The association of mechanical dyssynchrony and resynchronization therapy with survival in heart failure with a wide QRS complex: a two-world study.

Setting up a randomized trial to assess the association of mechanical dyssynchrony (MD) and the success of cardiac resynchronization therapy (CRT) in heart failure with a wide QRS complex is ethically challenging. We therefore investigated this association in a retrospective cohort study observing different treatment strategies which were chosen based on the availability of health care resources. The survival of 500 patients from six Western European centers treated with CRT was compared to their 137 Eastern European counterparts not treated with CRT, with regard to the presence of MD. MD was visually assessed and was defined as the presence of apical rocking and/or septal flash. Patients were followed for a mean of 26 ± 8 months for the occurrence of death of any cause. As compared with medical therapy alone, CRT was associated with a more favorable survival (hazard ratio (HR), 0.53; 95% confidence interval (CI) 0.35-0.79; P = 0.002). Patients with MD treated by CRT had better survival than patients belonging to all other groups-they showed 72%, 66% and 56% reduction in all-cause mortality, respectively, compared to patients with MD not treated by CRT (HR 0.28; 95% CI 0.17-0.44), patients without MD treated by CRT (HR 0.34; 95% CI 0.22-0.52) and patients without MD not treated by CRT (HR 0.44; 95% CI 0.25-0.76). Patients with wide QRS complex who are treated with CRT have a significantly better survival when MD is present.

Assessment of mechanical dyssynchrony can improve the prognostic value of guideline-based patient selection for cardiac resynchronization therapy.

Aim: To determine if incorporation of assessment of mechanical dyssynchrony could improve the prognostic value of patient selection based on current guidelines. Methods and results: Echocardiography was performed in 1060 patients before and 12 ± 6 months after cardiac resynchronization therapy (CRT) implantation. Mechanical dyssynchrony, defined as the presence of apical rocking or septal flash was visually assessed at the baseline examination. Response was defined as ≥15% reduction in left ventricular end-systolic volume at follow-up. Patients were followed for a median of 59 months (interquartile range 37-86 months) for the occurrence of death of any cause. Applying the latest European guidelines retrospectively, 63.4% of the patients had been implanted with a Class I recommendation, 18.2% with Class IIa, 9.4% with Class IIb, and in 9% no clear therapy recommendation was present. Response rates were 65% in Class I, 50% in IIa, 38% in IIb patients, and 40% in patients without a clear guideline-based recommendation. Assessment of mechanical dyssynchrony improved response rates to 77% in Class I, 75% in IIa, 62% in IIb, and 69% in patients without a guideline-based recommendation. Non-significant difference in survival among guideline recommendation classes was found (Log-rank P = 0.2). Presence of mechanical dyssynchrony predicted long-term outcome better than guideline Classes I, IIa, IIb (Log-rank P < 0.0001, 0.006, 0.004, respectively) and in patients with no guideline recommendation (P = 0.02). Comparable results were observed using the latest American Guidelines. Conclusion: Our data suggest that current guideline criteria for CRT candidate selection could be improved by incorporating assessment of mechanical asynchrony.

Long-Term Outcome After CRT in the Presence of Mechanical Dyssynchrony Seen With Chronic RV Pacing or Intrinsic LBBB.

OBJECTIVES: The aim of this study was to compare the volumetric response and the long-term survival after cardiac resynchronization therapy (CRT) in patients with intrinsic left bundle branch block (LBBB) versus chronic right ventricular pacing (RVP) with respect to the presence of mechanical dyssynchrony (MD). BACKGROUND: Chronic RVP induces an iatrogenic LBBB and asynchronous left ventricular contraction that is potentially reversible by upgrading to CRT. METHODS: A total of 914 patients eligible for CRT (117 with conventional pacemakers and 797 with intrinsic LBBB) were included in the study. MD was visually assessed before CRT and was defined as the presence of either apical rocking and/or septal flash on baseline echocardiograms. Patients with a left ventricular end-systolic volume decrease of ≥15% during the follow-up were considered responders. Patients were followed for all-cause mortality during the median follow-up of 48 months (interquartile range: 29 to 66 months). RESULTS: MD was observed in 51% of patients with RVP versus 77% in patients with intrinsic LBBB (p < 0.001). Patients with RVP and MD had a similar likelihood of volumetric response as did patients with intrinsic LBBB and MD (adjusted odds ratio: 0.71; 95% confidence interval: 0.33 to 1.53; p = 0.385). There was no significant difference in long-term survival between patients with RVP and intrinsic LBBB (adjusted hazard ratio: 1.101; 95% confidence interval: 0.658 to 1.842; p = 0.714). Patients with visual MD and either intrinsic LBBB or RVP had a more favorable survival than those without MD (p < 0.001). CONCLUSIONS: The likelihood of volumetric response and a favorable long-term survival of patients with RVP was similar to those of patients with intrinsic LBBB and were mainly determined by the presence of MD and not by the nature of LBBB.

Following up adult patients with tetralogy of fallot: The role of echocardiography.

