect of Csf3 or Edn1 silencing on inflammation was modest, whereas toll-like receptor (TLR) 4 inhibition reduced a large proportion of macrophage activation. @*Conclusions@#We demonstrated that the proinflammatory milieu with high levels of PA or mmLDL promoted macrophage activation and the expression of associated genes such as Nlrp3, Csf3, and Edn1. Although the TLR4 pathway appeared to be most relevant, additional role of other genes in this process provided insights regarding the potential targets for intervention.

Sodium-glucose Co-transporter 2 Inhibitors: a New Path for Heart Failure Treatment

Results from cardiovascular outcome trials (CVOT) with 5 different sodium-glucose cotransporter 2 inhibitors (SGLT2i; empagliflozin, canagliflozin, dapagliflozin, ertugliflozin, sotagliflozin), initially developed for their glucose-lowering effect by blocking tubular glucose reabsorption in kidney, have been shown to decrease the risk of heart failure hospitalization (HFH) across a range of patients with and without atherosclerotic cardiovascular disease in patients with type 2 diabetes mellitus (T2DM). Following these CVOT results, SGLT2i (dapagliflozin, empagliflozin, sotagliflozin) also were reported to reduce HFH and cardiovascular death in patients with heart failure with reduced ejection fraction (HFrEF), regardless of existence or absence of T2DM. Ongoing studies have been conducted to evaluate the clinical benefit of SGLT2i (empagliflozin, dapagliflozin) in patients with heart failure with preserved ejection fraction (HFpEF). Although SGLT2i brought us to the entrance of a new era for prevention of HF incidence and worsening of HF, the search for pivotal mechanism of SGLT2i to improve our pharmacological armamentarium should continue in order to protect every HF patient from fatal progression of HF disease. In this review, we summarized the updated clinical evidences on SGLT2i (rather than basic and translational evidence) for reduction of HF risk in T2DM patients and favorable clinical outcomes in both HFrEF and HFpEF patients.

Nlrp3, Csf3, and Edn1 in Macrophage Response to Saturated Fatty Acids and Modified Low-Density Lipoprotein

Background and Objectives@#The relationship between metabolic stress, inflammation, and cardiovascular disease is being studied steadily. The aim of this study was to evaluate the effect of palmitate (PA) and minimally modified low-density lipoprotein (mmLDL) on macrophages and to identify the associated pathways. @*Methods@#J774 macrophages were incubated with PA or mmLDL and lipopolysaccharide (LPS). Secretion of inflammatory chemokines and the expression of corresponding genes were determined. The phosphorylation of extracellular signal-regulated kinase (ERK) mitogen-activated protein kinase was also assessed. RNA sequencing of macrophages was performed to identify the genes regulated by PA or mmLDL. Some of the genes regulated by the 2 agents were validated by knocking down the cells using small interfering RNA. @*Results@#PA or mmLDL promoted the secretion of interleukin (IL)-6 and IL-1β in LPSstimulated macrophages, and this was accompanied by higher phosphorylation of ERK. RNA sequencing revealed dozens of genes that were regulated in this process, such as Csf3 and Edn1, which were affected by PA and mmLDL, respectively. These agents also increased Nlrp3 expression. The effect of Csf3 or Edn1 silencing on inflammation was modest, whereas toll-like receptor (TLR) 4 inhibition reduced a large proportion of macrophage activation. @*Conclusions@#We demonstrated that the proinflammatory milieu with high levels of PA or mmLDL promoted macrophage activation and the expression of associated genes such as Nlrp3, Csf3, and Edn1. Although the TLR4 pathway appeared to be most relevant, additional role of other genes in this process provided insights regarding the potential targets for intervention.

