Trimethylamine N-oxide is associated with coronary atherosclerotic burden in non-ST-segment myocardial infarction patients: SZ-NSTEMI prospective cohort study.

Trimethylamine N-oxide (TMAO) is reported to accelerate atherosclerosis and the development of adverse cardiac outcomes. Relationship between coronary atherosclerotic burden and TMAO has been examined in stable coronary artery disease and ST-segment elevation myocardial infarction, but not in non-ST-segment elevation myocardial infarction (NSTEMI). We examined the association between TMAO and coronary atherosclerotic burden in NSTEMI. In this prospective cohort study, two groups including NSTEMI (n = 73) and age-sex matched Healthy (n = 35) individuals were enrolled between 2019 and 2020. Coronary atherosclerotic burden was stratified based on the number of diseased coronary vessels and clinical risk scores including SYNTAX and GENSINI. Fasting plasma TMAO was measured by isotope dilution high-performance liquid chromatography. The median plasma TMAO levels were significantly higher in the NSTEMI group than in the Healthy group, respectively (0.59 µM; interquartile range [IQR]: 0.43-0.78 versus 0.42 µM; IQR: 0.33-0.64; P = 0.006). Within the NSTEMI group, higher TMAO levels were observed in the multivessel disease (MVD) versus single vessel disease (P = 0.002), and intermediate-high risk (score ≥ 23) versus low risk (score < 23) of SYNTAX (P = 0.003) and GENSINI (P = 0.005). TMAO level remained an independent predictor of MVD (odds ratio [OR]: 5.94, P = 0.005), intermediate-high risk SYNTAX (OR: 3.61, P = 0.013) and GENSINI scores (OR: 4.60, P = 0.008) following adjustment for traditional risk factors. Receiver operating characteristic curve (AUC) analysis for TMAO predicted MVD (AUC: 0.73, 95% confidence interval [Cl]: 0.60-0.86, P = 0.002), intermediate-high SYNTAX score (AUC: 0.70, 95% Cl: 0.58-0.82, P = 0.003) and GENSINI score (AUC: 0.70, 95% Cl: 0.57-0.83, P = 0.005). In all, TMAO levels are independently associated with high coronary atherosclerotic burden in NSTEMI.

A Predictive Model for Super-Response to Cardiac Resynchronization Therapy: The QQ-LAE Score.

OBJECTIVES: It is important to identify super-responders who can derive most benefits from cardiac resynchronization therapy (CRT). We aimed to establish a scoring model that can be used for predicting super-response to CRT. METHODS: We retrospectively reviewed 387 CRT patients. Multivariate logistic regression analysis was performed to identify predictors for super-response (defined as an absolute increase in left ventricular ejection fraction of ≥15% at 6-month follow-up) and to create a score model. Multivariate Cox proportional-hazard regression analysis was conducted to assess associations with the long-term endpoint (defined as cardiac death/heart transplant, heart failure (HF) hospitalization, or all-cause death) across the score categories at follow-up. RESULTS: Among 387 patients, 109 (28.2%) met super-response. In multivariable analysis, 5 independent predictors (QQ-LAE) were identified: prior no fragmented QRS (odds ratio (OR) = 3.10 (1.39, 6.94)), QRS duration ≥170 ms (OR = 2.37 (1.35, 4.12)), left bundle branch block (OR = 2.57 (1.04, 6.37)), left atrial diameter <45 mm (OR = 3.27 (1.81, 5.89)), and left ventricular end-diastolic dimension <75 mm (OR = 4.11 (1.99, 8.48)). One point was attributed to each predictor, and three score categories were identified. The proportion of super-response after 6-month CRT implantation in patients with scores 0-3, 4, and 5 was 14.6%, 40.3%, and 64.1%, respectively (P < 0.001). Patients with score 5 had an 88% reduction in the risk of cardiac death/heart transplant (P=0.042), a 71% reduction in the risk of HF hospitalization (P=0.048), and an 89% reduction in the risk of all-cause mortality (P=0.028) compared to patients with scores 0-3. CONCLUSIONS: The QQ-LAE score can be used for prediction of super-response to CRT and selection of most suitable patients in clinical practices.

