Performance of the Seattle Heart Failure Model in implantable defibrillator patients treated with cardiac resynchronization therapy.

The Seattle Heart Failure Model (SHFM) is a validated multivariate risk prediction model for mortality in patients with heart failure, using widely available clinical variables. The aim of this study was to assess the performance of the SHFM when applied to patients with heart failure who received cardiac resynchronization therapy devices with defibrillation. A total of 413 patients were identified from 2 prospective implantable cardioverter-defibrillator registries who received cardiac resynchronization therapy devices with defibrillation for the primary prevention of sudden death. Baseline laboratory and clinical data were entered in the SHFM to calculate predicted survival. The end point was all-cause mortality. During a median follow-up period of 2.8 years, 78 patients died and 9 underwent heart transplantation. Observed versus predicted 5-year mortality rates were 11.6% versus 11.4%, 21.5% versus 22.1%, and 41.4% versus 46.1% by ascending tertile of Seattle Heart Failure Score, respectively. No systematic or substantial errors of risk estimation were observed. Discrimination was excellent; the C-statistic ranged from 0.78 at 1-year follow-up to 0.70 at 5-year follow-up, and the Hosmer-Lemeshow chi-square statistic was 0.87 (p = 0.65). In conclusion, in patients with heart failure who received cardiac resynchronization therapy devices with defibrillation, the SHFM offers adequate discrimination of risk for all-cause mortality and estimation of mortality risk without substantial or systematic errors.

How should I treat an unusual referral for heart transplantation?

BACKGROUND: A 55 years old man was referred for cardiac transplantation because of intractable angina and fatigue. INVESTIGATION: Physical examination, laboratory test, echocardiography, exercise ECG, MRI and coronary arteriography. DIAGNOSIS: Multiple coronary artery fistulae. MANAGEMENT: Beta-blockers, angiotensin-converting enzyme inhibitor ICD.

Prediction of appropriate defibrillator therapy in heart failure patients treated with cardiac resynchronization therapy.

The necessity of implantable cardioverter-defibrillator (ICD) implantation in patients with systolic heart failure (HF) who undergo cardiac resynchronization therapy (CRT) may be questioned. The aim of this study was to identify patients at low risk for sustained ventricular arrhythmia. One hundred sixty-nine consecutive patients with HF (mean age 60 +/- 12 years, 125 men, 73% in New York Heart Association class III) referred for CRT and prophylactic, primary prevention ICD implantation underwent baseline clinical and echocardiographic assessment and regular device follow-up. The primary study end point was appropriate ICD therapy. During a mean follow-up period of 654 +/- 394 days, 35 patients (21%) had sustained ventricular arrhythmias requiring appropriate ICD therapy. Of the 3 patients who experienced sudden cardiac death, 2 had been treated with appropriate ICD therapy before sudden cardiac death. In a multivariate model, only history of nonsustained ventricular tachycardia (p = 0.001), a severely (<20%) decreased left ventricular ejection fraction (p = 0.001), and digitalis therapy (p = 0.08) independently predicted appropriate ICD therapy. Patients with 0 (n = 46), 1 (n = 36), 2 (n = 73), and 3 (n = 14) risk factors for appropriate ICD therapy had a 7%, 14%, 27%, and 64% and 0%, 6%, 10%, and 43% incidence of appropriate ICD therapy for ventricular arrhythmias and for rapid ventricular tachycardia or ventricular fibrillation, respectively. In conclusion, apart from commonsense considerations (age and significant co-morbidities), ICD addition seems ineffective in CRT patients without nonsustained ventricular tachycardia, digoxin therapy, and severely reduced left ventricular systolic function.

Four-year follow-up of treatment with intramyocardial skeletal myoblasts injection in patients with ischaemic cardiomyopathy.

AIMS: Studies reporting improved left ventricular (LV) function of percutaneous skeletal myoblast (SkM) injection in patients with ischaemic cardiomyopathy had follow-up not exceeding 12 months, and did not include a control group. Our group has reported evidence for myoblast efficacy in the first five out of the 14 treated patients. The objective of the present evaluation was to assess if these effects were sustained at long-term follow-up. We compared function of patients treated with SkM 4 years earlier with a matched control group. Secondary endpoints included mortality, NYHA class, N-terminal pro-B-natriuretic peptide levels, incidence of arrhythmias, and quality of life. METHODS AND RESULTS: Fourteen patients with ischaemic cardiomyopathy who underwent SkM injection were compared with 28 non-randomized control patients matched for age, sex, location, and extent of myocardial infarction. Contrast echocardiography and tissue Doppler imaging (TDI) was performed to compare global and regional LV function. At 4-year follow-up, three patients (21%) had died in the treated group and 11 patients (39%) in the control group (P = 0.8). In the survivors, LV ejection fraction (EF) was 35 +/- 10% and 37 +/- 9% in the SkM group and 36 +/- 8% and 36 +/- 6% in the controls at baseline and 4 years follow-up, respectively (P = 0.96 between groups at follow-up). TDI-derived systolic velocity in the injected sites was 5.4 +/- 1.8 cm/s in the SkM group when compared with 5.1 +/- 1.6 cm/s in corresponding sites in the control group (P = 0.47). None of the secondary endpoints showed a difference between the groups. However, in the patients fitted with an internal cardioverter defibrillator, more arrhythmias leading to interventions occurred in the treated group than in the control group, 87% and 13%, respectively (P = 0.015). CONCLUSION: Percutaneous intramyocardial SkM injection in ischaemic cardiomyopathy has no sustained positive effect on resting global or regional LV function, respectively, at 4-year follow-up. Moreover, the procedure may induce a higher risk of developing serious arrhythmias, but larger patient series are required before more precise characterization of the safety and efficacy profile of the procedure is possible.