Ventricular arrhythmias in super-responders to cardiac resynchronization therapy.

INTRODUCTION AND OBJECTIVES: Cardiac resynchronization therapy is associated with improved quality of life and reduced morbidity and mortality in patients with severe ventricular dysfunction and wide QRS. However, its role in the reduction of ventricular arrhythmias is more controversial. METHODS: We compared the incidence of ventricular arrhythmias in patients who were undergoing cardiac resynchronization therapy with an implantable cardioverter-defibrillator in terms of the degree of echocardiographic response to resynchronization. Patients were classified in 3 subgroups;super-responders, responders, and nonresponders. RESULTS: We included 196 patients who were followed up for a median 30.1 months [interquartile range, 18.0-55.1 months]. We recorded the presence of ventricular arrhythmias in 37 patients (18.8%); 3 patients (5.9%) in the super-responder group had ventricular arrhythmias vs 14 (22.2%) among the responders and 20 (24.4%) in the group of nonresponders (P = .025). In multivariate analysis, the only independent predictors of the appearance of ventricular arrhythmias were secondary-prevention device implantation (odds ratio = 4.04; 95% confidence interval, 1.52-10.75; P=.005), absence of echocardiographic super-response (odds ratio=3.81; 95% confidence interval, 1.04-13.93; P=043), QRS >160 ms (odds ratio=2.39; 95% confidence interval, 1.00-1.35; P=.049) and treatment with amiodarone (odds ratio=2.47; 95% confidence interval, 1.03-5.91; P=.041). CONCLUSIONS: The patients classified as super-responders to cardiac resynchronization therapy had a significant reduction in incidence of ventricular arrhythmias by comparison with the other patients. Despite this, arrhythmic episodes do not completely disappear in this subgroup.

Arritmias ventriculares en superrespondedores a la terapia de resincronización cardiaca / Ventricular arrhythmias in super-responders to cardiac resynchronization therapy

Introducción y objetivos La terapia de resincronización cardiaca se asocia a mejora de la calidad de vida y reducción de la morbimortalidad de los pacientes con disfunción ventricular grave y QRS ancho. Sobre su papel en la reducción de arritmias ventriculares, hay más discusión. Métodos Se comparó la incidencia de arritmias ventriculares en pacientes portadores de desfibrilador automático implantable con función de resincronización cardiaca, según el grado de respuesta ecocardiográfica a la resincronización. Se clasificó a los pacientes en tres subgrupos: superrespondedores, respondedores y no respondedores. Resultados Se incluyó a 196 pacientes seguidos durante una mediana de 30,1 [intervalo intercuartílico, 18,0-55,1] meses. Se documentó presencia de arritmias ventriculares en 37 pacientes (18,8%); 3 pacientes (5,9%) del grupo de superrespondedores presentaron arritmias ventriculares, en comparación con 14 (22,2%) del grupo de respondedores y 20 (24,4%) del grupo de no respondedores (p = 0,025). En el análisis multivariable, el implante del dispositivo en prevención secundaria (odds ratio = 4,04; intervalo de confianza del 95%, 1,52-10,75; p = 0,005), la ausencia de superrespuesta ecocardiográfica (odds ratio = 3,81; intervalo de confianza del 95%, 1,04-13,93; p = 0,043), un QRS > 160ms (odds ratio = 2,39; intervalo de confianza del 95%, 1,00-1,35; p = 0,049) y el tratamiento con amiodarona (odds ratio = 2,47; intervalo de confianza del 95%, 1,03-5,91; p = 0,041) fueron los únicos predictores independientes de aparición de arritmias ventriculares. Conclusiones: Los pacientes superrespondedores a la terapia de resincronización cardiaca presentan una disminución significativa en la incidencia de arritmias ventriculares respecto a los demás pacientes. Pese a ello, los episodios arrítmicos no llegan a desaparecer por completo en este subgrupo

