Brief Report: Consequences of Presentation With Advanced HIV Disease in Pregnancy: Data From a National Study in Italy.

Among 469 women with a diagnosis of HIV in pregnancy, 74 (15.8%) presented with less than 200 CD4 cells per cubic millimeter. The only variable significantly associated with this occurrence was African origin (odds ratio: 2.22, 95% confidence intervals: 1.32 to 3.75, P = 0.003). Four women with low CD4 (5.6%), compared with none with higher CD4 counts, had severe AIDS-defining conditions (P < 0.001) during pregnancy or soon after delivery, and one transmitted HIV to the newborn. Early preterm delivery (<32 weeks) was significantly more frequent with low CD4 (6.2% vs. 1.4%, P = 0.015). An earlier access to HIV testing, particularly among immigrants of African origin, can prevent severe HIV-related morbidity.

Hemodynamic changes before acute heart failure episodes in patients with advanced systolic left ventricular dysfunction.

AIM: We sought to verify which changes in right ventricular pressures occur before acute heart failure (HF) in patients with advanced systolic left ventricular (LV) dysfunction. In patients with chronic HF, continuous hemodynamic monitoring by implantable devices may detect increases in pulmonary pressures before the onset of symptoms. METHODS: A device which allowed monitoring of right ventricular systolic (RVSP) and diastolic pressure (RVDP) and an estimate of pulmonary artery diastolic pressure (ePAD) was implanted in 10 patients with advanced LV systolic dysfunction and frequent cardiovascular hospitalizations [mean age 56.8 years; New York Heart Association (NYHA) classes IIIb-IV; LV ejection fraction at echocardiography 21 +/- 2%]. RESULTS: During a follow-up period of 15 +/- 12 months, 18 hospitalizations due to acute HF were recorded; 10 episodes were characterized by symptoms due to low-cardiac output (LCO) and eight episodes were characterized by symptoms due to pulmonary congestion. RVSP and ePAD increased before six hospitalizations and decreased before three episodes; RVDP increased before 10 hospitalizations and decreased before one. The extent of RVDP increase was 16 +/- 24% before pulmonary congestion episodes and 29 +/- 32% before LCO episodes. CONCLUSION: An increase in RVDP was the most frequent hemodynamic change detected by the implantable hemodynamic monitor before hospitalizations due to acute HF in patients having advanced systolic LV dysfunction.

Limited thoracotomy as a second choice alternative to transvenous implant for cardiac resynchronisation therapy delivery.

AIMS: Left ventricular (LV) pacing via transvenous implantation has an overall success rate ranging from 88% to 92%. The aim of this study was to assess whether LV pacing via limited thoracotomy would be feasible and safe when used on a routine basis for those cases in which standard transvenous procedures proved to be ineffective or unsatisfactory. METHODS AND RESULTS: We enrolled 33 patients (8 females, 65+/-10 years) who experienced a transvenous implantation failure. All patients underwent a limited thoracotomy and an epicardial lead was implanted. The procedure time was 51+/-28 min. No surgical or post-operative complications occurred and optimal lateral position was achieved for all patients. In the 12 months follow-up period, 5 patients died from refractory heart failure, the remaining patients did not experience complications. At implant, the mean pacing threshold was 1.3+/-0.7 V, bi-ventricular pacing impedance was 476+/-201 Omega and R-wave amplitude was 15.0+/-6.1 mV. No significant differences were found in any of the electrical parameters between baseline and follow-up. Significant improvement was observed in functional and echocardiographic parameters. CONCLUSION: Our results suggest that a combined approach to cardiac resynchronisation therapy delivery, including a transvenous attempt followed by a back up thoracotomic procedure, could potentially guarantee the success.

Simultaneous vs. sequential biventricular pacing in dilated cardiomyopathy: an acute hemodynamic study.

AIMS: Simultaneous biventricular pacing improves left ventricular (LV) systolic performance in patients with dilated cardiomyopathy and intraventricular conduction delay. We tested the hypothesis that further improvements can be obtained using sequential biventricular pacing by optimizing both atrioventricular and interventricular delays. METHODS AND RESULTS: In 12 patients, LV pressure, right ventricular (RV) pressure and respective rates of change of pressure (dP/dt) were acutely measured during biventricular pacing with different atrioventricular and interventricular (VVi) intervals ranging from -60 to +40 ms. The average increase vs. baseline in maximum LV dP/dt was higher for sequential than for simultaneous biventricular pacing (VDD mode: 35+/-20 vs. 29+/-18%, P<0.01; DDD mode: 38+/-23 vs. 34+/-25%, P<0.01), with a minority of patients accounting for most of the difference. The mean optimal VVi was -25+/-21 ms in VDD mode and -25+/-26 ms in DDD mode. With these settings, RV dP/dt was not significantly different from baseline. QRS shortening was not predictive of LV dP/dt increase. CONCLUSION: A significant increase of LV dP/dt with no change in RV dP/dt can be obtained by sequential biventricular pacing as compared to simultaneous biventricular pacing. The highest LV dP/dt is achieved when LV is stimulated before RV. The hemodynamic advantage might be of clinical significance in selected cases.

