Improvement in Echocardiographic Indexes of Systolic Heart Failure Post-Kidney Transplantation: A Retrospective Analysis.

INTRODUCTION: End-stage renal disease is a major risk factor for cardiovascular morbidity and mortality, which can be partially eliminated by kidney transplantation. Systolic heart failure might be considered contraindication for kidney transplant, although some patients demonstrate myocardial recovery post-transplant. We aimed to identify and characterize the phenomenon of reverse myocardial remodeling in kidney transplanted patients. METHODS: The study is a retrospective cohort of patients undergoing kidney transplants between 2016 and 2019 (n = 604) at Rabin Medical Center. Patients were assessed according to availability of two echocardiographic examinations: pre- and post-kidney transplant. The change in estimated ejection fraction (EF) and possible predictors of myocardial recovery were examined. RESULTS: Data of 293 patients was available for the final analysis. Eighty-one (28%) patients had a LVEF improvement equal to or above 5%, whereas 36 (12%) patients had a LVEF improvement of 10% or more post-transplantation. Twenty-five patients (8.5%) had moderate or severe systolic heart failure with LVEF reduced to 40% or less at baseline. 13 of them (52%) had a LVEF improvement of ≥5%, and 10 patients (40%) had an improvement of ≥10% in their EF. Cox regression analyses identified female gender as the only independent variable associated with LVEF improvement of at least 10%. CONCLUSION: Renal transplantation might lead to improved LV systolic function in some patients.

The Relationship between Nocturnal Dipping Status, Morning Blood Pressure Surge, and Hospital Admissions in Patients with Systolic Heart Failure. / A Relação entre o Estado Dipping Noturno, Aumento da Pressão Arterial Matinal e Internações Hospitalares em Pacientes com a Insuficiência Cardíaca Sistólica.

BACKGROUND: Hypertension is a known risk factor for developing heart failure. However, there is limited data to investigate the association between morning blood pressure surge (MBPS), dipping status, echocardiographic parameters, and hospital admissions in patients with systolic heart failure. OBJECTIVES: To evaluate the relationship between morning blood pressure surge, non-dipper blood pressure pattern, echocardiographic parameters, and hospital admissions in patients with systolic heart failure. METHODS: We retrospectively analyzed data from 206 consecutive patients with hypertension and a left ventricular ejection fraction below 40%. We divided the patients into two groups according to 24-hour ambulatory blood pressure monitoring (ABPM) results: dippers (n=110) and non-dippers (n=96). Morning blood pressure surge was calculated. Echocardiographic findings and hospital admissions during follow-up were noted. Statistical significance was defined as p < 0.05. RESULTS: The study group comprised 206 patients with a male predominance and mean age of 63.5 ± 16.1 years. The non-dipper group had significantly more hospital admissions compared to dippers. There was a positive correlation between MBPS and left atrial volume index (r=0.331, p=0.001), the ratio between early mitral inflow velocity and flow propagation velocity (r= 0.326, p=0.001), and the ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/Em) (r= 0.314, p=0.001). Non-dipper BP, MBPS, and E/Em pattern were found to be independently associated with increased hospital admissions. CONCLUSION: MBPS is associated with diastolic dysfunction and may be a sensitive predictor of hospital admission in patients with systolic heart failure.

FUNDAMENTO: A hipertensão é um fator de risco conhecido para o desenvolvimento de insuficiência cardíaca. No entanto, há dados limitados para investigar a associação entre pico de pressão arterial matinal (PPAM), estado dipper, parâmetros ecocardiográficos e internações hospitalares em pacientes com insuficiência cardíaca sistólica. OBJETIVOS: Avaliar a relação entre aumento matinal da pressão arterial, padrão de pressão arterial não-dipper, parâmetros ecocardiográficos e internações hospitalares em pacientes com insuficiência cardíaca sistólica. MÉTODOS: Analisamos retrospectivamente os dados de 206 pacientes consecutivos com hipertensão e fração de ejeção do ventrículo esquerdo abaixo de 40%. Dividimos os pacientes em dois grupos de acordo com os resultados da monitoramento ambulatorial da pressão arterial (MAPA) de 24 horas: dippers (n=110) e não-dippers (n=96). O aumento matinal da pressão arterial foi calculado. Achados ecocardiográficos e internações hospitalares durante o acompanhamento foram anotados. A significância estatística foi definida como p < 0,05. RESULTADOS: O grupo de estudo foi composto por 206 pacientes com predominância do sexo masculino e idade média de 63,5 ± 16,1 anos. O grupo não-dipper teve significativamente mais internações hospitalares em comparação com os dippers. Houve correlação positiva entre PPAM e índice de volume do átrio esquerdo (r=0,331, p=0,001), relação entre velocidade de influxo mitral precoce e velocidade de propagação do fluxo (r= 0,326, p=0,001) e relação entre influxo mitral precoce velocidade e velocidade diastólica inicial do anel mitral (E/Em) (r= 0,314, p=0,001). Verificou-se que a PA não-dipper, PPAM e o padrão E/Em estão independentemente associados ao aumento das admissões hospitalares. CONCLUSÃO: O PPAM está associado à disfunção diastólica e pode ser um preditor sensível de internação hospitalar em pacientes com insuficiência cardíaca sistólica.

