Predictors of survival in patients undergoing cardiac rehabilitation after transcatheter aortic valve implantation.

AIMS: Cardiac rehabilitation may improve physical and functional recovery after transcatheter aortic valve implantation (TAVI), but outcome predictors in TAVI patients are usually based on assessments made before or at the time of TAVI without regard to cardiac rehabilitation referral. We aimed to assess exercise-based cardiac rehabilitation-derived parameters that may predict 3-year outcome in TAVI patients undergoing residential cardiac rehabilitation. METHODS AND RESULTS: In 95 consecutive TAVI patients (82.7 ±â€Š4.9 years, 65% women) who underwent a 3-week cardiac rehabilitation program, at 3-year follow-up 35 deaths occurred. Compared with survivors, nonsurvivors had longer stay in cardiac rehabilitation (29.5 ±â€Š12.3 vs. 21.6 ±â€Š7.5 days, P = 0.0001), worse serum creatinine at admission/discharge (1.59 ±â€Š0.86 vs. 1.26 ±â€Š0.43 mg/dl, P = 0.0164; 1.52 ±â€Š0.61 vs. 1.23 ±â€Š0.44 mg/dl, P = 0.011), higher Cumulative Illness Rated State Comorbidity Index (5.4 ±â€Š1.5 vs. 4.6 ±â€Š1.8, P = 0.036) and Barthel Index at admission/discharge (51.8 ±â€Š24.5 vs. 68.1 ±â€Š23.2, P = 0.0016; 73.5 ±â€Š27.2 vs. 88.6 ±â€Š15.3, P = 0.0007), higher Morse Fall Risk score (35.6 ±â€Š24 vs. 24.3 ±â€Š14.1, P = 0.0056), and were less likely to train above the median exercise workload (fit) (11 vs. 35%, P = 0.008) or perform the 6-min walk test (6MWT) at admission/discharge (NO-6MWT: 34 vs. 12%, P = 0.008) and walked less distance on admission (6MWT: 129.6 ±â€Š88.3 vs. 193.3 ±â€Š69.8 m, P = 0.008). Univariate predictors of 3-year survival were cardiac rehabilitation duration, serum creatinine, Cumulative Illness Rated State Comorbidity Index, Barthel Index and NO-6MWT at admission/discharge, 6MWT at admission, Morse Fall Risk score at discharge and fit. Multivariate analysis confirmed exercise tolerance, Barthel Index and sCr at discharge as predictors. CONCLUSION: In TAVI patients who undergo cardiac rehabilitation, lower exercise tolerance, higher Barthel Index and sCr at discharge may predict 3-year mortality.

Cardiac rehabilitation after transcatheter aortic valve implantation compared to patients after valve replacement.

AIMS: To evaluate feasibility, safety, and outcome of an exercise-based residential cardiac rehabilitation program in transcatheter aortic valve implantation (TAVI) patients compared to elderly patients after surgical valve replacement (sAVR). METHODS: From January 2010 to January 2013, 65 consecutive TAVI and 70 sAVR older than 70 years were enrolled. Six-min walk test (6MWT) distance, Barthel index, Morse Fall Scale (MFS) on admission and discharge, Cumulative Illness Rated State-Comorbidity Index (CIRS-CI), and echocardiography were assessed. Patients underwent a 3-week intensive cardiac rehabilitation program. RESULTS: Compared with sAVR, TAVI had worse CIRS-CI (4.8 ±â€Š1.5 vs. 3.4 ±â€Š1.5; P = 0.00001), left ventricle ejection fraction (55.3 ±â€Š9 vs. 59.2 ±â€Š7.7; P = 0.008), Barthel index (67 ±â€Š24 vs. 79 ±â€Š21; P = 0.0018), and MFS (36 ±â€Š22 vs. 25 ±â€Š19; P = 0.002) on admission and at discharge (Barthel index 85 ±â€Š17 vs. 93 ±â€Š14; P = 0.005 and MFS 30 ±â€Š20 vs. 20 ±â€Š12; P = 0.0001), despite a significant improvement at discharge of Barthel index (85 ±â€Š17 vs. 67 ±â€Š24; P = 0.001) and MFS (36 ±â€Š22 vs. 30 ±â€Š20; P > 0.01). TAVI attended safely cardiac rehabilitation, but tolerated a significantly lower workload and had reduced 6MWT both on admission and discharge compared with sAVR (162 ±â€Š87vs. 216 ±â€Š82; P = 0.00001, and 240 ±â€Š92 vs. 33295; P = 0.00001, respectively), despite a net improvement at discharge in 6MWT (240 ±â€Š92 vs. 162 ±â€Š92; P < 0.001). CONCLUSION: Intensive cardiac rehabilitation after TAVI is safe, well tolerated, and leads to a net improvement in disability, risk of falls, and exercise capacity, similar to that observed in less disabled sAVR patients, favoring home discharge and relatively independent life at home. A persistent higher disability, comorbidity profile, and risk of falls at discharge characterize TAVI patients compared with sAVR patients of similar age.

Flow-mediated dilation normalization predicts outcome in chronic heart failure patients.