Anti-Inflammatory Effect for Atherosclerosis Progression by Sodium-Glucose Cotransporter 2 (SGLT-2) Inhibitor in a Normoglycemic Rabbit Model

BACKGROUND AND OBJECTIVES@#We sought to investigate an anti-atherosclerotic and anti-inflammatory effect of sodium-glucose cotransporter-2 (SGLT-2) inhibitors in normoglycemic atherosclerotic rabbit model.@*METHODS@#Male New Zealand white rabbits (n=26) were fed with a 1% high-cholesterol diet for 7 weeks followed by normal diet for 2 weeks. After balloon catheter injury, the rabbits were administered with the Dapagliflozin (1mg/kg/day) or control-medium for 8 weeks (n=13 for each group). All lesions were assessed with angiography, optical coherence tomography (OCT), and histological assessment.@*RESULTS@#Atheroma burden (38.51±3.16% vs. 21.91±1.22%, p<0.01) and lipid accumulation (18.90±3.63% vs. 10.20±2.03%, p=0.047) was significantly decreased by SGLT-2 inhibitor treatment. The SGLT-2 inhibitor group showed lower macrophage infiltration (20.23±1.89% vs. 12.72±1.95%, p=0.01) as well as tumor necrosis factor (TNF)-α expression (31.17±4.40% vs. 19.47±2.10%, p=0.025). Relative area of inducible nitric oxide synthase+ macrophages was tended to be lower in the SGLT-2 inhibitor-treated group (1.00±0.16% vs. 0.71±0.10%, p=0.13), while relative proportion of Arg1⁺ macrophage was markedly increased (1.00±0.27% vs. 2.43±0.64%, p=0.04). As a result, progression of atherosclerosis was markedly attenuated in SGLT-2 inhibitor treated group (OCT area stenosis, 32.13±1.20% vs. 22.77±0.88%, p<0.01). Mechanistically, SGLT-2 treatment mitigated the inflammatory responses in macrophage. Especially, Toll-like receptor 4uclear factor-kappa B signaling pathway, and their downstream effectors such as interleukin-6 and TNF-α were markedly suppressed by SGLT-2 inhibitor treatment.@*CONCLUSIONS@#These results together suggest that SGLT-2 inhibitor exerts an anti-atherosclerotic effect through favorable modulation of inflammatory response as well as macrophage characteristics in non-diabetic situation.

Left ventricular response after cardiac resynchronization therapy is related to early leftatrial volume reduction

Background/Aims@#The current study aimed to elucidate a time-course change in left atrial volume after cardiac resynchronization therapy (CRT) and to verify factors associated with left atrial volume reduction (LAVR) and its prognostic implications. @*Methods@#The records of 97 patients were retrospectively reviewed after CRT.Echocardiographic data were analyzed at baseline before CRT, at early follow-up FU) (≤ 1 year, median 6 months), and at late FU (median 30 months). Left ventricular volume response (LVVR) was defined as 15% reduction in left ventricular (LV) end-systolic volume (ESV). LAVR was classified into two groups by the median value at early FU: LAVR (≥ 7.5%) and no LAVR (< 7.5%). @*Results@#LV ESV index continuously decreased from baseline to early FU and from early FU to late FU (106.1 ± 47.4 mL/m2 vs. 87.6 ± 51.6 mL/m2 vs. 72.5 ± 57.1 mL/m2).LA volume index decreased from baseline to early FU, but there were no reductions thereafter (51.8 ± 21.9 mL/m2 vs. 45.1 ± 19.6 mL/m2 vs. 44.9 ± 23.0 mL/m2).The only echocardiographic factor associated with LAVR was change in E velocity(odds ratio [OR], 1.04;p = 0.002). Early LAVR (OR, 10.05;p = 0.002) was an independent predictor for late LVVR. @*Conclusions@#LAVR was related to reduction in E velocity, suggesting its relation with optimization of LV filling pressure. Early LAVR was a predictor for LVVR to CRT in long-term FU.