Right Ventricular Free Wall Strain and Effect of Defibrillator Implantation in Patients With Nonischemic Systolic Heart Failure.

BACKGROUND: Patients with nonischemic systolic heart failure have an increased risk of malignant ventricular arrhythmias and sudden cardiovascular death. Because the risk is less pronounced than for patients with ischemic cause of heart failure more discriminating tools are needed to identify patients most likely to benefit from implantable cardioverter-defibrillator (ICD) implantation. Right ventricular (RV) dysfunction is associated with a worse prognosis, but whether RV free wall strain (RV-FWS) measured with echocardiography can identify the patients most likely to benefit from ICD implantation is not known. METHODS AND RESULTS: In this extended follow-up analysis of the Danish Study to Assess the Efficacy of ICDs in Patients with Non-ischemic Systolic Heart Failure on Mortality (DANISH) trial, RV-FWS was measured with echocardiography in 445 patients before randomization. RV dysfunction was defined as an RV-FWS of greater than -20%. The primary end point was all-cause mortality. The median RV-FWS was -18% (quartiles -23% to -14%), and RV dysfunction was measured in 255 patients (57%). During a median follow-up of 5.7 years, 170 patients (38%) died. There was a statistically significant interaction between RV dysfunction and the effect of ICD implantation (P = .003), also after adjusting for known cardiovascular risk factors (P = .01). ICD implantation significantly decreased all-cause mortality in patients with RV dysfunction (hazard ratio 0.54, 95% confidence interval 0.36-0.80, P = .002), but not in patients with normal RV function (hazard ratio 1.34, 95% confidence interval 0.84-2.12, P = .22). CONCLUSIONS: In patients with nonischemic systolic heart failure, RV dysfunction on echocardiography was associated with a greater effect of ICD implantation and could be used to select patients with benefit from ICD treatment.

Efficacy of Doppler echocardiography-guided ivabradine therapy.

BACKGROUND: The purpose of this study was to evaluate the advantage of heart rate (HR) modulation using ivabradine referring Doppler echocardiography over the conventional ivabradine therapy without echocardiography guide in patients with systolic heart failure. METHODS: From October 2020, our institute updated the protocol of ivabradine therapy, in which HR was optimized to minimize the overlap between the two left ventricular inflow waves using Doppler echocardiography (echo-guided group). The degree of cardiac reverse remodeling at 3-month follow-up was compared between the echo-guided group and the conventional ivabradine therapy group treated before October 2020. RESULTS: A total of 28 patients (62 years old, 17 men) were included, and 18 patients were from echo-guided group. Left ventricular ejection fraction increased significantly in the echo-guided group (from 41% [28%, 49%] to 55% [37%, 66%], p = 0.007), whereas it remained unchanged in the conventional group (p = 0.333). Systolic blood pressure and the daily dose of carvedilol increased significantly only in the echo-guided group (p = 0.009 and p = 0.001, respectively). CONCLUSIONS: Among those with systolic heart failure, a Doppler echocardiography guide might be a promising therapeutic tool in modulating HR by ivabradine in facilitating reverse remodeling.

Doppler Echocardiography-Guided Heart Rate Modulation Therapy Using Ivabradine in a Patient with Systolic Heart Failure.