Tetralogy of Fallot (TOF) is one of the most common cyanotic congenital heart diseases. With surgical repair and the advances in postoperative care, contemporary mortality has dramatically improved and an increasing number of patients survive into adulthood, leading to a growing number of adult TOF. However, residual anatomic and hemodynamic abnormalities are encountered in nearly all patients, making follow-up mandatory. Furthermore, mortality starts to increase 25 years after surgery, emphasizing that, in adult TOF, closer monitoring is necessary. We review here the role of echocardiography in the follow-up of the TOF patients, emphasizing the role of multiple echocardiographic techniques. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:79-95, 2017.

Relationship of visually assessed apical rocking and septal flash to response and long-term survival following cardiac resynchronization therapy (PREDICT-CRT).

AIMS: Apical rocking (ApRock) and septal flash (SF) are often observed phenomena in asynchronously contracting ventricles. We investigated the relationship of visually assessed ApRock and SF, reverse remodelling, and long-term survival in cardiac resynchronization therapy (CRT) candidates. METHODS AND RESULTS: A total of 1060 patients eligible for CRT underwent echocardiographic examinations before and 12 ± 6 months after device implantation. Three blinded physicians were asked to visually assess the presence of ApRock and SF before device implantation and also their correction by CRT 12 ± 6 months post-implantation. Patients with a left ventricular (LV) end-systolic volume decrease of ≥15% during the first year of follow-up were regarded as responders. Patients were followed for a median period of 46 months (interquartile range: 27-65 months) for the occurrence of death of any cause. If corrected by CRT, visually assessed ApRock and SF were associated with reverse remodelling with a sensitivity of 84 and 79%, specificity of 79 and 74%, and accuracy of 82 and 77%, respectively. ApRock (hazard ratio [HR] 0.40, 95% confidence interval [CI] 0.30-0.53, P < 0.0001) and SF (HR 0.45 [CI 0.34-0.61], P < 0.001) were independently associated with lower all-cause mortality after CRT and had an incremental value over clinical variables and QRS width for identifying CRT responders. Both the absence of ApRock/SF and unsuccessful correction of ApRock/SF despite CRT were associated with a high risk for non-response and an unfavourable long-term survival. CONCLUSION: A specific LV mechanical dyssynchrony pattern, characterized by ApRock and SF, is associated with a more favourable long-term survival after CRT. Both parameters are also indicators of an effective therapy.

From Clinical Considerations to Theory - Blood Pressure Variability Profiles and Patterns.

BACKGROUND: Blood pressure variability (BPV) has recently been associated with adverse cardiovascular (CV) events, endothelial dysfunction as well as both CV and non-CV morbidity and mortality. Different BPV indicators have been associated with increased CV risk. METHODS: We included 744 hypertensive patients referred to our clinic for uncontrolled arterial hypertension (HTN) between 2012 and 2014, with a minimum of 40 successful daytime and 8 successful nighttime readings on automatic blood pressure monitoring (ABPM Meditech-05 device, recordings at 15-20 minutes intervals during daytime and 20-30 minutes intervals during nighttime). Exclusion criteria were presence of secondary HTN, significant CV disease and estimated glomerular filtration rate <30 ml/min/1.73 m2. BPV was expressed as dipping pattern, BP load, SD of 24-hour mean BP, average weighted SD and average real variability (ARV). RESULTS: All patients were known hypertensives, however their average blood pressure (BP) values on 24-hour ABPM were below 135/85 mmHg. The average dipping was higher in dippers (p<0.01) and nighttime systolic BP (SBP) load was increased among the non-dippers group (p<0.01). Mean diastolic BP (DBP) was slightly increased in dippers vs. non-dippers (75.82 ± 10.28 mmHg vs. 71.42 ± 10.17 mmHg, p<0.01). Of the total of 407 dippers, 31.2% displayed an extreme dipping pattern, whereas 29.67% of the 337 non-dippers were risers. In our study, average SBP, daytime and nighttime SBP SD and ARV did not differ significantly between the two extreme groups, as opposed to classical indicators such as SBP load (p<0.01) and weighted SD (p 0.02). CONCLUSION: In the emergency hospital setting, hypertensive patients can have normal mean BP values, but still can display a very high variability and in most cases abnormal dipping profiles, requiring a strictly controlled drug therapy that is able to match each individual's chronobiology.

Pulmonary veno-occlusive disease: a rare cause of pulmonary hypertension in systemic sclerosis. Case presentation and review of the literature .

Pulmonary veno-occlusive disease (PVOD) is a rare cause of pulmonary arterial hypertension (PAH). Because of the similar clinical picture of dyspnea on exertion and signs of right heart failure, PVOD is difficult to distinguish from idiopathic PAH. However, the distinction is mandatory because PVOD has a worse prognosis and, more importantly, the administration of PAH specific therapy (vasodilators) can precipitate severe acute pulmonary oedema. We present a challenging case of PAH in a patient with systemic sclerosis in whom a marked decrease in functional capacity after the initiation of bosentan therapy led to the diagnosis of PVOD. Management of PVOD patients is challenging and referral for lung transplantation should be done at the moment of diagnosis.