Introduction and objectives: Cardiac resynchronization therapy is associated with improved quality of life and reduced morbidity and mortality in patients with severe ventricular dysfunction and wide QRS. However, its role in the reduction of ventricular arrhythmias is more controversial. Methods: We compared the incidence of ventricular arrhythmias in patients who were undergoing cardiac resynchronization therapy with an implantable cardioverter-defibrillator in terms of the degree of echocardiographic response to resynchronization. Patients were classified in 3 subgroups; superresponders, responders, and non responders. Results: We included 196 patients who were followed up for a median 30.1 months [interquartile range,18.0-55.1 months]. We recorded the presence of ventricular arrhythmias in 37 patients (18.8%);3 patients (5.9%) in the super-responder group had ventricular arrhythmias vs 14 (22.2%) among the responders and 20 (24.4%) in the group of non responders (P = .025). In multivariate analysis, the only independent predictors of the appearance of ventricular arrhythmias were secondary-prevention device implantation (odds ratio = 4.04; 95% confidence interval, 1.52-10.75; P=.005), absence of echocardiographic super-response (odds ratio=3.81; 95% confidence interval, 1.04-13.93; P = 043), QRS >160ms (odds ratio=2.39; 95% confidence interval, 1.00-1.35; P=.049) and treatment with amiodarone (odds ratio=2.47; 95% confidence interval, 1.03-5.91; P = .041). Conclusions: The patients classified as super-responders to cardiac resynchronization therapy had a significant reduction in incidence of ventricular arrhythmias by comparison with the other patients. Despite this, arrhythmic episodes do not completely disappear in this subgroup

Efectividad y seguridad de la monitorización a distancia de los pacientes portadores de Holter insertable / Effectiveness and safety of remote monitoring of patients with an implantable loop recorder

Introducción y objetivos. El Holter insertable es una herramienta de probada eficacia en el estudio de pacientes con síncope y palpitaciones. La monitorización a distancia de los pacientes portadores de marcapasos y desfibriladores automáticos implantables se ha demostrado efectiva y segura. El objetivo de este estudio es analizar la efectividad y la seguridad de la monitorización a distancia de los pacientes portadores de Holter insertable. Métodos. Estudio retrospectivo observacional en el que se analizó a 109 pacientes portadores de Holter insertable y se comparó a dos grupos poblacionales: uno con seguimiento convencional con visitas presenciales trimestrales (41 pacientes) y otro con monitorización a distancia con transmisiones transtelefónicas mensuales y visitas anuales (68 pacientes). El seguimiento medio fue 64 (0,57-164,57) semanas. Se analizó el diagnóstico de un evento significativo, definido como aquel que llevó a una actitud terapéutica y justificó los síntomas que motivaron el implante, así como el tiempo medio desde el implante al diagnóstico y el tratamiento específico. Resultados. Se diagnosticó un evento significativo en el 82,6% de los casos; el 54,4% de ellos con registro electrocardiográfico normal; el 26,7%, asistolia; el 15,6%, taquicardia y el 3,3%, bradicardia. El tiempo medio desde el implante al diagnóstico fue 260 (5-947) días en seguimiento convencional, frente a 56 (0-650) días en los pacientes con monitorización a distancia (p < 0,01), lo que llevó a un tratamiento dirigido en este grupo un promedio de 187 días antes sin complicaciones secundarias. Conclusiones. La monitorización a distancia de los pacientes con Holter insertable permite acortar significativamente el tiempo hasta el diagnóstico y el tratamiento dirigido sin minar la seguridad del paciente (AU)

Introduction and objectives. Implantable loop recorders have proven efficacy in the study of patients with syncope and palpitations. Remote monitoring of patients with pacemakers and implantable cardioverter-defibrillators has been shown to be safe and effective. The purpose of this study was to analyze the safety and effectiveness of remote monitoring in patients with an implantable loop recorder. Methods. Retrospective observational study in which 109 patients with an implantable loop recorder were analyzed and 2 population groups were compared: 1 receiving conventional follow-up consisting of 3-monthly office visits (41 patients) and 1 with remote monitoring via monthly telephone transmissions and yearly visits (68 patients). The mean follow-up was 64 weeks (range, 0.57-164.57 weeks). The study analyzed diagnosis of a significant event, defined as any event that led to a therapeutic approach and explained the symptoms leading to the implant, as well as the mean time from implant to diagnosis and the specific treatment. Results. A significant event was diagnosed in 82.6% of patients; of these, 54.4% had a normal electrocardiogram; 26.7%, asystole; 15.6%, tachycardia, and 3.3%, bradycardia. The mean time from implant to diagnosis was 260 days (range, 5-947 days) in conventional follow-up, compared with 56 days (range, 0-650 days) in patients with remote monitoring (P<.01), which led to targeted treatment in this group 187 days earlier, on average, with no secondary complications. Conclusions. Remote monitoring of patients with an implantable loop recorder can significantly shorten the time to diagnosis and targeted treatment, without adversely affecting patient safety (AU)

Effectiveness and safety of remote monitoring of patients with an implantable loop recorder.