Heart rate reduction using ivabradine, a selective If channel blocker that purely decreases heart rate without affecting hemodynamics, improves clinical outcomes in patients with systolic heart failure. However, the ideal heart rate that should be a target remains unknown. Our team recently proposed a methodology using Doppler echocardiography to estimate ideal heart rate, at which E-wave and A-wave stand adjacent without overlap. However, the implication of Doppler echocardiography-guided heart rate modulation therapy using ivabradine remains uncertain. We had a 72-year-old man with systolic heart failure and sinus tachycardia who initiated ivabradine therapy. Ivabradine dose was adjusted between 5.0 mg/day and 10.0 mg/day and continued for 12 weeks to minimize the overlap between the two echocardiography waves, accompanying improvement in cardiac output, left ventricular ejection fraction, plasma B-type natriuretic peptide, and six-minute walk distance. Doppler echocardiography-guided heart rate regulation therapy using ivabradine may be a promising strategy to improve cardiac function and clinical outcomes in patients with systolic heart failure, although further studies are required to validate this hypothesis.

Spectrum of cardiovascular diseases at a referral tertiary care hospital in Somalia, Mogadishu: an echocardiographic study.

BACKGROUND: To investigate the frequencies and patterns of cardiovascular diseases (CVDs), including rheumatic and congenital heart diseases, among patients with abnormal hearts assessed by echocardiographic examination. METHODS: This retrospective, descriptive registry reviewed abnormal echocardiographic findings of 1140 patients aged 0-100 years who were admitted to the cardiology outpatient clinic at a tertiary training institution in Mogadishu. RESULTS: Hypertensive heart disease (HHD) (n:454, 39.8%), valvular heart disease (VHD) (n:395, 34.6%), and heart failure with reduced ejection fraction (HFrEF) (n:351, 30.8%) were the most frequent comorbidities. Congenital heart diseases (CHDs) were detected in 151 (13.2%) of the patients, with the most common ones including atrial septal defect (ASD) (n:37, 3.2%) and ventricular septal defect (VSD) (n:26, 2.3%). Rheumatic heart disease (RHD) was observed in 84 (7.4%) patients, among whom the most common age range was 16-30 years (40.5%), followed by 31-45 years (31%) and 0-15 years (15.5%). Mitral insufficiency (n:541, 47.5%) was detected as the most frequent VHD, followed by aortic insufficiency (n:437, 38.3%), and tricuspid insufficiency (n:264, 23.2%) and mitral valve stenosis (n:39, 3.4%) was the least common VHD. CONCLUSION: In the present study, we found that HHD was the most common comorbidity, followed by VHD, and HFrEF. Moreover, the most common VHD was mitral insufficiency and the most common CHD was ASD.

Increased ratio of sST2/LVMI predicted cardiovascular mortality and heart failure rehospitalization in heart failure with reduced ejection fraction patients: a prospective cohort study.

BACKGROUND: Inflammation is one of the principal triggering mechanisms for left ventricular fibrosis and remodeling in heart failure, leading to adverse clinical outcomes. Soluble suppression of tumorigenicity 2 (sST2), a member of the interleukin-1 receptor family, is assumed to play a significant role in the fibrotic response to inflammation. Left ventricular mass index (LVMI) is a parameter of the prefibrotic inflammatory phase of heart failure preceding remodeling. The present study aimed to investigate the prognostic value of the sST2/LVMI ratio in heart failure with reduced ejection fraction. METHODS: This was a prospective cohort study. A total of 45 consecutive patients with heart failure with reduced ejection fraction, treated between September 2015 and December 2016, were enrolled. The sST2/LVMI ratio was measured at baseline. The primary endpoint was a composite of cardiovascular mortality and readmission for heart failure. The prognostic impact of the sST2/LVMI ratio was evaluated using a multivariable Cox proportional hazards regression model. RESULTS: Forty-five patients were enrolled in this study. Their average age was 48 ± 14 years, and approximately 20% of them were men. Patients were followed for 9 months, during which the primary outcome occurred in 15 patients. Kaplan-Meier analysis showed that patients with a high sST2/LVMI ratio (≥ 0.39) had shorter event-free survival than those with intermediate (between 0.39 and 0.24) and low ratios (< 0.24) (log-rank, P = 0.022). The fully adjusted multivariable Cox regression analysis showed that the sST2/LVMI ratio was positively associated with the composite outcome in patients with heart failure with reduced ejection fraction after adjusting for confounders (hazard ratio 1.64, 95% confidence interval 1.06 to 2.54). By subgroup analysis, a stronger association was found with age between 40 and 55 years, systolic blood pressure < 115 or ≥ 129 mmHg, diastolic blood pressure < 74 mmHg, hematocrit < 44.5%, and interventricular septum thickness ≥ 8.5 mm. CONCLUSION: In patients with heart failure with reduced ejection fraction, the relationship between the sST2/LVMI ratio and the composite outcome was linear. A higher baseline ratio of sST2/LVMI was associated with an increased risk of cardiovascular mortality and heart failure rehospitalization in the short-term follow-up.