Correlations between low thyroid function and incidence of atrial fibrillation in hypertrophic obstructive cardiomyopathy.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia in patients with hypertrophic obstructive cardiomyopathy (HOCM). Data regarding the correlations of thyroid dysfunction and the incidence of AF in HOCM are quite limited. This study aimed to reveal the correlations between different thyroid status and the corresponding incidence of AF in a large HOCM cohort. METHODS: A total of 806 HOCM patients with complete information on thyroid function tests and comprehensive cardiac evaluations were recruited. The participants were divided into the AF group (n = 159) and non-AF group (n = 647) according to established medical history and results of Holter monitoring. The thyroid status of the study population and the corresponding incidence of AF were assessed and analyzed. RESULTS: Hypothyroidism accounted for the greatest proportion of thyroid dysfunction in HOCM patients. The incidence of AF significantly increased in individuals with both overt (P = 0.022) and subclinical (P = 0.007) hypothyroidism. Compared with participants in the non-AF group, those with positive AF episodes presented with lower free triiodothyronine (FT3) (2.86 ± 0.52 pg/mL vs. 3.01 ± 0.42 pg/mL, P = 0.001), higher free thyroxine (FT4) (1.24 ± 0.25 ng/dL vs. 1.15 ± 0.16 ng/dL, P < 0.001), and remarkably increased levels of thyrotropin (TSH) (12.6% vs. 5.3%, P = 0.001). Multivariable analyses demonstrated that the concentrations of FT3 (odds ratio [OR] = 0.470, 95% confidence interval [CI]: 0.272-0.813, P = 0.007) and FT4 (OR = 17.992, 95% CI: 5.750-56.296, P < 0.001), as well as TSH levels above normal ranges (OR = 2.276, 95% CI: 1.113-4.652, P = 0.024) were independently associated with the occurrence of AF in the large HOCM cohort. CONCLUSIONS: This study indicated a strong link between low thyroid function and the presence of AF in HOCM. Hypothyroidism (both overt and subclinical states) seems to be valuable for assessing the incidence of AF in patients with HOCM.

Predictive value of Tpeak-Tend interval for ventricular arrhythmia and mortality in heart failure patients with an implantable cardioverter-defibrillator: A cohort study.

BACKGROUND: Tpeak-Tend interval (TpTe), a measurement of transmural dispersion of repolarization (TDR), has been shown to predict ventricular tachyarrhythmia in cardiac resynchronization therapy with defibrillator (CRT-D) patients. However, the ability of TpTe to predict ventricular tachyarrhythmia and mortality for heart failure patients with a cardioverter-defibrillator (ICD) is not clear. The purpose of this study was to assess the predictive ability of TpTe in heart failure patients with ICD. METHODS AND RESULTS: We enrolled 318 heart failure patients treated after ICD. Patients were divided into 3 groups according to their post-implantation TpTe values and were evaluated every 6 months. The primary endpoint was appropriate ICD therapy. The secondary endpoint was all-cause mortality. During long-term follow-up, the TpTe > 110 ms group (n = 111) experienced more VT/VF episodes (45%) and all-cause mortality (25.2%) than the TpTe 90-110 ms group (n = 109) (26.4%, 14.5%) and TpTe < 90 ms group (n = 98) (11.3%, 11.3%) (overall P < .05, respectively). In Cox regression, longer post-implantation TpTe was associated with an increased number of VT/VF episodes [HR: 1.017; 95% CI: 1.008-1.026; P < .001], all-cause mortality [HR: 1.015; 95% CI: 1.004-1.027; P = .010] and the combined endpoint [HR: 1.018; 95%CI: 1.010-1.026; P < .001]. CONCLUSIONS: Post-implantation TpTe was an independent predictor of both ventricular arrhythmias and all-cause mortality in heart failure patients with an implanted ICD.

