Value of right ventricular-left ventricular interlead electrical delay to predict reverse remodelling in cardiac resynchronization therapy: the INTER-V pilot study.

AIMS: Few studies have systematically evaluated the value of intra-procedural parameters in predicting response to cardiac resynchronization therapy (CRT). We investigated whether intracardiac (electrogram) measurements of electrical delays between the positioned right ventricular (RV) and left ventricular (LV) leads at implantation could predict the mid-term CRT response. METHODS AND RESULTS: Fifty-two patients underwent CRT implantation according to standard techniques and clinical indications. The RV-LV interlead electrical delay measured during spontaneous rhythm and the difference between the pacing-induced (Deltap) RV-LV interlead electrical delays measured during RV and LV pacing were defined intraoperatively using the electrical depolarizations registered at the ventricular leads on the device programmer. At 6 months, a reduction of LV end-systolic volume > or = 15% was used to define CRT responders. Responders (62%), when compared with non-responders, showed a higher proportion of ischaemic aetiology (P = 0.007) and a lower value of DeltapRV-LV interlead electrical delay (22.1 +/- 18.4 vs. 46.3 +/- 15.0 ms, P = 0.0001). At multivariate analysis, the DeltapRV-LV interlead electrical delay was the only independent predictor of response to CRT (P = 0.001). For such a parameter, the receiving operating characteristic curve analysis identified a cut-off value of 42 ms corresponding with the highest accuracy: sensitivity 90.6%; specificity 70%; positive and negative predictive value 83% and 82%, respectively. Conversely, no difference was ascertained between responders and non-responders when RV-LV interlead electrical delay was measured during spontaneous rhythm (76.1 +/- 28.5 vs. 89.6 +/- 21.2, P = 0.078). CONCLUSION: Intraprocedural measuring of paced RV-LV interlead electrical delay obtained during RV and LV pacing predicts mid-term CRT response.

Management of traumatic implantable cardioverter defibrillator lead perforation of the right ventricle after car accident: a case report.

The authors reported a case of traumatic implantable cardioverter defibrillator (ICD) lead perforation of the right ventricular (RV) apex caused by a motor vehicle accident. Clinical and echocardiographic features combined with changes in electrical parameters of the offending lead were decisive for the final diagnosis. Optimal management of ICD lead RV wall perforation is currently unclear. In our report, RV perforation was responsible for cardiac tamponade. This complication was uneventfully managed by open surgical procedure.

Evaluation of pacemaker dependence in patients on ablate and pace therapy for atrial fibrillation.

AIMS: In patients with atrial fibrillation (AF) and uncontrolled ventricular rate, radiofrequency (RF) ablation of the atrioventricular (AV) node and pacemaker (PM) implantation (ablate and pace) is a valid therapeutic approach, especially in elderly patients. The aim of our study was to evaluate the PM dependence and the incidence of correlated clinical phenomena in a patients population with AV block induced by RF ablation of the AV junction. METHODS AND RESULTS: One-hundred and sixty-three patients (71 men; mean age 71 +/- 8 years) who had undergone ablate and pace therapy were evaluated. The patients underwent assessment of quality of life, impairment of consciousness, stroke/transient ischaemic attack (TIA), hospitalizations for heart failure, episodes of palpitations, and instrumental evaluation of PM dependence during PM inhibition (absence of escape rhythm; asystolic pause >5 s; escape rhythm <30 bpm after rhythm stabilization). Correlation between instrumentally evaluated PM dependence and clinical history was analysed. Hundred and thirty-two patients were evaluated after a mean follow-up period of 36 months [31 subjects (19%) died before the evaluation]; 55 patients (42%) were classified as PM-dependent: 38 (69%) complained of disturbances (19 dizziness, 15 pre-syncope, 4 syncope); 77 patients (58%) were considered non-PM-dependent: symptoms (dizziness, flush) were reported by only 3 (4%). No significant differences emerged between PM-dependent and non-PM-dependent patients with regard to episodes of pre-syncope, syncope, stroke/TIA, hospitalizations for heart failure, and quality of life. CONCLUSION: This study confirms that ablate and pace is an effective and safe approach in subjects with chronic or recurrent AF and uncontrolled ventricular rate.

Value of baseline left lateral wall postsystolic displacement assessed by M-mode to predict reverse remodeling by cardiac resynchronization therapy.