Usefulness of Global Longitudinal Strain to Predict Heart Failure Progression in Patients With Nonobstructive Hypertrophic Cardiomyopathy.

While predicting prognosis to anticipate adverse disease course has long been an aspiration in hypertrophic cardiomyopathy (HC), reliable markers of progressive and unrelenting heart failure symptoms in the absence of obstruction are not well characterized. We sought to evaluate markers of systolic function, including the role of global longitudinal strain (GLS), to identify nonobstructive HC patients at risk for future heart failure. A cohort of 296 consecutive nonobstructive HC patients (42 ± 18years; 75% male) with NYHA class I/II symptoms and preserved systolic function at study entry (EF: 65 ± 6%), were followed for progressive heart failure symptoms (increase in ≥ 1 NYHA functional class) and/or development of systolic dysfunction (EF < 50%). Over median follow-up of 4 ± 3 years, 35 study patients (10%) experienced new heart failure events, including 31 with progressive symptoms and 4 who developed systolic dysfunction. Abnormal GLS < 16% was associated with a 5-fold increase in risk for heart failure compared to GLS > 18% (p < 0.001). GLS remained an independent predictor of heart failure even after adjustment for other relevant disease variables including EF (OR 1.23, p = 0.005). However, notably, when GLS and EF were combined, the prediction of heart failure for individual patients was enhanced (net reclassification improvement 0.55; p = 0.002). Together, GLS < 16% and EF 50% to 59% were associated with a 12.5-fold greater risk for heart failure versus patients with GLS > 18% and EF ≥ 60%, who were at the lowest risk. In conclusion, in nonobstructive HC with no or mild symptoms and preserved EF, abnormal GLS is a strong independent predictor for subsequent development of progressive heart failure symptoms and/or systolic dysfunction. Furthermore, the greatest power in predicting outcome in nonobstructive HC is achieved by combining GLS with EF to identify HC patients at the highest risk for heart failure progression and systolic dysfunction.

Neutrophil degranulation biomarkers characterize restrictive echocardiographic pattern with diastolic dysfunction in patients with diabetes.

OBJECTIVE: To investigate the potential association between neutrophil degranulation and patterns of myocardial dysfunction in a cohort of patients with type 2 diabetes mellitus (T2DM). BACKGROUND: Two distinct phenotypes of diabetic cardiomyopathy have been described: a restrictive phenotype with diastolic dysfunction (restrictive/DD) and a dilative phenotype with systolic dysfunction (dilative/SD). However, the underlying determinants of these two patterns are not yet recognized. METHODS: In this single-centre, observational, cross-sectional study, 492 patients were recruited. Ultrasonographic measurements were performed by two experienced sonographers, blinded to the clinical data of the participants. Serum biomarkers of neutrophil degranulation were measured by enzyme-linked immunosorbent sandwich assay (ELISA). RESULTS: After adjustment for confounders, resistin, myeloperoxidase, matrix metalloproteinase 8 and matrix metalloproteinase 9/tissue inhibitor of metalloproteinases 1 complex were positively associated with the restrictive/DD pattern compared with the normal pattern. Similarly, MPO was positively associated with the dilative/SD pattern compared with the normal pattern, and resistin was negatively associated with the dilative/SD pattern compared with the restrictive/DD pattern. CONCLUSIONS: Neutrophil degranulation is associated with the restrictive/DD echocardiographic pattern in patients with T2DM, but not with the normal pattern and dilative/SD patterns. Neutrophils could have a pivotal role in the pathogenesis of myocardial dysfunction, and particularly diastolic dysfunction, in patients with T2DM.

Partial anomalous pulmonary venous return after orthotopic heart transplantation case report.