Predictors of non-response to cardiac resynchronization therapy implantation in patients with class I indications: the markedly dilated left ventricular end-diastolic dimension and the presence of fragmented QRS.

BACKGROUND: Cardiac resynchronization therapy (CRT) is a highly effective treatment in patients with a class I recommendation. However, a small proportion of the strictly selected patients still fail to respond. This study was designed to identify predictors of non-response in patients with class I indications for CRT and determine the non-response probability of the patients. METHODS: A total of 296 consecutive patients with a class I recommendation received CRT from January 2009 to January 2017 were retrospectively analyzed. Multivariate logistic regression analysis was performed to identify predictors for non-response (defined as cardiac death, heart transplantation, or HF hospitalization during 1-year follow-up). RESULTS: Among 296 patients, 30 (10.1%) met non-response. Multivariate analysis demonstrated that non-response to CRT was associated with a fragmented QRS (odd ratio (OR) = 2.86, 95% CI: 1.14-7.12; P = 0.025) and left ventricular end-diastolic dimension (LVEDD) ≥ 77 mm (OR = 3.02, 95% CI: 1.17-7.82; P = 0.022). Patients with both of the predictors had a non-response probability of 46.2% (95% CI: 19.1%-73.3%). CONCLUSION: In patients with left bundle branch block and wider QRS duration, the proportion of non-response to CRT is not low in real world. The presence of the dilated LVEDD or fragmented QRS is a strong predictor of non-response to CRT. The probability of non-response in the patients with the two predictors was 46.2%.

Does 'super-responder' patients to cardiac resynchronization therapy still have indications for neuro-hormonal antagonists? Evidence from long-term follow-up in a single center.

BACKGROUND: Whether cardiac resynchronization therapy super-responders (CRT-SRs) still have indications for neuro-hormonal antagonists or not remains uninvestigated. METHODS: We reviewed clinical data from 376 patients who underwent CRT implantation in Fuwai Hospital from 2009 to 2015 and followed up to 2017. CRT-SRs were defined by an improvement of the New York Heart Association functional class and left ventricular ejection fraction to ≥ 50% in absolute values at 6-month follow-up. All CRT-SRs were assigned into two groups on the basis of whether persistently receiving neuro-hormonal antagonists (NHA) (defined as angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and ß-blockers) after 6-month follow-up and then we compared long-term outcome. RESULTS: A total of 60 patients met criteria for super-response. One of thirteen (7.7%) CRT-SRs without NHA had all-cause death, which also occurred in 2 of 47 (4.3%) in CRT-SRs with NHA (P = 0.526). However, 3 of 13 (23.1%) CRT-SRs without NHA had heart failure (HF) hospitalization, 1 of 47 (2.1%) CRT-SRs with NHA had this endpoint (P = 0.040). Besides, subgroup analysis indicated that, for ischemic etiology group, CRT-SRs receiving NHA had considerably lower incidence of HF hospitalization than those without NHA (0 vs. 75%, P = 0.014), which was not observed in non-ischemic etiology group (2.6% vs. 0, P = 1.000) during long-term follow-up. CONCLUSIONS: Our study found that for ischemic etiology, compared with CRT-SRs with NHA, CRT-SRs without NHA were associated with a higher risk of HF hospitalization. However, for non-ischemic etiology, we found that CRT-SRs with NHA or without NHA at follow-up were associated with similar outcomes, which needed further investigation by prospective trials.

Repetitive optimizing left ventricular pacing configurations with quadripolar leads improves response to cardiac resynchronization therapy: A single-center randomized clinical trial.

