Impact of preventive substrate catheter ablation on implantable cardioverter-defibrillator interventions in patients with ischaemic cardiomyopathy and infarct-related coronary chronic total occlusion.

AIMS: Primary prevention patients with ischaemic cardiomyopathy and chronic total occlusion of an infarct-related coronary artery (CTO) are at a particularly high risk of implantable cardioverter-defibrillator (ICD) therapy occurrence. The trial was designed to evaluate the efficacy of preventive CTO-related substrate ablation strategy in ischaemic cardiomyopathy patients undergoing primary prevention ICD implantation. METHODS AND RESULTS: The PREVENTIVE VT study was a prospective, multicentre, randomized trial including ischaemic patients with ejection fraction ≤40%, no documented ventricular arrhythmias (VAs), and evidence of scar related to the coronary CTO. Patients were randomly assigned 1:1 to a preventive substrate ablation before ICD implantation or standard therapy with ICD implantation only. The primary outcome was a composite of appropriate ICD therapy or unplanned hospitalization for VAs. Secondary outcomes included the primary outcome's components, the incidence of appropriate ICD therapies, cardiac hospitalization, electrical storm, and cardiovascular (CV) mortality. Sixty patients were included in the study. During the mean follow-up of 44.7 ± 20.7 months, the primary outcome occurred in 5 (16.7%) patients undergoing preventive substrate ablation and in 13 (43.3%) patients receiving only ICD [hazard ratio (HR): 0.33; 95% confidence interval (CI): 0.12-0.94; P = 0.037]. Patients in the preventive ablation group also had fewer appropriate ICD therapies (P = 0.039) and the electrical storms (Log-rank: P = 0.01). While preventive ablation also reduced cardiac hospitalizations (P = 0.006), it had no significant impact on CV mortality (P = 0.151). CONCLUSION: Preventive ablation of the coronary CTO-related substrate in patients undergoing primary ICD implantation is associated with the reduced risk of appropriate ICD therapy or unplanned hospitalization due to VAs.

Case report: Treatment of tachycardia-induced cardiogenic shock with permanent His bundle pacing and atrioventricular node ablation.

Tachycardia-induced cardiomyopathy (T-CMP) related to supraventricular arrhythmia is a rare and often unrecognized cause of refractory cardiogenic shock. When rhythm control interventions are ineffective or no longer pursued, atrioventricular node ablation (AVNA) with pacemaker implantation is indicated. Conduction system pacing provides normal synchronous activation of the ventricles after AVNA. However, there is a lack of data on pace and ablate strategy in hemodynamically unstable patients. We report on 2 patients with T-CMP presenting with refractory cardiogenic shock who were successfully treated with His bundle pacing in conjunction with AVNA.

Systolic murmur in disguise: subclavian artery stenosis as an overlooked cause of missed case of hypertension.

In this report we present a case of missed hypertension due to subclavian artery stenosis. A 77 year-old female patient, initially thought as being normotensive, was referred to us due to newly discovered systolic heart murmur suspicious for aortic stenosis. We noted inter-arm blood pressure difference of 30 mmHg, with higher, hypertensive values on right arm. Further workup and medical imaging excluded aortic stenosis and revealed an asymptomatic, hemodynamically significant, stenosis of left subclavian artery. Due to absence of symptoms, the patient has been managed with conservative therapy for subclavian stenosis and hypertension, and she is currently in good conditions and followed up for any signs of disease progression. This case clearly shows importance of measuring blood pressure on both arms when initially diagnosing hypertension as this is often overlooked and is key to properly diagnose hypertension and possible subclavian stenosis.