BACKGROUND: Partial anomalous pulmonary venous return (PAPVR) is a congenital heart defect. Reports of repair and treatment in pediatric cases have been published, but incidence of PAPVR in adults is not common. To our knowledge, there has not been a diagnosis of left-sided PAPVR after a heart transplant an in adult patient. CASE PRESENTATION: A 62-year-old patient with ischemic cardiomyopathy and systolic heart failure underwent orthotopic heart transplantation. The immediate post-operative course was remarkable for an elevated cardiac index and pulmonary artery pressures as well as decreased systemic vascular resistance. The post-operative echocardiogram did not reveal an intra-cardiac shunt. However, computed tomographic angiography (CTA) showed a left superior pulmonary vein draining into the innominate vein. Operative repair of the left superior pulmonary venous connection to the left atrial appendage was completed under cardiopulmonary bypass with beating heart. Her hemodynamics improved immediately, and she had an unremarkable postoperative course. CONCLUSIONS: While uncommon, any patient with a high cardiac output and abnormal hemodynamics after heart transplant should be evaluated for the existence of a shunt. While not a part of all traditional preoperative imaging protocols, a chest CTA should be considered if PAPVR is suspected as it can both diagnose the condition and enable a plot of the corrective course of surgical action.

Cardiac computed tomography improves the identification of cardiomechanical complications among patients with suspected left ventricular assist device malfunction.

BACKGROUND: Left ventricular assist devices (LVAD) are increasingly used for durable mechanical circulatory support in advanced heart failure. While LVAD therapy provides substantial improvement in mortality and quality of life, long-term therapy confers increased risk for device complications. We evaluated if cardiac computed tomography (CCT) improves the detection of cardiomechanical complications among patients with LVAD and suspected device malfunction. METHODS: In this study, we compared the diagnostic performance of CCT and transthoracic echocardiography (TTE) for the identification of cardiomechanical LVAD complications, including thrombus or neointimal hyperplasia, inflow cannula malposition with dynamic obstruction, fixed outflow obstruction, device infection, and severe aortic regurgitation. Complications were confirmed with surgical evaluation, pathologic assessment, or response to therapeutic intervention. RESULTS: Among 58 LVAD patients, who underwent CCT and TTE for suspected LVAD dysfunction, there were 49 confirmed cardiomechanical LVAD complications among 43 (74.1%) patients. The most common LVAD complication was thrombus or neointimal hyperplasia (65.3%), followed by dynamic obstruction (26.5%). Individually, CCT identified 29 of the 49 (59.2%) confirmed LVAD cardiomechanical complications, whereas TTE alone identified a complication in 11 cases (22.4%). However, diagnostic performance was greatest when the two modalities were used in combination, yielding a sensitivity of 67%, specificity of 93%, PPV of 97%, NPV of 47% and diagnostic accuracy of 73%. CONCLUSION: The novel and complementary use of CCT with TTE for the evaluation of suspected device malfunction improves the accurate identification of cardiomechanical LVAD complication compared to either modality alone.

Predicting ventricular tachyarrhythmia in patients with systolic heart failure based on texture features of the gray zone from contrast-enhanced magnetic resonance imaging.

BACKGROUND: Previous research showed that gray zone detected by late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) imaging could help identify high-risk patients. In this study, we investigated whether LGE-CMR gray zone heterogeneity measured by image texture features could predict cardiovascular events in patients with heart failure (HF). METHOD: This is a retrospective cohort study. Patients with systolic HF undergoing CMR imaging were enrolled. Cine and LGE images were analyzed to derive left ventricular (LV) function and scar characteristics. Entropy and uniformity of gray zones were derived by texture analysis. RESULTS: A total of 82 systolic HF patients were enrolled. After a median 1021 (25%-75% quartiles, 205-2066) days of follow-up, the entropy (0.60 ± 0.260 vs. 0.87 ± 0.28, p = 0.013) was significantly increased while the uniformity (0.68 ± 0.14 vs. 0.53±0.15, p = 0.016) was significantly decreased in patients with ventricular tachycardia or ventricular fibrillation (VT/VF). The percentage of core scar (21.9 ± 10.6 vs. 30.6 ± 10.4, p = 0.029) was higher in cardiac mortality group than survival group while the uniformity (0.55 ± 0.17 vs. 0.67 ± 0.14, p = 0.018) was lower in cardiac mortality group than survival group. A multivariate Cox regression model showed that higher percentage of gray zone area (HR = 8.805, 1.620-47.84, p = 0.045), higher entropy (>0.85) (HR = 1.391, 1.092-1.772, p = 0.024) and lower uniformity (≦0.54) (HR = 0.535, 0.340-0.842, p = 0.022) were associated with VT/VF attacks. Also, higher percentage of gray zone area (HR = 5.716, 1.379-23.68, p = 0.017), core scar zone (HR = 1.939, 1.056-3.561, p = 0.025), entropy (>0.85) (HR = 1.434, 1.076-1.911, p = 0.008) and lower uniformity (≦0.54) (HR = 0.513, 0.296-0.888, p = 0.009) were associated with cardiac mortality during follow-up. CONCLUSIONS: Gray zone heterogeneity by texture analysis method could provide additional prognostic value to traditional LGE-CMR substrate analysis method.