BACKGROUND: This study aimed to investigate whether repetitive optimizing left ventricular pacing configurations (LVPCs) with quadripolar leads (QUAD) can improve response to cardiac resynchronization therapy (CRT). METHODS: Fifty-two eligible patients were enrolled and 1:1 randomized to either the quadripolar LV leads (QUAD) group or the conventional bipolar leads (CONV) group. In the QUAD group, optimization of LVPC was performed for all patients before discharge and for nonresponders at 3 months follow-up. Clinical evaluations and transthoracic echocardiograms were performed before, 3, and 6 months after CRT implantation. RESULTS: At 3 months follow-up, 16 of 25 (64%) patients in the CONV group (1 patient was lost to follow-up) and 18 of 26 (69%) patients in the QUAD group were classified as responders. After optimizing the LVPCs in 3-month nonresponders in the QUAD group, 21 of 26 (80.8%) patients in the QUAD group were classified as responders at 6 months as compared with 17 of 25 (68%) patients in the CONV group. Left ventricular end-systolic volume (LVESV) reduction, left ventricular ejection fraction (LVEF) increase, and New York Heart Association (NYHA) functional class reduction at 6 months were significantly greater in the QUAD group than in the CONV group (LVESV: -26.9 ±â€Š13.8 vs -17.2 ±â€Š13.3%; P = .013; LVEF: +12.7 ±â€Š8.0 vs +7.8 ±â€Š6.3 percentage points; P = .017; NYHA: -1.27 ±â€Š0.67 vs -0.72 ±â€Š0.54 functional classes; P = .002). CONCLUSIONS: Compared with conventional bipolar leads, CRT using quadripolar leads with repetitive optimized LVPCs resulted in an additional increase in LVEF and reduction in LVESV and NYHA functional class at 6-month follow-up.

Clinical outcome of cardiac resynchronization therapy in dilated-phase hypertrophic cardiomyopathy.

BACKGROUNDS: Clinical trials have demonstrated that cardiac resynchronization therapy (CRT) is effective in patients with "non-ischemic cardiomyopathy". However, patients with dilated-phase hypertrophic cardiomyopathy (DHCM) have been generally excluded from such trials. We aimed to compare the clinical outcome of CRT in patients with DHCM, idiopathic dilated cardiomyopathy (IDCM), or ischemic cardiomyopathy (ICM). METHODS: A total of 312 consecutive patients (DHCM: n = 16; IDCM: n = 231; ICM: n = 65) undergoing CRT in Fuwai hospital were studied respectively. Response to CRT was defined as reduction in left ventricular end-systolic volume (LVESV) ≥ 15% at 6-month follow-up. RESULTS: Compared with DHCM, IDCM was associated with a lower total mortality (HR: 0.35, 95% CI: 0.13-0.90), cardiac mortality (HR: 0.29; 95% CI: 0.11-0.77), and total mortality or heart failure (HF) hospitalizations (HR: 0.34, 95% CI: 0.17-0.69), independent of known confounders. Compared with DHCM, the total mortality, cardiac mortality and total mortality or HF hospitalizations favored ICM but were not statistically significant (HR: 0.59, 95% CI: 0.22-1.61; HR: 0.59, 95% CI: 0.21-1.63; HR: 0.54, 95% CI: 0.26-1.15; respectively). Response rate to CRT was lower in the DHCM group than the other two groups although the differences didn't reach statistical significance. CONCLUSIONS: Compared with IDCM, DHCM was associated with a worse outcome after CRT. The clinical outcome of DHCM patients receiving CRT was similar to or even worse than that of ICM patients. These indicate that DHCM behaves very differently after CRT.

Aneurysm-related ischemic ventricular tachycardia: safety and efficacy of catheter ablation.

Left ventricular aneurysm (LVA) postmyocardial infarction (MI) might be an arrhythmogenic substrate. We examined the safety and efficacy of catheter ablation of LVA-related ventricular tachycardia (VT).Thirty-three consecutive patients who underwent primary catheter ablation of ischemic VT were divided into LVA group (11 patients, mean age 61.9 years, 10 men) and none LVA group. Acute procedural outcomes, complications, and long-term outcomes were assessed.In LVA group, average number of induced VTs were 3.2 ±â€Š2.6 (range 1-7), clinical VTs were located in the ventricular septum scar zone in 4 (36.4%) patients, acute success was achieved in 7 (63.6%) patients, partial success in 3 (27.3%) and failure in 1 patient, while none LVA group showing a statistically similar distribution of acute procedural outcomes (P = 0.52). There were no major or life-threatening complications. VT-free survival rate at median 19 (1-44) months follow-up was numerically but not significantly lower in LVA versus none LVA group (48.5% vs 62.8%, log-rank P = 0.40).Catheter ablation of ischemic VT in the presence of LVA appears feasible and effective, with about one-third of cases having septal ablation targets. Further studies are warranted.