INTRODUCTION AND OBJECTIVES: Implantable loop recorders have proven efficacy in the study of patients with syncope and palpitations. Remote monitoring of patients with pacemakers and implantable cardioverter-defibrillators has been shown to be safe and effective. The purpose of this study was to analyze the safety and effectiveness of remote monitoring in patients with an implantable loop recorder. METHODS: Retrospective observational study in which 109 patients with an implantable loop recorder were analyzed and 2 population groups were compared: 1 receiving conventional follow-up consisting of 3-monthly office visits (41 patients) and 1 with remote monitoring via monthly telephone transmissions and yearly visits (68 patients). The mean follow-up was 64 weeks (range, 0.57-164.57 weeks). The study analyzed diagnosis of a significant event, defined as any event that led to a therapeutic approach and explained the symptoms leading to the implant, as well as the mean time from implant to diagnosis and the specific treatment. RESULTS: A significant event was diagnosed in 82.6% of patients; of these, 54.4% had a normal electrocardiogram; 26.7%, asystole; 15.6%, tachycardia, and 3.3%, bradycardia. The mean time from implant to diagnosis was 260 days (range, 5-947 days) in conventional follow-up, compared with 56 days (range, 0-650 days) in patients with remote monitoring (P<.01), which led to targeted treatment in this group 187 days earlier, on average, with no secondary complications. CONCLUSIONS: Remote monitoring of patients with an implantable loop recorder can significantly shorten the time to diagnosis and targeted treatment, without adversely affecting patient safety.

Ventricular arrhythmias among implantable cardioverter-defibrillator recipients for primary prevention: impact of chronic total coronary occlusion (VACTO Primary Study).

BACKGROUND: An implantable cardioverter-defibrillator (ICD) is the therapy of choice for primary prevention in patients with ischemia who are at risk for sudden cardiac death (SCD). One third of patients with significant coronary disease have chronic total coronary occlusion (CTO), which is associated with long-term mortality in patients with previous myocardial infarction. However, the impact of CTO on the occurrence of ventricular arrhythmias and long-term mortality in ICD recipients remains unknown. METHODS AND RESULTS: All consecutive patients with coronary artery disease receiving ICD therapy for the prevention of SCD were included in the study. Among other characteristics, the existence of CTO was assessed. During follow-up, the occurrence of appropriate device delivery because of ventricular arrhythmias as well as mortality were noted. A total of 162 patients (mean age, 62±9 years; 93% men) with an ICD were included and followed for a median of 26 months (interquartile range, 12-42). At least 1 CTO was present in 71 (44%) patients. Appropriate device therapy was detected in 18% of the patients during the follow-up. The presence of CTO was associated with higher ventricular arrhythmia and mortality rates (log-rank test, <0.01). Multivariable analysis revealed that CTO was independently associated with appropriate ICD intervention (hazard ratio, 3.5; P=0.003). CONCLUSIONS: In patients with ischemic heart disease receiving ICDs for primary prevention of SCD, CTO is an independent predictor for the occurrence of ventricular arrhythmias and has an adverse impact on long-term mortality.

Efectos a largo plazo (5 años) de bosentán en pacientes con hipertensión arterial pulmonar / Long-term (5 Years) effects of bosentan in patients with pulmonary arterial hypertension

