Advanced heart failure: a contemporary approach

Advanced heart failure (HF) is defined as the persistence of severe symptoms despite the use of optimized medical, surgical, and device therapies. These patients require timely advanced treatments, such as heart transplantation or long-term mechanical circulatory support (MCS). Inotropic agents are often used to reduce congestion and increase cardiac output, while renal replacement therapy may be beneficial if necessary. Cardiac resynchronization therapy has clear benefits in patients with HF with reduced ejection fraction, particularly with left bundle branch block (QRS duration > 130 ms). The role of implantable cardioverter-defibrillators in advanced HF patients requires further investigation considering the introduction of novel HF medications. In selected patients with significant secondary mitral regurgitation, transcatheter edge-to-edge repair can help delay heart transplantation or long-term MCS. In later stages, the appropriateness of heart transplantation should be evaluated, and the use of short- or long-term MCS may be considered. A multidisciplinary HF management program is crucial for patients with advanced HF. Recent treatment advances, including drugs, devices, and MCS, have broadened the options available to patients with advanced HF and this trend is expected to continue.

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.

Clinical and genetic relationships between the QTc interval and risk of a stroke among atrial fibrillation patients undergoing catheter ablation

Background and objectives@#A prolonged QTc interval is associated with an increased risk of a stroke or atrial fibrillation (AF). However, its direct causal relationship with AF associated a stroke has not been proven yet. To examine whether QTc interval is causally linked with risk of stroke in AF patients, we used the Mendelian randomization analysis. @*Subjects and methods@#Among 2742 patients (73.6% male; 58.2 ± 11.0 years old; 69.5% with paroxysmal AF) who underwent AF catheter ablation, we analyzed 1766 patients who had preablation sinus rhythm electrocardiograms off antiarrhythmic drugs after excluding amiodarone users. Among them, 1213 subjects had genome-wide association study dataset analyzable for the Mendelian randomization. We explored the mechanistic relationships between QTc interval (ms) and the risk of a stroke by analyzing the Mendelian randomization (1213 subjects) after reviewing 35 genetic polymorphisms associated with the QTc in 31 European descent studies. @*Results@#Among the patients in the higher quartile with a higher QTc, CHA2DS2-VASc score (p < 0.001), and age (p  < 0.001), the proportions of a prior stroke (p  < 0.001), females, heart failure, and persistent AF were significantly higher than in those in the lower quartile. The QTc was independently associated with the CHA2DS2-VASc score (β, 4.63E−5; 95% confidence interval, 3.57E−6–8.90E−5; p  = 0.034) and ischemic strokes (odds ratio, 1.01; 95% confidence interval, 1.00–1.01; p  = 0.027). However, there was no direct causal relationship between the QTc and CHA2DS2-VASc score or a prior stroke in either the one-sample or two-sample Mendelian randomizations. @*Conclusion@#The QTc was independently associated with the CHA2DS2-VASc score and strokes among the patients with AF who underwent catheter ablation, despite no genetically direct causal relationship.

Incidence, Predictors, and Clinical Outcomes of New-Onset Diabetes Mellitus after Percutaneous Coronary Intervention with Drug-Eluting Stent

We investigated the incidence, predictors, and long-term clinical outcomes of new-onset diabetes mellitus (DM) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES). A total of 6,048 patients treated with DES were retrospectively reviewed and divided into three groups: 1) known DM (n = 2,365; fasting glucose > 126 mg/dL, glycated hemoglobin > 6.5%, already receiving DM treatment, or previous history of DM at the time of PCI); 2) non-DM (n = 3,247; no history of DM, no laboratory findings suggestive of DM at PCI, and no occurrence of DM during follow-up); and 3) new-onset DM (n = 436; non-DM features at PCI and occurrence of DM during follow-up). Among 3,683 non-DM patients, 436 (11.8%) patients were diagnosed with new-onset DM at 3.4 ± 1.9 years after PCI. Independent predictors for new-onset DM were high-intensity statin therapy, high body mass index (BMI), and high level of fasting glucose and triglycerides. The 8-year cumulative rate of major adverse cardiac events (a composite of cardiovascular death, myocardial infarction, stent thrombosis, or any revascularization) in the new-onset DM group was 19.5%, which was similar to 20.5% in the non-DM group (P = 0.467), but lower than 25.0% in the known DM group (P = 0.003). In conclusion, the incidence of new-onset DM after PCI with DES was not low. High-intensity statin therapy, high BMI, and high level of fasting glucose and triglycerides were independent predictors for new-onset DM. Long-term clinical outcomes of patients with new-onset DM after PCI were similar to those of patients without DM.

Transvenous Implantation of a DDDR Pacemaker in a Patient with Extracardiac Conduit Fontan Circulation / 대한내과학회지

As the survival rate of patients with complex congenital heart disease has improved and the number of adult patients with congenital heart disease has risen, arrhythmias and heart failure have become important issues in these patients. Cardiac implantable electronic devices, including pacemakers, are also on the rise. Transvenous implantation or epicardial pacemaker implantation is challenging in patients with complex congenital heart disease. Here we report a case in which a dual-chamber pacing, dual-chamber sensing, dual response and rate-adaptive (DDDR) pacemaker was implanted transvenously into a patient with congenital heart disease. A 34-year-old male with extracardiac conduit Fontan circulation complained of dizziness; an electrocardiogram revealed junctional bradycardia. We performed transvenous implantation of a DDDR pacemaker via trans-conduit puncture. In conclusion, transvenous implantation of a pacemaker is feasible in patients with extracardiac conduit Fontan circulation.

Metallic Foreign Body in Heart Mimicking Moderator Band

A foreign body in heart is rare, but it is more frequently encountered than the past as iatrogenic causes are increasing. Clinicians should be aware that foreign body could be mistaken for normal structure of heart. In order for accurate diagnosis, multi-imaging modalities should be used for information of exact location, mobility and hemodynamic effects. A decision to intervene should be made based on potential harms harbored by foreign bodies. Endovascular retrieval should be considered as an option. However, when fatal complications occur or when foreign bodies are embedded deeply, a surgical removal should be attempted.

Metallic Foreign Body in Heart Mimicking Moderator Band

A foreign body in heart is rare, but it is more frequently encountered than the past as iatrogenic causes are increasing. Clinicians should be aware that foreign body could be mistaken for normal structure of heart. In order for accurate diagnosis, multi-imaging modalities should be used for information of exact location, mobility and hemodynamic effects. A decision to intervene should be made based on potential harms harbored by foreign bodies. Endovascular retrieval should be considered as an option. However, when fatal complications occur or when foreign bodies are embedded deeply, a surgical removal should be attempted.

Transcatheter Aortic Valve Implantation Using CoreValve by Transaortic Approach

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is now considered as an alternative treatment option for severe aortic stenosis (AS) patients who cannot undergo surgical aortic valve replacement (AVR). CASE REPORT: We describe the first Korean case of transaortic TAVI with mini-sternotomy using CoreValve. A 83-year-old woman with severe AS and recent history of non-ST elevation myocardial infarction was referred to our institution for TAVI intervention. There was no amenable peripheral vascular access for transfemoral or trans-subclavian approach. Considering the relatively high procedural risk of transapical approach in this patient, we performed transaortic TAVI with mini-sternotomy. CONCLUSION: The present case suggests transaortic approach may be an effective and safe strategy for TAVI in high risk severe AS patients without eligible femoral or subclavian access routes.