Short-Term Availability of Viable Left Ventricular Pacing Sites with Quartet™ Quadripolar Leads.

BACKGROUND Whether quadripolar leads can provide sufficient viable left ventricular pacing sites (LVPSs) for device optimization and multipoint pacing remains unclear. This study aimed to evaluate the acute and 3-month availability of viable LVPSs provided by a quadripolar LV pacing lead. MATERIAL AND METHODS A single-center cohort study evaluated consecutive patients who underwent a CRT implant with the QuartetTM LV lead under local guidelines. The availability of viable LVPSs was assessed at the pre-discharge and 3-month follow-up visit. Bipolar lead configurations, which served as the control group, were modeled by eliminating the 2 proximal electrodes on the Quartet™ LV lead. RESULTS A total of 24 patients were enrolled and finished 3-month follow-up. The mean follow-up period was 93±3 days. At pre-discharge, the Quartet™ LV lead provided more viable LVPSs compared with the bipolar equivalents (median 3 [IQR 2-4] vs. median 2 [IQR 1-2], P<0.001). The percentage of patients with at least 1, 2, 3, and 4 viable LVPSs were 100% (24/24), 91.7% (22/24), 58.3% (14/24), and 33.3% (8/24) for Quartet™ leads and 91.7% (22/24), 70.8% (17/24), 0% (0/24), and 0% (0/24) for bipolar lead configurations, respectively. The median and IQR values of viable LVPSs provided by the Quartet™ LV lead remained the same (3 [IQR 2-4]) between pre-discharge and 3-month follow-up (P=0.45). CONCLUSIONS Compared with the bipolar equivalent, QuartetTM LV lead provides more viable LVPSs and opportunities for CRT optimization and multipoint LV pacing. The number of LVPSs provided by Quartet™ leads remained unchanged between pre-discharge and 3-month follow-up.

Predictors of super-response to cardiac resynchronization therapy: the significance of heart failure medication, pre-implant left ventricular geometry and high percentage of biventricular pacing.

BACKGROUND: Super-responders (SRs) are defined as patients who show crucial cardiac function improvement after cardiac resynchronization therapy (CRT). The purpose of this study is to identify and validate predictors of SRs after CRT. METHODS: This study enrolled 201 patients who underwent CRT during the period from 2010 to 2014. Clinical and echocardiographic evaluations were conducted before CRT and 6 months after. Patients with a decrease in New York Heart Association (NYHA) functional class ≥ 1, a decrease in left ventricular end-systolic volume (LVESV) ≥ 15%, and a final left ventricular ejection fraction (LVEF) ≥ 45% were classified as SRs. RESULTS: 29% of the 201 patients who underwent CRT were identified as SRs. At baseline, SRs had significantly smaller left atrial diameter (LAD), LVESV, left ventricular end-diastolic volume (LVEDV) and higher LVEF than the non-super-responders (non-SRs). The percentage of patients using angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARB) was higher in SRs than non-SRs. Most SRs had Biventricular (BiV) pacing percentage greater than 98% six months after CRT. In the multivariate logistic regression analysis, the independent predictors of SRs were lower LVEDV [odd ratios (OR): 0.93; confidence intervals (CI): 0.90-0.97], use of ACEI/ARB (OR: 0.33; CI: 0.13-0.82) and BiV pacing percentage greater than 98% (OR: 0.29; CI: 0.16-0.87). CONCLUSION: Patients with a better compliance of ACEI/ARB and a less ectatic ventricular geometry before CRT tends to have a greater probability of becoming SRs. Higher percentage of BiV pacing is essential for becoming SRs.