Introducción y objetivos. Bosentán ha demostrado eficacia en el tratamiento de la hipertensión pulmonar a corto plazo. Sus efectos después de 2-3 años son poco conocidos. Nuestro objetivo es analizar la eficacia y la seguridad a largo plazo (5 años) del bosentán en los pacientes tratados en nuestra unidad. Métodos. Se analizaron en forma retrospectiva y secuencial diversos parámetros clínicos, funcionales y analíticos en una serie unicéntrica de pacientes tratados con bosentán en monoterapia desde 2002 hasta 2009. El éxito terapéutico se definió como supervivencia sin eventos clínicos o deterioro que requiriese adición de otros vasodilatadores pulmonares. Resultados. La serie incluye a 20 pacientes (el 70% mujeres; media de edad, 46±14 años; el 65% con cardiopatías congénitas), con una mediana de seguimiento de 64 meses. A corto plazo, se observó una mejoría significativa de parámetros hemodinámicos, clínicos y funcionales, que en los dos últimos se mantuvo a los 5 años. La supervivencia total a 5 años fue del 95% (84-100%). El éxito terapéutico se mantuvo a 1, 2, 3, 4 y 5 años en el 95% (84-100%), el 83% (65-100%), el 78% (58-98%), el 61% (38-84%) y el 41% (16-66%), respectivamente. El grupo con mejor evolución a largo plazo se caracterizó por cifras de NT-proBNP al año < 400 pg/ml (p=0,013). Conclusiones. En esta serie, el éxito terapéutico obtenido con bosentán en monoterapia se mantuvo en el 78% a 3 años y en el 41% a 5 años. El grupo con éxito a largo plazo mostró valores más bajos de NT-proBNP al año del tratamiento. La supervivencia a 5 años fue del 95% (AU)

Introduction and objectives. Bosentan has proven efficacy in pulmonary hypertension in the short term. Little is known about its effects beyond 2 to 3 years. Our objective was to analyze the efficacy and safety of bosentan in the long term (5 years) in patients treated in our center. Methods. This retrospective study sequentially analyzed clinical, functional, and laboratory parameters in a series of patients treated initially with bosentan as monotherapy from 2002 to 2009 in a single hospital. Treatment success was defined as survival without clinical worsening that required additional pulmonary vasodilators. Results. We included 20 patients (70% women, mean age 46±14 years, 65% congenital heart disease), with a median follow-up of 64 months. One patient required withdrawal of bosentan due to adverse effects. At 4 months, significant improvements were achieved in hemodynamic, clinical and functional parameters. Clinical and functional benefits persisted at 5-year follow-up. Overall 5-year survival after beginning bosentan therapy was 95% (84%-100%). Treatment success at 1, 2, 3, 4 and 5 years was 95% (84%-100%), 83% (65%-100%), 78% (58%-98%), 61% (38%-84%), and 41% (16%-66%), respectively. The group with better outcomes had NT-proBNP levels at 1 year<400 pg="" ml=""> P=.013). Conclusions. In our series, treatment success with bosentan in monotherapy was maintained in 78% at 3-year follow-up and 41% at 5-year follow-up. The group with long-term success showed significantly lower NT-proBNP levels at 1-year follow-up. Survival at 5 years in our series was 95% (AU)

Long-term (5 years) effects of bosentan in patients with pulmonary arterial hypertension.

INTRODUCTION AND OBJECTIVES: Bosentan has proven efficacy in pulmonary hypertension in the short term. Little is known about its effects beyond 2 to 3 years. Our objective was to analyze the efficacy and safety of bosentan in the long term (5 years) in patients treated in our center. METHODS: This retrospective study sequentially analyzed clinical, functional, and laboratory parameters in a series of patients treated initially with bosentan as monotherapy from 2002 to 2009 in a single hospital. Treatment success was defined as survival without clinical worsening that required additional pulmonary vasodilators. RESULTS: We included 20 patients (70% women, mean age 46 ± 14 years, 65% congenital heart disease), with a median follow-up of 64 months. One patient required withdrawal of bosentan due to adverse effects. At 4 months, significant improvements were achieved in hemodynamic, clinical and functional parameters. Clinical and functional benefits persisted at 5-year follow-up. Overall 5-year survival after beginning bosentan therapy was 95% (84%-100%). Treatment success at 1, 2, 3, 4 and 5 years was 95% (84%-100%), 83% (65%-100%), 78% (58%-98%), 61% (38%-84%), and 41% (16%-66%), respectively. The group with better outcomes had NT-proBNP levels at 1 year <400 pg/mL (P=.013). CONCLUSIONS: In our series, treatment success with bosentan in monotherapy was maintained in 78% at 3-year follow-up and 41% at 5-year follow-up. The group with long-term success showed significantly lower NT-proBNP levels at 1-year follow-up. Survival at 5 years in our series was 95%.

Abordaje radial para ablación del His ante fibrilación auricular rápida en portador de DAI-TRC / Radial approach to his bundle ablation for fast atrial fibrillation in a patient with an ICD-CRT device

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