Phenotyping progression of secondary mitral regurgitation in chronic systolic heart failure.

BACKGROUND: Secondary mitral regurgitation (sMR) drives adverse cardiac remodelling in patients with heart failure with reduced ejection fraction (HFrEF). Progression in severity over time contributes to a transition towards more advanced HF stages. Early identification of patients at risk for sMR progression remains challenging. We therefore sought to assess a broad spectrum of neurohumoral biomarkers in patients with HFrEF to explore their ability to predict progression of sMR. METHODS: A total of 249 HFrEF patients were enrolled. Biomarkers encompassing key neurohumoral pathways in heart failure were sampled at baseline, and sMR progression was assessed over 3 years of follow-up. RESULTS: Of 191 patients with nonsevere sMR at baseline, 18% showed progressive sMR within three years after study enrolment. Progression of sMR was associated with higher levels of MR-proADM (adj.OR 2.25, 95% CI 1.29-3.93; P = .004), MR-proANP (adj.OR 1.84, 95% CI 1.14-3.00; P = .012), copeptin (adj.OR 1.66, 95% CI 1.04-2.67; P = .035) and CT-pro-ET1 (adj.OR 1.68, 95% CI 1.06-2.68; P = .027) but not with NT-proBNP (P = .54). CONCLUSION: Increased plasma levels of neurohumoral cardiac biomarkers are predictors of sMR progression in patients with HFrEF and add easily available incremental prognostic information for risk stratification. Importantly, NT-proBNP was not useful to predict progressive sMR in the present analysis. On the contrary, MR-proANP, primarily produced in the atria, copeptin partly triggered by intra-cardiac and intra-arterial pressures and MR-proADM, a marker of forward failure and peripheral released vasoactive CT-proET1, increase based on a progressive loading burden by sMR and may thus serve as better predictors of sMR progression.

Ecocardioscopia, periodo formativo necesario para médicos generalistas / Ecocardioscopy, a need of training period for general physicians

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Prevalence of cardiac amyloidosis among elderly patients with systolic heart failure or conduction disorders.

Objective: Cardiac amyloid infiltration can lead to systolic heart failure (HF) or to conduction disorders (CD). Patients with transthyretin (ATTR) amyloidosis are particularly exposed. We sought to determine the prevalence of ATTR and AL among patients >60 years admitted with CD or unexplained systolic HF and increased wall thickness. Materials and Methods: We studied 143 patients (57% males, 79 ± 9 years) with HF (N = 28) or CD requiring pacemaker implantation (N = 115). In total, 139 (97%) patients (28 with HF and 111 with CD) underwent 99mTc-DPD scintigraphy to detect ATTR, and 105 (73%; 19 HF and 86 CD) underwent AL screening. Results: Five patients (4%; 95%CI:0-7%) exhibited wild-type ATTR (ATTRwt) amyloidosis, 2 (2%; 95%CI:0-4%) had CD and 3 (11%; 95%CI:0-23%) HF. No patient showed AL. The 2 ATTRwt patients with CD were previously asymptomatic, did not show classical ECG signs and exhibited mild LV hypertrophy with preserved LVEF. By contrast, all ATTRwt patients with HF had ECG and echocardiographic signs of amyloid. During a mean follow-up of 18 ± 11 months, 3(60%) patients with ATTRwt amyloidosis (1 CD and 2 HF) and 14(10.4%) without died. Conclusion: Prevalence of ATTRwt amyloidosis in patients with CD requiring pacemaker is low. Although, additional studies are needed, prevalence seems to be higher in elderly patients with systolic HF.