Anti-Inflammatory Effect for Atherosclerosis Progression by Sodium-Glucose Cotransporter 2 (SGLT-2) Inhibitor in a Normoglycemic Rabbit Model

BACKGROUND AND OBJECTIVES: We sought to investigate an anti-atherosclerotic and anti-inflammatory effect of sodium-glucose cotransporter-2 (SGLT-2) inhibitors in normoglycemic atherosclerotic rabbit model.METHODS: Male New Zealand white rabbits (n=26) were fed with a 1% high-cholesterol diet for 7 weeks followed by normal diet for 2 weeks. After balloon catheter injury, the rabbits were administered with the Dapagliflozin (1mg/kg/day) or control-medium for 8 weeks (n=13 for each group). All lesions were assessed with angiography, optical coherence tomography (OCT), and histological assessment.RESULTS: Atheroma burden (38.51±3.16% vs. 21.91±1.22%, p<0.01) and lipid accumulation (18.90±3.63% vs. 10.20±2.03%, p=0.047) was significantly decreased by SGLT-2 inhibitor treatment. The SGLT-2 inhibitor group showed lower macrophage infiltration (20.23±1.89% vs. 12.72±1.95%, p=0.01) as well as tumor necrosis factor (TNF)-α expression (31.17±4.40% vs. 19.47±2.10%, p=0.025). Relative area of inducible nitric oxide synthase+ macrophages was tended to be lower in the SGLT-2 inhibitor-treated group (1.00±0.16% vs. 0.71±0.10%, p=0.13), while relative proportion of Arg1⁺ macrophage was markedly increased (1.00±0.27% vs. 2.43±0.64%, p=0.04). As a result, progression of atherosclerosis was markedly attenuated in SGLT-2 inhibitor treated group (OCT area stenosis, 32.13±1.20% vs. 22.77±0.88%, p<0.01). Mechanistically, SGLT-2 treatment mitigated the inflammatory responses in macrophage. Especially, Toll-like receptor 4/nuclear factor-kappa B signaling pathway, and their downstream effectors such as interleukin-6 and TNF-α were markedly suppressed by SGLT-2 inhibitor treatment.CONCLUSIONS: These results together suggest that SGLT-2 inhibitor exerts an anti-atherosclerotic effect through favorable modulation of inflammatory response as well as macrophage characteristics in non-diabetic situation.

Left Ventricular End-Systolic Volume Can Predict 1-Year Hierarchical Clinical Composite End Point in Patients with Cardiac Resynchronization Therapy

PURPOSE: This study aimed to elucidate which echocardiographic criteria at three time points, for cardiac resynchronization therapy (CRT) response, are accurate in discriminating the hierarchical clinical composite end point (HCCEP). MATERIALS AND METHODS: We included 120 patients (age, 66.1±12.6 years; men, 54.2%) who underwent CRT implantation for heart failure (HF). Echocardiography was performed before and at 3, 6, and 12 months after CRT implantation. The 1-year HCCEP included all-cause mortality, hospitalization for HF, and New York Heart Association functional class for 12 months. CRT response criteria were decrease in left ventricular (LV) end-systolic volume (LVESV) >15%, decrease in LV end-diastolic volume >15%, absolute increase in LV ejection fraction (LVEF) ≥5%, relative increase in LVEF ≥15%, and decrease in mitral regurgitation ≥1 grade. Temporal changes in CRT response rates, accuracy of CRT response criteria at each time and cutoff value for the discrimination of improvement in HCCEP, and agreements with improvement in HCCEP were analyzed. RESULTS: HCCEP improvement rates were 65.8% in total group. In nonischemic group, CRT response rates according to all echocardiographic criteria significantly increased with time. In ischemic group, CRT response rate did not significantly change with time. In total group, ΔLVESV at 6 months (ΔLVESV6) had the most significant accuracy for the discrimination of HCCEP (area under the curve=0.781). The optimal cutoff value of ΔLVESV6 was 13.5% (sensitivity=0.719, specificity=0.719). ΔLVESV6 had fair agreement with HCCEP (κ=0.391, p < 0.001). CONCLUSION: ΔLVESV6 is the most useful echocardiographic CRT response criterion for the prediction of 1-year HCCEP.