Although left ventricular (LV) dyssynchrony assessed by ultrasound is emerging as superior to QRS duration in predicting response to cardiac resynchronization therapy (CRT), the role of conventional echocardiographic parameters of dyssynchrony is still debated. Forty-eight patients with heart failure in New York Heart Association classes III to IV, LV ejection fraction < or =35%, and QRS duration > or =120 ms were studied. LV dyssynchrony was evaluated by M-mode as septal-to-posterior wall motion delay and left lateral wall postsystolic displacement (LWPSD). Interventricular dyssynchrony was defined as the difference between the LV and right ventricular preejection periods measured by standard Doppler. Reverse remodeling was defined as an LV end-systolic volume decrease > or =15% after 6 months of CRT. Thirty-one patients (65%) were considered responders to CRT. At baseline responders differed from nonresponders by having less severe New York Heart Association class (p = 0.006), lower percentage of ischemic cause (p = 0.006), longer PR interval (p = 0.013), shorter LV diastolic filling time corrected for heart rate (p = 0.005), and presence of LWPSD (p = 0.003). At multivariate analysis, predictors of CRT response were LWPSD (odds ratio [OR] 1.045, 95% confidence interval [CI] 1.001 to 1.091; p = 0.043), LV diastolic filling time corrected for heart rate (OR 0.855, 95% CI 0.744 to 0.981, p = 0.026), and nonischemic cause (OR 0.109, 95% CI 0.018 to 0.657, p = 0.016). In conclusion, preimplantation assessment of cardiac dyssynchrony based on M-mode LWPSD may predict LV reverse remodeling after CRT, especially in patients with nonischemic cause and shorter diastolic filling time. This suggests the potential role of baseline postsystolic mechanical phenomena in determining response to CRT independently of QRS duration.

The beneficial effect of insulin, glucose, and dipyridamole on regional left ventricular function early after acute myocardial infarction.

BACKGROUND: High-dose glucose-insulin-potassium (GIK) solution has beneficial effects on reducing mortality in acute myocardial infarction. Dipyridamole (DIP) is a powerful antioxidant and increases adenosine concentration. Experimentally, GIK and DIP have additive protective effects in ischemia-reperfusion injury. AIM: This work aims to assess the acute effects of DIP alone, GIK alone, and GIK+DIP on left ventricular function in patients evaluated early after an acute myocardial infarction. METHODS: Ten male patients (age 63+/-11 years) with uncomplicated acute myocardial infarction were evaluated within 3 days after admission. All had been treated with systemic thrombolysis and were on full therapy (including beta-blockers) at the time of testing. They underwent stress echocardiography [2D echo, with wall motion score index (WMSI) evaluated in a 16-segment model of the left ventricle, with each segment scored from 1=normal to 4=dyskinetic] during low-dose DIP alone (0.28 mg/kg in 4 min); GIK alone (4-h infusion of glucose 30%, 25 insulin units, and 40 mEq of KCl, at an infusion rate of 1.5 ml/kg/h); and GIK+DIP. RESULTS: Regional systolic function (baseline WMSI=1.69+/-0.2) improved after DIP (1.54+/-0.1), GIK (1.54+/-0.1), and, to a greater extent, after GIK+DIP (1.33+/-0.2; p<0.001 vs. baseline; p<0.05 vs. DIP; p<0.05 vs. GIK). CONCLUSION: High-dose GIK has an acute beneficial effect on regional left ventricular function in patients with acute myocardial infarction. This beneficial effect is potentiated by low-dose DIP coadministration.

[A rare cardiac tumor: the malignant fibrous histiocytoma. Description of a case]. / Una rara neoplasia cardiaca: l'istiocitoma fibroso maligno. Descrizione di un caso.

The present report describes the case of a 61-year-old woman with malignant fibrous histiocytoma of the left atrium originating from the left atrial free wall, operated on in emergency for a suspected large left atrial myxoma that, at the echo scan, was consistently protruding through the left atrioventricular orifice at each diastole and was almost completely occluding the left ventricular inflow, causing signs of congestive heart failure and severe dyspnea. Surgery was performed as radically as possible, but the histological examination of the specimen revealed the exact diagnosis of the neoplasm. About 75% of primary tumors are benign and 75% of these are atrial myxomas. The malignant tumors consist of various sarcomas: myxosarcoma, liposarcoma, angiosarcoma, fibrosarcoma, leiomyosarcoma, osteosarcoma, synovial sarcoma, rhabdomyosarcoma, undifferentiated sarcoma, reticulum cell sarcoma, neurofibrosarcoma, and malignant fibrous histiocytoma. The long-term results for sarcomas are very poor and there are few survivors after several months from surgery due to the extent of local spread and invasion or because of the frequent distant metastases. Malignant fibrous histiocytoma constitutes about 2% of all cardiac malignancies, which might grow within several localized areas, occasionally in the heart. Echocardiography represents the best examination procedure for both diagnosis and follow-up of patients with cardiac tumors.