Cardiac resynchronization and implantable cardioverter defibrillator therapy: preliminary results from the InSync Implantable Cardioverter Defibrillator Italian Registry.

The aim of this study was to evaluate ventricular arrhythmias occurring in recipients of the InSync ICD for the primary and secondary prevention of sudden death. The InSync ICD was implanted in 142 patients (128 men; mean age 65 +/- 10 years) with heart failure (mean NYHA functional Class 3.0 +/- 0.7) and wide QRS (mean 159 +/- 33 ms). The underlying etiology was ischemic in 55%, idiopathic in 33%, and valvular or hypertensive cardiomyopathy in 12% of patients. The numbers of arrhythmic episodes/100 patient-months was computed with their 95% CI, assuming a Poisson distribution. Implants were performed in 48 (34%) patients who did not have an ACC/AHA guidelines Class I indication for ICD therapy. A total of 104 patients were compliant for follow-up visits. During a 9-month median (range 0.1-24) follow-up of 104 compliant patients, 19 experienced a total of 94 ventricular arrhythmias, all successfully interrupted or self-terminated, with a median number of two separate episodes, corresponding to a rate of 10 episodes/100 person-month (95% CI 8-12). A rate of 12 episodes/100 person-months (95% CI 10-15) was measured in the subgroup of patients with ACC/AHA class I indications, versus two episodes/100 person-months (95% CI 1-5) in the remainder of the population. Among 12 deaths, 9 were due to heart failure, 1 to a non-cardiovascular cause, and 2 to unknown causes. The implantation of ICD in heart failure patients has been prominently extended to primary prevention. Patients without standard ICD indications experienced life-threatening arrhythmic events. The impact of ICD combined with cardiac resynchronization therapy on arrhythmic profile, mortality, and costs in this subgroup of patients need to be more precisely studied, with a particular focus on the various types of underlying heart disease.

Patient selection for biventricular pacing.

INTRODUCTION: Biventricular pacing improves functional status in the majority of patients with drug-refractory heart failure, dilated cardiomyopathy, and interventricular conduction delay. The aim of this study was to analyze the baseline clinical and functional data of a cohort of patients implanted with a biventricular stimulation system in a single-center experience, to verify if the pathophysiologic characteristics of patients affect outcome, and to determine if preliminary identification of the right candidates for the new therapy is possible with noninvasive parameters. METHODS AND RESULTS: Since March 1999, 52 patients with advanced heart failure (idiopathic cardiomyopathy 50%, ischemic cardiomyopathy 35%, other etiology 15%) and left bundle branch block underwent cardiac resynchronization and were followed prospectively. Paired analysis over mean (+/- SD) follow-up of 348 +/- 154 days showed an overall significant decrease of QRS width (baseline 194 +/- 33.2 msec vs follow-up 159.6 +/- 20.1 msec), New York Heart Association (NYHA) functional class (baseline 3.2 +/- 0.5 vs follow-up 2.3 +/- 0.5), quality-of-life score (baseline 54 +/- 25 vs follow-up 25 +/- 16), and increase of maximal VO2 (baseline 12.6 +/- 2.5 mL/kg/min vs follow-up 15.0 +/- 3.3 mL/kg/min). There were 80% responders (documented, persistent decrease > or = 1 NYHA class) and 20% nonresponders (same NYHA class or decline of status; need for heart transplant; death due to progressive pump failure). No significant differences in baseline clinical and functional variables between the two subgroups were observed. In responders, there was a highly significant global improvement of all variables; in nonresponders, no parameters changed between baseline and follow-up. CONCLUSION: These data confirm the role of biventricular pacing in improving the functional status of the great majority of a selected patient population having advanced heart failure and left bundle branch block with wide QRS complex. Basal demographic, clinical, and functional characteristics are not helpful in preliminary selection of responders. Simple evaluation of NYHA class confirms favorable outcome (improvement of functional and hemodynamic status).