Correction: Need Assessment for Smartphone-Based Cardiac Telerehabilitation / 대한의료정보학회지

The final degrees of education for the third and fourth authors were mutually misplaced.

The Korean Organ Transplant Registry (KOTRY): Second Official Adult Heart Transplant Report

BACKGROUND AND OBJECTIVES@#This second adult heart transplantation (HTx) report is based on Korean Organ Transplant Registry data submitted on 400 HTxs in recipients of all ages.@*METHODS@#From March 2014 to December 2017, a total of 400 HTxs were performed at 4 major centers in Korea. We analyzed demographics and characteristics according to transplant years. Patterns of immunosuppression, allograft rejection, and survival after HTx were analyzed. Donor and recipient age were highlighted.@*RESULTS@#Some distinct differences in HTx statistics were noted. Mean donor age increased significantly in the most recent years compared to 2014–2015, while mean recipient age did not change. The proportion of patients on pre-transplant extracorporeal membrane oxygenation (ECMO) increased over time. One-year and intermediate-term survival was significantly worse in patients on pre-transplant ECMO compared to those without mechanical support. Over the years, tacrolimus has increased to become the most frequently used calcineurin inhibitor over cyclosporine, while the number of patients using steroids both at discharge and 1-year follow-up has declined. Age did not affect 1-year survival, but significantly affected intermediate-term survival.@*CONCLUSIONS@#From 2014 to 2017, centers were willing to accept older donors to address increasing organ shortages and more patients received transplant under ECMO care. Increasing age was a strong independent factor for intermediate-term survival, however, post-transplant comorbidities did not differ among age groups. Further studies with longer follow-up duration are needed to better understand age-related post-transplant prognosis.

Effect of Niacin on Carotid Atherosclerosis in Patients at Low-Density Lipoprotein-Cholesterol Goal but High Lipoprotein (a) Level: a 2-Year Follow-Up Study

OBJECTIVE: To examine the effect of niacin on the progression of carotid intima-media thickness (IMT) in patients with high level of lipoprotein (Lp) (a). METHODS: Patients at low-density lipoprotein-cholesterol goal but with Lp (a) >25 mg/dL and mean carotid IMT >0.75 mm were included. Eligible patients were randomized at a 1:2 ratio into one of two groups for 24 months: control or 1,500 mg extended release niacin. The primary study outcomes were the percentage changes in mean and maximal carotid IMT. The percentage change in lipid profiles including Lp (a) was analyzed as a secondary study outcome. RESULTS: Among 96 randomized patients, 31 completed the study (mean age: 65 years; male: 44%). At follow-up, the percentage change in mean carotid IMT was not significantly different between the two groups (−1.4%±15.5% and −1.1%±7.3% in the control and niacin groups, respectively, p=0.95). The percentage change in maximal carotid IMT was also similar in the two groups (0.7%±16.5% and −4.4%±11.6%, respectively, p=0.35). Elevation of high-density lipoprotein-cholesterol tended to be higher in the niacin group (p=0.07), and there was a significant difference in the percentage change in hemoglobin A1c between the two groups (−1.9%±2.2% and 3.3%±6.7%, respectively, p=0.02). Reduction of Lp (a) was greater in the niacin-treated group compared to placebo, but the difference was not statistically significant. CONCLUSION: Treatment with niacin for two years did not inhibit the progression of carotid intima-media thickening in patients with high Lp (a) level. However, this study may have been underpowered to evaluate the primary study outcome.

