Effect of Novel Programming on Inappropriate Implantable Cardioverter-Defibrillator Therapy in Patients With Very Low Ejection Fraction (from A MADIT-RIT).

The Multicenter Automatic Defibrillator Implantation Trial - Reduce Inappropriate Therapy showed a significant reduction in the risk of inappropriate therapy in patients with a programmed high-rate cutoff ≥200 beats per minute or delayed therapy for events ≥170 beats per minute compared with conventional programming. We aimed to characterize outcomes by left ventricular ejection fraction (LVEF) ranges for patients with high-rate, delayed, or conventional implantable cardioverter-defibrillator programming. We assessed the effect of LVEF (LVEF <15%, LVEF 15% to 25%, LVEF >25%) on the risk of inappropriate conventional implantable cardioverter-defibrillator therapy and death in Multicenter Automatic Defibrillator Implantation Trial - Reduce Inappropriate Therapy. Inappropriate therapies and death were independently evaluated by the adjudication committee. Statistical methods involved Kaplan-Meier time-to-event graphs and Cox proportional hazards regression analyses. The study involved 140 patients (9%) with LVEF 15%, 585 with LVEF 15% to 25% (39%), and 774 with LVEF >25% (52%). High-rate or delayed programming significantly reduced the risk of inappropriate therapy compared with conventional programming in patients with all LVEFs (p <0.001 for all LVEF). Patients with LVEF <15% had an exceptional 97% lower risk of inappropriate therapy, with high-rate programming than conventional programming (hazard ratio 0.028, p = 0.001), without an increase in mortality. High-rate and delayed programming is superior to conventional programming in all LVEF ranges, without adverse effects.

Aortic plaque dehiscence caused by rotational atherectomy with Kokeshi phenomenon in a patient with aortic stenosis successfully treated with transcatheter aortic valve replacement.

Rotational atherectomy (RA) is an important interventional technique to facilitate effective percutaneous coronary intervention of severely calcified lesions. Despite the improved probability of better procedural outcomes during angioplasty, the use of RA is associated with an inherent risk of complications. Here, we present a case of a woman in her mid-90s with severe aortic stenosis (AS) who underwent RA facilitated angioplasty of the right coronary artery (RCA), with the procedure complicated by the Kokeshi phenomenon. Manual traction to retrieve the burr resulted in dehiscence of an aortic plaque near the ostium of the RCA. Unfortunately, the patient's risk profile precluded surgery. After a multidisciplinary discussion, a self-expanding Core Valve Evolut R prosthesis (Medtronic, Minneapolis, Minnesota, USA) was successfully implanted, with improvement in the AS and stabilisation of the aortic plaque. This is the first reported case of successful non-operative management of a mobile-aortic plaque caused by RA with a transcatheter prosthesis.

Management of Heparin-Induced Thrombocytopenia Using Plasmapharesis in Patients Undergoing HeartMate 3 Left Ventricular Assist Device.

Heparin-induced thrombocytopenia (HIT) type-2 is a rare, but life-threatening complication that presents a unique challenge in patients undergoing cardiac surgery. Patients that require cardiac surgery with HIT present a dilemma between intraoperative anticoagulation, perioperative bleeding risk, and perioperative thrombotic events. We describe a case series of four patients who developed HIT in their hospital course before HeartMate 3 (HM3) left ventricular assist device implantation. Following a multidisciplinary approach, all patients did well intraoperatively with an approach of preoperative plasmapheresis, intraoperative unfractionated heparin (UFH), and postoperative conversion to bivalirudin with a bridge to warfarin. However, two patients had postoperative bleeding complications on bivalirudin. This case series details the therapeutic challenges encountered for HM3 implantation in patients with HIT and offers a therapeutic alternative to intraoperative bivalirudin in the effort to decrease perioperative complications in this challenging patient population.

Left Ventricular Reverse Remodeling in Cardiac Resynchronization Therapy and Long-Term Outcomes.

OBJECTIVES: The aim of this study was to evaluate the association between improvement in left ventricular end-systolic volume (LVESV) with cardiac resynchronization therapy (CRT) and mortality and whether this relationship was modified by the presence of a left bundle branch block (LBBB) electrocardiographic pattern. BACKGROUND: Left ventricular reverse remodeling in patients receiving CRT has been shown to predict outcomes. However, the extent to which reverse remodeling contributes to long-term survival is not well understood. METHODS: Changes in LVESV were assessed in MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy) patients receiving CRT with a defibrillator (CRT-D) and echocardiograms available at 1 year (n = 752), stratified by LBBB, relative to long-term all-cause mortality, compared with those with implantable cardioverter-defibrillators (ICDs) only (n = 684). RESULTS: In patients with LBBB, a reduction in LVESV of >35% (median) translated into significantly lower risk for long-term mortality (hazard ratio [HR]: 0.34; p < 0.001), heart failure (HF) events (HR: 0.21; p < 0.001), and HF or death (HR: 0.27; p < 0.001) compared with patients with ICDs only. Patients with reductions in LVESV ≤35% had a significantly lower risk for HF, and HF or death, and a nonsignificantly lower rate of death compared with those with ICDs only (HR: 0.74; p = 0.13). Risk reduction in HF events was uniform across all LVESV quartiles. In patients without LBBB, there was no survival benefit (HR: 0.68; p = 0.271) despite an LVESV reduction greater than the median (>27.6%). CRT-D patients without LBBB with the least reverse remodeling (quartile 1) had a more than 3-fold increased risk for death compared with those with ICDs only (HR: 3.11; p < 0.001). CONCLUSIONS: In patients with LBBB, CRT-D-induced reduction in LVESV at 1 year is associated with long-term survival benefit. Despite left ventricular reverse remodeling with CRT-D, there is no survival benefit and potential harm in patients without LBBB.

Atrial myxoma presenting as acute ischaemic stroke and chronic right lower leg claudication.

A 48-year-old man presented with acute onset of left facial numbness, ataxic gait and double vision. He also complained of chronic right lower leg pain with acute onset a year prior to presentation. His vital signs were within normal limits. Physical exam was notable for right-sided intranuclear opthalmoplegia, decreased sensation to light touch on the left side of his body, left-sided dysmetria and ataxic gait. Neuroimaging showed evidence of acute stroke in the cerebellum and brainstem, for which he was treated with thrombolytics. An echocardiogram revealed a 5×3 cm left atrial myxoma, which was surgically resected. Subsequent imaging of his lower extremity revealed a chronic common iliac artery occlusion for which he underwent angioplasty. His claudication symptoms resolved, and he was without any neurological deficits at a 2-year follow-up visit.

Non-response to Cardiac Resynchronization Therapy.

PURPOSE OF REVIEW: Cardiac resynchronization therapy (CRT) is an effective treatment option for therapy-refractory mild to severe heart failure (HF) patients with reduced ejection fraction and left ventricular (LV) conduction delay. Multiple clinical trials have shown that CRT improves cardiac function and overall quality of life, as well as reduces HF hospitalizations, health care costs, and mortality. RECENT FINDINGS: Despite its effectiveness, the "non-response" rate to CRT is around 30%, remaining a major challenge that faces electrophysiologists and researchers. It has been recently suggested that the etiology of CRT non-response is multifactorial, and it requires a multifaceted approach to address it. In this focused review, we will summarize the definitions of CRT non-response, identify key factors for CRT non-response, and offer a simplified framework to address CRT non-response with the main goal of improving CRT outcomes.