Acute and Chronic Changes and Predictive Value of Tpeak-Tend for Ventricular Arrhythmia Risk in Cardiac Resynchronization Therapy Patients.

BACKGROUND: Prolongation of the Tpeak-Tend (TpTe) interval as a measurement of transmural dispersion of repolarization (TDR) is an independent risk factor for chronic heart failure mortality. However, the cardiac resynchronization therapy's (CRT) effect on TDR is controversial. Therefore, this study aimed to evaluate CRTs acute and chronic effects on repolarization dispersion. Furthermore, we aimed to investigate the relationship between TpTe changes and ventricular arrhythmia. METHODS: The study group consisted of 101 patients treated with CRT-defibrillator (CRT-D). According to whether TpTe was shortened, patients were grouped at immediate and 1-year follow-up after CRT, respectively. The echocardiogram index and ventricular arrhythmia were observed and compared in these subgroups. RESULTS: For all patients, TpTe slightly increased immediately after CRT-D implantation, and then decreased at the 1-year follow-up (from 107 ± 23 to 110 ± 21 ms within 24 h, to 94 ± 24 ms at 1-year follow-up, F = 19.366,P< 0.001). No significant difference in the left ventricular reverse remodeling and ventricular tachycardia/ventricular fibrillation (VT/VF) episodes between the TpTe immediately shortened and TpTe immediately nonshortened groups. However, patients in the TpTe at 1-year shorten had a higher rate of the left ventricular (LV) reverse remodeling (65% vs. 44%, χ2 = 4.495, P = 0.038) and less VT/VF episodes (log-rank test, χ2 = 10.207, P = 0.001) compared with TpTe 1-year nonshortened group. TpTe immediately after CRT-D independently predicted VT/VF episodes at 1-year follow-up (hazard ratio [HR], 1.030; P = 0.001). CONCLUSIONS: Patients with TpTe shortened at 1-year after CRT had a higher rate of LV reverse remodeling and less VT/VF episodes. The acute changes of TpTe after CRT have minimal value on mechanical reverse remodeling and ventricular arrhythmia.

Optimized Fluoroscopy Setting and Appropriate Project Position Can Reduce X-ray Radiation Doses Rates during Electrophysiology Procedures.

BACKGROUND: Nonfluoroscopic three-dimensional electroanatomical system is widely used nowadays, but X-ray remains indispensable for complex electrophysiology procedures. This study aimed to evaluate the value of optimized parameter setting and different projection position to reduce X-ray radiation dose rates. METHODS: From June 2013 to October 2013, 105 consecutive patients who underwent complex ablation were enrolled in the study. After the ablation, the radiation dose rates were measured by two different settings (default setting and optimized setting) with three projection positions (posteroanterior [PA] projection; left anterior oblique [LAO] 30° projection; and LAO 45° projection). The parameter of preset voltage, pulse width, critical voltage, peak voltage, noise reduction, edge enhancement, pulse rate, and dose per frame was modified in the optimized setting. RESULTS: The optimized setting reduced radiation dose rates by 87.5% (1.7 Gy/min vs. 13.6 Gy/min, P < 0.001) in PA, 87.3% (2.5 Gy/min vs. 19.7 Gy/min, P < 0.001) in LAO 30°, 85.9% (3.1 Gy/min vs. 22.1 Gy/min, P < 0.001) in LAO 45°. Increase the angle of projection position will increase the radiation dose rate. CONCLUSIONS: We can reduce X-ray radiation dose rates by adjusting the parameter setting of X-ray system. Avoiding oblique projection of large angle is another way to reduce X-ray radiation dose rates.

Regression of fragmented QRS complex: a marker of electrical reverse remodeling in cardiac resynchronization therapy.