Characteristics and Safety of Cardiopulmonary Exercise Testing in Elderly Patients with Cardiovascular Diseases in Korea

PURPOSE: Clinical use of cardiopulmonary exercise tests (CPETs) is increasing in elderly patients with cardiovascular (CV) diseases. However, data on Korean populations are limited. In this study, we aimed to examine the characteristics and safety of CPET in an elderly Korean population with CV disease. MATERIALS AND METHODS: We retrospectively analyzed records of 1485 patients (older than 65 years in age, with various underlying CV diseases) who underwent CPET. All CPET was performed using the modified Bruce ramp protocol. RESULTS: The mean age of patients was 71.6±4.7 years with 63.9% being men, 567 patients aged 60–65 years, 818 patients aged 70–79 years, and 100 patients aged 80–89 years. The mean respiratory exchange ratio was 1.09±0.14. During CPET, three adverse cardiovascular events occurred (total 0.20%), all ventricular tachycardia. All subjects showed an average exercise capacity of 21.3±5.5 mL/kg/min at peak VO2 and 6.1±1.6 metabolic equivalents of task, and men showed better exercise capacity than women on most CEPT parameters. A significant difference was seen in peak oxygen uptake according to age group (65–69 years, 22.9±5.8; 70–79 years, 20.7±5.1; 80–89 years, 17.0±4.5 mL/kg/min, p<0.001). The most common causes for CPET termination were dyspnea (64.8%) and leg pain (24.3%), with higher incidence of leg pain in octogenarians compared to other age groups (65–69 years, 22.4%; 70–79 years, 24.6%; 80–89 years, 32.0%, p<0.001). CONCLUSION: CPET was relatively a safe and useful modality to assess exercise capacity, even in an elderly Korean population with underlying CV diseases.

The Korean Organ Transplant Registry (KOTRY): Second Official Adult Heart Transplant Report

BACKGROUND AND OBJECTIVES: This second adult heart transplantation (HTx) report is based on Korean Organ Transplant Registry data submitted on 400 HTxs in recipients of all ages. METHODS: From March 2014 to December 2017, a total of 400 HTxs were performed at 4 major centers in Korea. We analyzed demographics and characteristics according to transplant years. Patterns of immunosuppression, allograft rejection, and survival after HTx were analyzed. Donor and recipient age were highlighted. RESULTS: Some distinct differences in HTx statistics were noted. Mean donor age increased significantly in the most recent years compared to 2014–2015, while mean recipient age did not change. The proportion of patients on pre-transplant extracorporeal membrane oxygenation (ECMO) increased over time. One-year and intermediate-term survival was significantly worse in patients on pre-transplant ECMO compared to those without mechanical support. Over the years, tacrolimus has increased to become the most frequently used calcineurin inhibitor over cyclosporine, while the number of patients using steroids both at discharge and 1-year follow-up has declined. Age did not affect 1-year survival, but significantly affected intermediate-term survival. CONCLUSIONS: From 2014 to 2017, centers were willing to accept older donors to address increasing organ shortages and more patients received transplant under ECMO care. Increasing age was a strong independent factor for intermediate-term survival, however, post-transplant comorbidities did not differ among age groups. Further studies with longer follow-up duration are needed to better understand age-related post-transplant prognosis.

Association of Newly Developed Right Bundle Branch Block with Graft Rejection Following Heart Transplantation

PURPOSE: We aimed to examine associations between right bundle branch block (RBBB) following heart transplantation (HT) and graft rejection. MATERIALS AND METHODS: We investigated 51 patients who underwent endomyocardial biopsies, electrocardiogram, right-side cardiac catheterization, and echocardiography at 1 month and 1 year after HT. We classified patients into four groups according to the development of RBBB, based on electrocardiogram at 1 month and 1 year: 1) sustained RBBB, 2) disappeared RBBB, 3) newly developed RBBB, and 4) sustained non-RBBB. The RBBB was defined as an RSR' pattern in V1 with a QRS duration ≥100 ms on electrocardiogram. RESULTS: The newly developed RBBB group (n=13, 25.5%) had a higher rate of new onset graft rejection (from grade 0 to grade ≥1R, 30.8% vs. 10.0% vs. 21.4%, p=0.042) at 1 year, compared with sustained RBBB (n=10, 19.6%) and sustained non-RBBB group (n=28, 54.9%). In contrast, the incidence of resolved graft rejection (from grade ≥1R to grade 0) was higher in the sustained RBBB group than the newly developed RBBB and sustained non-RBBB groups (70.0% vs. 7.7% vs. 25.0%, p=0.042). Left atrial volume index was significantly higher in the newly developed RBBB group than the sustained RBBB and sustained non-RBBB groups (60.6±25.9 mL/m2 vs. 36.0±11.0 mL/m2 vs. 38.4±18.1 mL/m2, p=0.003). CONCLUSION: Close monitoring for new development of RBBB at 1 year after HT, which was associated with a higher incidence of new onset graft rejection, may be helpful to identify high risk patients for graft rejection.

