Assisted reproduction in patients with cardiac disease: A retrospective review.

OBJECTIVE: To assess risks of assisted reproduction in patients with cardiac disease. STUDY DESIGN: Retrospective case note review of patients with cardiac disease undergoing ART over a 10 year period in the obstetric cardiac services of three UK tertiary centres. Assessment of maternal, obstetric and fetal complications during ART and resultant pregnancies. RESULTS: 34 patients with cardiac disease underwent 51 cycles of assisted reproduction. 24 patients (71%) received pre-pregnancy counselling. Mean age at the start of an assisted reproduction cycle was 32 years. Modified WHO (mWHO) risk category for the 34 patients was mWHO I, n = 3; mWHO II, n = 13; mWHO II- III, n = 10; mWHO III, n = 7; mWHO IV, n = 1. The 51 assisted reproduction cycles resulted in 31 pregnancies in 29 patients, and 31 live births, including two sets of twins. Live birth rate per cycle was 60.8%. Twin pregnancy rate per cycle was 5.8%. Four patients experienced complications during assisted reproduction treatment (7.8% per cycle); one major intra-abdominal haemorrhage following egg collection in a patient with a mechanical aortic valve, one endocarditis, one mild ovarian hyperstimulation syndrome and one vagal syncope during egg collection. Four other patients experienced cardiac complications during resultant pregnancies (12.9%). 43% of mWHO class III patients experienced cardiac, obstetric or neonatal complications. Five babies were delivered pre-term (<37/40). CONCLUSIONS: This small study demonstrates that assisted reproduction carries increased risks of complications in patients with cardiac disease, but can be undertaken without major complication in the majority, as long as appropriate adjustments to treatment pathways are made, and they are managed through a multi-disciplinary team.

Cardiac resynchronization therapy outcomes in patients with chronic heart failure: cardiac resynchronization therapy with pacemaker versus cardiac resynchronization therapy with defibrillator.

AIMS: Cardiac resynchronization therapy (CRT) for chronic heart failure with left ventricular systolic dysfunction (LVSD) consistently improves survival against optimal medical therapy alone. Limited data exist comparing the outcomes between CRT with pacemaker (CRT-P) and with defibrillator (CRT-D). We aimed to investigate the long-term prognosis of patients who received CRT-P or CRT-D. METHODS AND RESULTS: Data were prospectively collected from consecutive patients with standard indications for CRT, who were implanted at a single large tertiary centre between 2008 and 2012. All-cause mortality was compared between those patients who received either CRT-P or CRT-D. A subgroup analysis was performed in patients with ischaemic cardiomyopathy. During the period in question, 795 patients received CRT devices: 544 (68.4%) CRT-P and 251 (31.6%) CRT-D. The mean follow-up was 1072 ±â€Š(SD 556) days. Overall, there was no survival benefit in those patients implanted with a CRT-D compared with CRT-P (hazard ratio 1.09, 95% confidence interval 0.84-1.41, P = 0.51). In patients with ischaemic chronic heart failure [n = 530 (66.7%)], there was a trend for improved survival with CRT-D; however, this was not significant after adjustment. In a subgroup analysis, there were no differences in mode-specific mortality in those patients implanted with CRT-D compared with CRT-P. CONCLUSION: In this large consecutive patient cohort, we did not find a survival benefit of CRT-D compared with CRT-P. Patients indicated for CRT devices may not reliably benefit from the addition of a defibrillator.

Comparative effectiveness of primary PCI versus fibrinolytic therapy for ST elevation myocardial infarction: a review of the literature.

AIM: To compare the effectiveness of primary percutaneous coronary intervention (pPCI) and fibrinolytic therapy (FL) for the acute management of ST elevation myocardial infarction (STEMI). METHODS: A review of guidelines and PubMed literature comparing clinical outcomes of patients with STEMI treated with pPCI or FL. RESULTS: Earlier trials reported reduced mortality and reinfarction with pPCI. Recent randomized data suggest similar outcomes for delayed pPCI compared with FL, especially in geographically remote areas. Guidelines recommend pPCI as the preferred reperfusion strategy for STEMI, if available within 120 mins of first medical contact. CONCLUSION: pPCI is the preferred treatment strategy for STEMI. However, FL with subsequent percutaneous coronary intervention remains a viable option for those in rural areas.

Pacing-associated left ventricular dysfunction? Think reprogramming first!

OBJECTIVE: Heart failure and left ventricular systolic dysfunction (LVSD) are common in patients with permanent pacemakers, but whether right ventricular (RV) pacing is contributory or merely a bystander in patients with more severe cardiac disease is controversial. The aim of the present study was to determine whether reprogramming of existing pacemakers to reduce RV pacing is safe and leads to improvements in cardiac function. METHODS: This was a prospective service evaluation of the effects of optimising pacemaker programming to avoid RV pacing in 66 consecutive attendees of a teaching hospital pacemaker clinic without complete heart block. The main outcome measures were left ventricular ejection fraction (LVEF), N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) levels, quality of life and cardiopulmonary exercise testing at baseline and after 6 months. RESULTS: At 6 months, the protocol reduced absolute RV pacing by a mean of 49% (95% CI 41% to 57%) (p<0.0001 from baseline) and resulted in a mean absolute improvement in LVEF of 6% (4% to 8%) (p<0.0001 from baseline) but no reduction in exercise capacity, NT-pro-BNP or quality of life. There was a relationship between the magnitude of change in EF and the reduction in RV pacing (p=0.04) and changes in NT-pro-BNP seemed to relate to change in RV pacing (p=0.07). CONCLUSIONS: Programming standard pacemakers to avoid RV pacing is safe, does not adversely affect patients' symptoms or quality of life and is associated with improved LV function, related to the reductions in RV pacing percentage.

Can implantable cardiac electronic device infections be defined as 'early' or 'late' based on the cause of infection?

Implantable cardiac electronic device (ICED) infections are a major cause of morbidity and mortality. Understanding the pathogenesis of these infections is important in their prevention and management. We hypothesized that ICED infections could be classified as 'early' or 'late', based on differences in microbiological cause within or beyond 1 year of implantation, respectively. A comprehensive review of the literature was undertaken to test this hypothesis. Prosthetic valve endocarditis cases were included for comparison. Articles were included if the time from device implantation to infection, definite evidence of infection (pocket/bacteraemia/endocarditis) and a positive microbiological diagnosis were included. There were no statistically significant differences in microbiology to support a 1 year cut-off between early and late ICED infection. Staphylococcus aureus and coagulase-negative staphylococci were the predominant causes of ICED infection both within and beyond 1 year of ICED implantation. To further assess the microbiological causes of ICEDs and their implications for pathogenesis a large-scale multi-centre study is required.