BACKGROUND: Fragmented QRS (fQRS) marks inhomogeneous activation and asynchronous cardiac contraction. It has been proved that cardiac resynchronization therapy (CRT) could reverse geometrical remodeling as well as correct electrical dyssynchrony. We aimed to investigate whether fQRS changed corresponding to the therapeutic response to CRT. METHODS: Patients who underwent de novo CRT implantation previously and had ≥1 follow-up between August 2012 and September 2013 in our hospital were investigated. Intrinsic electrocardiogram was recorded and fQRS in any lead was calculated. Response to CRT was defined as absolute improvement in left ventricular ejection fraction by ≥10% or by improvement >1 New York Heart Association class and without heart failure hospitalization. RESULTS: A total of 75 patients (48 male, mean ages, 61 ± 9 years) were included in this study. At a median follow-up of 13 months, 57 patients had response to CRT. Responders had narrowed QRS (from 167 ± 23 ms to 158 ± 19 ms, P = 0.003) and reduced fQRS post-CRT. Nonresponders had QRS prolonging (from 151 ± 26 ms to 168 ± 16 ms, P = 0.033) and increase in fQRS. Eleven of 12 patients with reduced fQRS were responders and 8 of 12 with increased fQRS were nonresponders. Both changes in QRS and fQRS correlated strongly with CRT response (r = 0.389, P = 0.001 and r = 0.403, P = 0.000, respectively). Reduction of fQRS in ≥1 leads had high specificity (95%) in association to responders, though in low sensitivity (19%). CONCLUSIONS: The changes in fQRS associated with therapeutic response to CRT. Regression of fQRS could be a maker of electrical reverse remodeling following CRT.

Association of body mass index with cardiac reverse remodeling and long-term outcome in advanced heart failure patients with cardiac resynchronization therapy.

BACKGROUND: The effect of adiposity on response to cardiac resynchronization therapy (CRT) and long-term outcome in patients undergoing CRT has not been previously reported. This study assessed the impact of baseline body mass index (BMI) on cardiac reverse remodeling and prognosis following CRT. METHODS AND RESULTS: A total of 247 CRT patients were included and divided into 4 groups according to baseline BMI. During 6-month follow-up, overweight and obese patients (BMI, 24-28 kg/m(2), ≥28 kg/m(2), respectively) were inclined to have better clinical and echocardiographic improvements (P<0.05) as well as higher response rate (P<0.001) than underweight and normal weight patients (BMI, <18.5 kg/m(2), 18.5-24 kg/m(2), respectively). During long-term follow-up, overweight and obese patients had lower all-cause mortality (P=0.015) and combined endpoint of death or HF hospitalizations (P=0.001) than underweight and normal weight patients. Compared with normal weight patients, underweight patients had a 2.29-fold increase in risk of combined endpoint events whereas overweight and obese patients had a reduction in the risk of death (66% and 58%, respectively) and combined endpoint events (52% and 38%, respectively). CONCLUSIONS: Patients with obesity and overweight derived more benefit from CRT. Higher BMI was independently associated with better clinical outcome in CRT patients.

Native QRS narrowing reflects electrical reversal and associates with anatomical reversal in cardiac resynchronization therapy.

PURPOSE: Abbreviation of paced QRS duration has been taken as electrical resynchronization imposed by cardiac resynchronization therapy (CRT). However, little is known about alteration in native QRS duration and its correlation with therapeutic response as well as anatomical remodeling post-CRT. METHODS: Data of 74 consecutive patients with complete ECG records were reviewed. Response was defined as absolute improvement in LVEF by ≥10% from baseline. Changes in native QRS duration (native ΔQRS) were analyzed to CRT response and to changes in echocardiography. RESULTS: Over median follow-up of 13 months, 47 patients had response to CRT and 30 subjects had abbreviation in native QRS duration. Native ΔQRS correlated positively with QRS duration pre- and post-CRT as well as with changes in echocardiography. Reversal of electrical remodeling as assessed by native QRS narrowing accompanied with greater improvements in LVEF (20% ± 11% vs 10% ± 10%, p = 0.000) and LVEDD (14 ± 11 mm vs. 4 ± 10 mm, p = 0.000). Multivariate analysis indicated that native ΔQRS was the lone independent factor of ECG in association to response to CRT (OR1.049, 95%CI 1.015-1.085, p = 0.004): 83.3% of patients with native QRS reduction were responders. Among the non-responders, 18.5% had native QRS narrowing at follow-ups. CONCLUSIONS: Native QRS narrowing associated with beneficial response and greater improvements in echocardiography. Abbreviation in native QRS duration could reflect electrical reversal imposed by CRT.