Need Assessment for Smartphone-Based Cardiac Telerehabilitation / 대한의료정보학회지

OBJECTIVES: To identify the current status of smartphone usage and to describe the needs for smartphone-based cardiac telerehabilitation of cardiac patients. METHODS: In 2016, a questionnaire survey was conducted in a supervised ambulatory cardiac rehabilitation (CR) program in a university affiliated hospital with the participation of heart failure or heart transplantation patients who were smartphone users. The questionnaire included questions regarding smartphone usage, demands for smartphone-based disease education, and home health monitoring systems. Results were described and analyzed according to principal diagnosis. RESULTS: Ninety-six patients (66% male; mean age, 53 ± 11 years), including 56 heart failure and 40 heart transplantation patients, completed the survey (completion rate, 95%). The median daily smartphone usage time was 120 minutes (interquartile range, 60–300), and the most frequently used smartphone function was text messaging (61.5%). Of the patients, 26% stated that they searched for health-related information using their smartphones more than 1 time per week. The major source of health-related information was Internet browsing (50.0%), and the least sought source was the hospital's website (3.1%). Patients with heart failure expressed significantly higher needs for disease education on treatment plan, home health monitoring of blood pressure, and body weight (χ2 = 5.79, 6.27, 4.50, p < 0.05). Heart transplantation patients expressed a significant need for home health monitoring of body temperature (χ2 = 5.25, p < 0.05). CONCLUSIONS: Heart failure and heart transplantation patients show high usage of and interest in mobile health technology. A smartphone-based cardiac telerehabilitation program should be developed based on high demand areas and modified to suit to each principal diagnosis.

Bioptome Perforation at Superior Vena Cava Anastomosis Site in Transplanted Heart

No abstract available.

High Prevalence and Clinical Implication of Myocardial Bridging in Patients with Early Repolarization

PURPOSE: Recent evidence suggests that early repolarization (ER) is related with myocardial ischemia. Compression of coronary artery by a myocardial bridging (MB) can be associated with clinical manifestations of myocardial ischemia. This study aimed to evaluate the associations of MB in patients with ER. MATERIALS AND METHODS: In consecutive patients (n=1303, age, 61±12 years) who had undergone coronary angiography, we assessed the prevalence and prognostic implication of MB in those with ER (n=142) and those without ER (n=1161). RESULTS: MB was observed in 54 (38%) and 196 (17%) patients in ER and no-ER groups (p<0.001). In multivariate analysis, MB was independently associated with ER (odd ratio: 2.9, 95% confidence interval: 1.98–4.24, p<0.001). Notched type ER was more frequently observed in MB involving the mid portion of left anterior descending coronary artery (LAD) (69.8% vs. 30.2%, p=0.03). Cardiac event was observed in nine (6.3%) and 22 (1.9%) subjects with and without ER, respectively. MB was more frequently observed in sudden death patients with ER (2 out of 9, 22%) than in those without ER (0 out of 22). CONCLUSION: MB was independently associated with ER in patients without out structural heart disease who underwent coronary angiography. Notched type ER was closely related with MB involving the mid portion of the LAD. Among patients who had experienced cardiac events, a higher prevalence of MB was observed in patients with ER than those without ER. Further prospective studies on the prognosis of MB in ER patients are required.