BACKGROUND: Reduced flow-mediated dilation (FMD) is a known prognostic marker in heart failure (HF), but may be influenced by the brachial artery (BA) diameter. Aiming to adjust for this influence, we normalized FMD (nFMD) by the peak shear rate (PSR) and tested its prognostic power in HF patients. METHODS AND RESULTS: BA diameter, FMD, difference in hyperemic versus rest brachial flow velocity (FVD), PSR (FVD/BA), and nFMD (FMD/PSR × 1000) were assessed in 71 HF patients. At follow-up (mean 512 days), 19 HF (27%) reached the combined endpoint (4 heart transplantations [HTs], 1 left ventricle assist device implantation [LVAD], and 14 cardiac deaths [CDs]). With multivariate Cox regression analysis, New York Heart Association functional class ≥III (hazard ratio [HR] 9.36, 95% confidence interval [CI] 2.11-41.4; P = .003), digoxin use (HR 6.36, 95% CI 2.18-18.6; P = .0010), FMD (HR 0.703, 95% CI 0.547-0.904; P = .006), PSR (HR 1.01, 95% CI 1.005-1.022; P = .001), FVD (HR 1.04, 95% CI 1.00-1.06; P = .02), and nFMD (HR 0.535, 95% CI 0.39-0.74; P = .0001) were predictors of unfavorable outcome. Receiver operating characteristic curve for nFMD showed that patients with nFMD >5 seconds had significantly better event-free survival than patients with nFMD ≤5 seconds (log-rank test: P < .0001). CONCLUSIONS: nFMD is a strong independent predictor of CD, HT, and LVAD in HF with left ventricular ejection fraction <40%. Patients with nFMD >5 seconds have a better prognosis than those with lower values.

Flow mediated dilation in patient with Berlin Heart Incor left ventricle assist device.

Endothelial function measured with brachial ultrasound (BU) is a validated prognostic factor in heart failure patients. LVAD (left ventricle assist device) application is a promising surgical technique to treat refractory heart failure patients both as a bridge to heart transplantation or as destination therapy. Clinical recovery in such patients may be associated to normal endothelial function measured by BU but, as recently reported, only in pulsatile flow LVAD patients. The present paper report a case of normal endothelial function even in a axial LVAD patient.

Infective endocarditis in drug addicts: role of HIV infection and the diagnostic accuracy of Duke criteria.

BACKGROUND: Intravenous drug users (IVDUs) are at increased risk of infective endocarditis. Moreover, HIV infection is common in IVDUs, with a reported prevalence of 40-90%. The clinical features of IVDUs with infective endocarditis and HIV infection may be peculiar. Few data have been reported on the diagnostic accuracy of Duke criteria in IVDUs with or without HIV infection, and a comparison of these two populations is lacking. METHODS: The present study aimed to compare prospectively the clinical features of patients with infective endocarditis with or without HIV infection and to evaluate the diagnostic accuracy of Duke criteria in these patients. The study population consisted of 201 consecutive adult IVDUs with a suspected infective endocarditis (102 patients with HIV infection and 99 patients without HIV infection). RESULTS: Infective endocarditis was the final diagnosis in 40 of 102 patients (38.2%) with HIV infection and in 55 of 99 HIV-negative patients (55.6%). Despite similar baseline features, longer vegetations were recorded in infective endocarditis without HIV infection (23.7 +/- 7.1 mm versus 13.6 +/- 6.8 mm; P = 0.001). Patients with infective endocarditis and HIV infection had a higher total mortality at 2 months (respectively 12.5% versus 1.8%; P = 0.09); almost all the deaths were recorded in patients with AIDS or a CD4 cell count below 200 per microl, and no deaths were recorded in patients with HIV infection and a CD4 cell count > 500 per microl. CONCLUSIONS: Despite no identical clinical features, Duke criteria had a similar sensitivity, specificity and diagnostic accuracy in IVDUs with and without HIV infection.

Uncomplicated non-Q wave myocardial infarction: long-term prognosis with a conservative echo-stress guided management strategy.

BACKGROUND: Whether an invasive or a conservative strategy should form the basis of an optimal management strategy for non-Q wave myocardial infarction is at present still subject of debate. We reported our observational experience with the long-term follow-up of patients with a first uncomplicated non-Q wave myocardial infarction and submitted to a conservative treatment strategy based on the in-hospital stress echocardiography and treadmill exercise. METHODS: We studied 134 consecutive patients admitted for a first uncomplicated non-Q wave myocardial infarction between 1991 and 1994. All patients were submitted to a dipyridamole echocardiography test (DET) between 5-7 days after admission and to a treadmill test before discharge. Coronary angiography and myocardial revascularization (coronary angioplasty or coronary artery bypass grafting) were performed according to the outcomes of the stress echo and treadmill test. RESULTS: The early and delayed follow-up results were quite good: 2.9% early hard events, 15% delayed hard events. DET negativity identified patients with a lower risk of both spontaneous and hard events. Multivariate analysis indicated the DET as the only predictive variable of spontaneous events within 1 year (p = 0.0001), of delayed spontaneous events (p = 0.0001) and of delayed hard events (p = 0.05). CONCLUSIONS: In this study, revascularization procedures performed on the basis of stress echo result in good short- and long-term outcomes in stabilized uncomplicated non-Q wave myocardial infarction. The patients with a negative DET had a very low rate of events. DET positivity identifies a higher risk group of patients, whatever treatment they subsequently undergo.

Brugada syndrome: a case report of an unusual association with vasospastic angina and coronary myocardial bridging.

This report describes a case of an unusual association between vasospastic angina, coronary myocardial bridging, and Brugada syndrome. The patient complained of chest pain followed by rhythmic palpitation and syncope. Brugada syndrome ECG markers were documented with transient ST-segment elevation in lateral leads. A coronary angiogram showed a myocardial bridging in the left anterior descending artery and coronary vasospasm was reproduced after intracoronary ergonovine injection in the circumflex coronary artery. Ventricular fibrillation was induced by programmed electrical stimulation. The described association can be important because interaction between ischemia and Brugada syndrome electrophysiological substrate could modulate individual susceptibility to life-threatening ventricular tachyarrhythmias.