High sensitivity C-reactive protein and cardfiac resynchronization therapy in patients with advanced heart failure.

BACKGROUND: The data on the prognostic values of high sensitivity C-reactive protein (hsCRP) levels in patients with advanced symptomatic heart failure (HF) receiving cardiac resynchronization therapy (CRT) are scarce. The aim of present study was to investigate the association of serum hsCRP levels with left ventricle reverse remodeling after six months of CRT as well as long-term outcome. METHODS: A total of 232 CRT patients were included. The assessment of hsCRP values, clinical status and echocardiographic data were performed at baseline and after six months of CRT. Long-term follow-up included all-cause mortality and hospitalizations for HF. RESULTS: During the mean follow-up periods of 31.3 ± 31.5 months, elevated hsCRP (> 3 mg/L) prior to CRT was associated with a significant 2.39-fold increase (P = 0.006) in the risk of death or HF hospitalizations. At 6-month follow-up, patients who responded to CRT showed significant reductions or maintained low in hsCRP levels (-0.5 ± 4.1 mg/L reduction) compared with non-responders (1.7 ± 6.1 mg/L increase, P = 0.018). Compared with patients in whom 6-month hsCRP levels were reduced or remained low, patients in whom 6-month hsCRP levels were increased or maintained high experienced a significantly higher risk of subsequent death or HF hospitalizations (Log-rank P < 0.001). The echocardiographic improvement was also better among patients in whom 6-month hsCRP levels were reduced or remained low compared to those in whom 6-month hsCRP levels were raised or maintained high. CONCLUSIONS: Our findings demonstrated that measurement of baseline and follow-up hsCRP levels may be useful as prognostic markers for timely potential risk stratification and subsequent appropriate treatment strategies in patients with advanced HF undergoing CRT.

OptiVol fluid index predicts acute decompensation of heart failure with a high rate of unexplained events.

BACKGROUND: Intrathoracic impedance monitoring has emerged as a promising new technique for the detection of impending heart failure (HF). Although false positive episodes have been reported in case reports and clinical trials, the efficacy and false positive rate in real-world practice remain unclear. OBJECTIVE: The aim of this study is to investigate the utility and reliability of the OptiVol alert feature in clinical practice. METHODS: We continuously recruited patients who underwent implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy with defibrillator (CRT-D) implantation with feature of intrathoracic impedance monitoring system in our center from Sep. 2010 to Oct. 2012. Regular in-office follow-up were required of all patients and the following information was collected at each visit: medical history, device interrogation, N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement and an echocardiogram. Worsening HF was defined as hospitalization or the presentation of signs or symptoms of HF. RESULTS: FORTY THREE PATIENTS (MALE: 76.7%, mean age: 57 ± 15 years, left ventricular ejection fraction (LVEF): 33% ± 14%) were included in this observational study. Fifty four alert events and 14 adjudicated worsening HF were detected within 288 ±163 days follow-up. Eleven (20.4%) alert episodes were associated with acute cardiac decompensation in 9 patients with a positive predictive value of 78.6%. Forty three audible alerts showed no connection to worsening HF. The unexplained alerts rate was 79.6% and 1.27 per person-year. Thirty seven alarm alerts were detected in patients with EF < 45%, among which 9 accompanied with HF, 17 alerts detected in patients with LVEF ≥ 45% and 2 associated with HF. There was no significant difference between the two groups (9/37 vs. 2/17; P = 0.47). CONCLUSIONS: Patients with normal or nearly normal left ventricular systolic function also exhibited considerable alert events. The OptiVol fluid index predicted worsening cardiac events with a high unexplained detection rate, and any alert must therefore be analyzed with great caution. Efforts to improve the specificity of this monitoring system represent a significant aspect of future studies.