Effects of Upgrade Versus De Novo Cardiac Resynchronization Therapy on Clinical Response and Long-Term Survival: Results from a Multicenter Study.

BACKGROUND: Benefits of cardiac resynchronization therapy (CRT) on morbidity and mortality in selected patients are well known. Although the number of upgrade procedures from single- or dual-chamber devices to CRT is increasing, there are only sparse data on the outcomes of upgrade procedures compared with de novo CRT. This study aimed to evaluate clinical response and survival in patients receiving de novo versus upgrade CRT defibrillator therapy. METHODS AND RESULTS: Prospectively collected outcome data were compared in patients undergoing de novo or upgrade CRT defibrillator implantation at 3 implant centers in Germany and Hungary. Clinical response was defined as an improvement by at least one New York Heart Association (NYHA) functional class. CRT implantation was performed in 552 consecutive patients of whom 375 underwent a de novo and 177 an upgrade procedure. Upgrade patients were more often implanted for secondary prevention, suffered more often from atrial fibrillation, chronic kidney disease, diabetes mellitus, and dyslipidemia, and had more often a non-LBBB (left bundle branch block) wide QRS complex, and lower left ventricular ejection fraction. Upgrade procedures were associated with a lower response rate compared to the de novo group (57% versus 69%, P univariate=0.008, P multivariate=0.021). During the follow-up of 37±28 months, survival was worse after upgrade compared with de novo CRT defibrillator implantations (hazard ratio, 1.65; 95% confidence interval, 1.22-2.24; P=0.001) even after careful adjustment for important baseline variables (adjusted hazard ratio, 1.68; 95% confidence interval, 1.20-2.34; P=0.002) and after propensity-score matching (propensity-adjusted hazard ratio, 1.79; 95% confidence interval, 1.08-2.95; P=0.023). CONCLUSIONS: Both clinical response and long-term survival were less favorable in patients undergoing CRT upgrade compared to de novo implantations.

Safety of transient elastography in patients with implanted cardiac rhythm devices.

BACKGROUND: At present the use of transient elastography (TE) in patients with pacemaker (PM) or implantable cardioverter defibrillator (ICD) devices is not recommended, since the safety due to the electromagnet embarked in the vibrator for producing the shearwave has not been evaluated. However, no adverse events of sonographic examinations in this patient group have been reported. AIMS: The aim of the present study was to evaluate the safety of TE in patients with PM or ICD. METHODS: In a prospective study we evaluated safety and function of such devices during TE. In 17 patients with PM and 17 patients with ICD, the function of the device was checked prior to and after TE examination. RESULTS: In none of the 34 patients changes in stimulation thresholds, electrode impedance and sensing were detected. CONCLUSION: Our findings support the assumption that the potential harm of TE in patients with PM and ICD is rare.

Optimal Anticoagulation Strategy for Cardioversion in Atrial Fibrillation.

For many patients with symptomatic atrial fibrillation, cardioversion is performed to restore sinus rhythm and relieve symptoms. Cardioversion carries a distinct risk for thromboembolism which has been described to be in the order of magnitude of 1 to 3 %. For almost five decades, vitamin K antagonist therapy has been the mainstay of therapy to prevent thromboembolism around the time of cardioversion although not a single prospective trial has formally established its efficacy and safety. Currently, three new direct oral anticoagulants are approved for stroke prevention in patients with non-valvular atrial fibrillation. For all three, there are data regarding its usefulness during the time of electrical or pharmacological cardioversion. Due to the ease of handling, their efficacy regarding stroke prevention, and their safety with respect to bleeding complications, the new direct oral anticoagulants are endorsed as the preferred therapy over vitamin K antagonists for stroke prevention in non-valvular atrial fibrillation including the clinical setting of elective cardioversion.

Role of N-terminal pro-brain natriuretic peptide and cystatin C to estimate renal function in patients with and without heart failure.

Blood cystatin C has increasingly been used as an endogenous marker for estimating glomerular filtration rate (GFR) and evaluating prognosis in patients with acute or chronic heart failure. The goal of the study was to investigate the impact of heart failure on the determination of renal function based on cystatin C or creatinine in nonacute cardiac patients. A total of 880 consecutive and clinically stable patients with heart disease were prospectively evaluated. Serum N-terminal pro-brain natriuretic peptide (NT-pro-BNP) showed a stronger correlation with cystatin C (r = 0.60, p <0.001) compared with creatinine (r = 0.46, p <0.001). Multivariate analysis identified estimated GFR according to the MDRD Study formula (p <0.001), serum NT-pro-BNP (p <0.001), use of immunosuppressive agents (p <0.001), and allopurinol treatment (p <0.001) as the strongest independent predictors of serum cystatin C. Parallel measurement of creatinine clearance using timed urine collection in a subgroup of 160 patients showed that estimated GFR according to cystatin C was almost identical to measured creatinine clearance independent of NT-proBNP. Conversely, creatinine-based calculation using the MDRD Study formula underestimated GFR in patients from the low (12 to 238 pg/ml) and medium (241 to 990 pg/ml) NT-pro-BNP tertiles. In conclusion, in patients without severe heart failure, indicated by low serum NT-pro-BNP, estimation of GFR using creatinine-based formulas underestimated renal function. The known prognostic impact of cystatin C in cardiac patients might result from a strong correlation with NT-pro-BNP, as well as its superior ability to predict renal function in patients with and without heart failure.

Cardiac (31)P-MRS compared to echocardiographic findings in patients with hypertensive heart disease without overt systolic dysfunction--preliminary results.

PURPOSE: To evaluate changes in high energy phosphate (HEP) metabolism in patients with hypertension and diastolic dysfunction but with normal LVEF>55% assessed by echocardiography and tissue Doppler. MATERIAL AND METHODS: 20 patients (16 men and 4 women, mean age 57+/-13 years) were studied with phosphorus magnetic resonance spectroscopy and echocardiography. MRS was performed at 1.5T using an ECG-gated CSI sequence with nuclear Overhauser effect. According to echocardiographical findings 12 patients were found to have a diastolic dysfunction, whereas 8 patients were identified as normal, serving as control group in the following statistical analysis. All patients had normal systolic function (LVEF>55%).Statistical analysis was made by using mean+/-S.D. for description of the data, Spearman correlation and two-tailed Student's t-test for independent samples. RESULTS: No differences were found in weight, age, LVEF, endsystolic volume, end-diastolic volume, cardiac output and BNP levels between patients and control group. Myocardial mass at end-diastole correlated significantly with PCr/ATP ratio (r=-0.66; p=0.04) in patients and control group. Myocardial PCr/ATP ratio in patients was significantly decreased compared to controls (1.21+/-0.22 vs. 1.54+/-0.24; p=0.006). CONCLUSIONS: Cardiac (31)P-MRS might offer a noninvasive means for detecting early states of heart failure in hypertensive patients.