Midkine proteins in cardio-vascular disease. Where do we come from and where are we heading to?

Midkine is a recently identified new growth factor/cytokine with pleiotropic functions in the human organism. First discovered in the late eighties, midkines have now become the subject of numerous studies in cardiovascular, neurologic, renal diseases and also various types of cancers. We summarize here the most important functions of midkine in cardiovascular diseases, emphasizing its role in inflammation and its antiapoptotic and proangiogenetic effects. Midkine has multiple roles in the organism, with the specific feature of being either beneficial or harmful depending on which tissue it acts on. Even though midkine has been shown to have cardiac protective effects against acute ischemia/reperfusion injury and to inhibit cardiac remodeling, it also promotes intimal hyperplasia and vascular stenosis. As such, different therapeutic strategies are currently being evaluated, consisting of administering either midkine proteins or midkine inhibitors depending on the desired outcome. More data is gathering to suggest that these novel therapies could become an adjunctive to standard cardiovascular therapy. Nonetheless, much is still to be learned about midkine. The encouraging results up till now require further studying in order to fully understand the complete profile of its mechanism of action and the clinical safety and efficacy of novel therapeutic opportunities offered by midkine molecular targeting.

Incremental value of the en face view of the tricuspid valve by two-dimensional and three-dimensional echocardiography for accurate identification of tricuspid valve leaflets.

BACKGROUND: In this study, advanced postprocessing of three-dimensional echocardiographic (3DE) data sets was used to identify tricuspid valve (TV) leaflets in two-dimensional echocardiographic (2DE) views, and the feasibility of the subcostal view to obtain 2DE en face views of the TV, as an alternative imaging option to image reconstruction from 3DE imaging, was also tested. METHODS: In 155 consecutive patients, attempts were made to obtain the en face view of the TV by 2DE imaging (from the subcostal window) and by reconstruction from 3DE imaging. Using both in-house-developed and commercially available software for postprocessing of 3DE data, image planes from the standard 2DE views were reconstructed and TV leaflets identified in each view. RESULTS: With 2DE imaging, all TV leaflets could be visualized in 58% of patients, compared with 56% using 3DE imaging. In 30 patients (19%), en face views of the TV could be obtained only by 3DE imaging. The anterior leaflet was the largest one in 90% of patients, and the smallest leaflet was either the posterior (49%) or septal (41%) leaflet. In 12% of patients, the TV was either bicuspid or quadricuspid. In patients with pacemakers, the position of the right ventricular lead relative to the TV leaflets was readily determined using both imaging techniques. Visible TV leaflets varied in all standard 2DE views because of variability in image planes and leaflet morphology. CONCLUSIONS: High variability in TV leaflet anatomy and the dependence on transducer position do not allow schematic leaflet identification. All existing TV leaflet identification schemes are therefore only partially correct, and if correct leaflet identification is needed, the use of an en face view is recommended.

Ordinary symptom for a serious pathology - giant solitary fibrous tumor of the pleura.

The solitary fibrous tumor of the pleura (SFTP) is a rare primary tumor arising from mesenchymal cells in the areolar tissue subjacent to the mesothelial-lined pleura. From an epidemiological standpoint, solitary fibrous tumors of the pleura account for less than 5% of primary pleural tumors, and commonly affect patients in the sixth and seventh decades. We presented the case of a 38-year-old woman, without any significant pathological history, who presented at the emergency room for unspecific respiratory symptoms. Imagistic investigations showed a giant opacity in the upper half part of the left hemithorax. The patient underwent surgery and en bloc resection of the tumor (30/25 cm) in oncological limits was performed. Definite diagnosis - solitary fibrous tumor of the pleura - was obtained through histological examination and immunohistochemistry. Even if SFTP are benign tumors, a long follow-up period is mandatory as even patients with complete resection are at risk of recurrence several years after surgery.

A rare cause of Dysphagia - Dysphagia aortica - complicated with intravascular disseminated coagulopathy.

ABSTRACT: Dysphagia aortica is an uncommon condition defined by the difficulty in swallowing caused by extrinsic compression of the esophagus due to an ectatic, tortuous, or aneurysmatic atherosclerotic thoracic aorta. We report the case of a 93 year old woman with dysphagia secondary to extrinsic compression by a giant sacciform aneurysm of the descending thoracic aorta. As a consequence of small liniar dissection tracts of the aneurysm, the patient developed disseminated intravascular coagulopathy with spontaneous forearm hematoma and multiple bruising, a clinical setting with a difficult therapeutic approach. Taking into account that aneurysm of the thoracic aorta is a very rare cause of dysphagia, the case report on this rare cause should contribute to better diagnosis of dysphagia aortica and swallowing difficulties in general. Dissecting aneurysm of the thoracic aorta is a very rare cause of DIC so the combination of easy bruising or spontaneous hematoma and an aortic aneurysm demands special caution.