Feasibility of a novel algorithm for automated reconstruction of the left atrial anatomy based on intracardiac echocardiography

Funding Acknowledgements

Type of funding sources: None.

Background

Intracardiac echocardiography (ICE) is frequently used to guide electrophysiology procedures. The novel pre-commercial automated algorithm is a model-based algorithm, developed using machine learning methodology, which reconstructs a 3D anatomy of the left atrium (LA) and its structures based on a set of 2D ultrasound (US) frames, without the need to manually annotate US contours. Potential advantages are shortening of mapping time and better anatomy resolution when compared to conventional anatomical mapping techniques.

Purpose

Determine the early feasibility of the automated LA anatomy algorithm in routine clinical setting.

Methods

We included 16 patients (64±9 years, 88% males, body mass index 27±3, parasternal long axis LA diameter 40±3mm) undergoing LA mapping/catheter ablation (conscious sedation in 56% and general anaesthesia in the remaining cases). 2D US frames were acquired from three ICE-positions: superior vena cava/high right atrium (RA) junction, RA and right ventricular outflow tract. The automated LA anatomy map was validated in two steps: 1) identification of anatomical structures (pulmonary veins [PV] and left atrial appendage) by alignment of the ablation catheter to the automated map; and 2) assessment of PV anatomical accuracy by analysing the relationship with the automated lesion tags (3mm lesion radius, 3mm for 8sec stability criteria and 5-20g average contact force) and the PV antrum of the automated map in 9 patients with paroxysmal atrial fibrillation undergoing first time point-by-point radiofrequency PV isolation (PVI). In step 2, PV pairs were divided into 6 segments (total of 12 segments per patient) and were classified as accurate, insufficient ("floating" lesion tags), or excessive anatomy (invisible lesion tags).

Results

Mean 2D US frames per patient was 29±6 and acquisition time was 16±4 min. In the step 1 validation, all anatomical structures were correctly identified in the 16 patients by the automated algorithm. The step 2 validation showed anatomical accuracy in 76% of all 108 PV segments analysed. There was a range of 0-2 and 0-5 of the total 12 segments per patient with insufficient and excessive anatomy, respectively. In all cases with PV segment anatomical discrepancy, this was corrected with standard anatomy collection with the ablation catheter in ≤2min. In the whole patient group, catheter ablation was successfully performed on the automated map without complications.

Conclusions

The automated ICE-based 3D LA map algorithm performed overall well and correctly identified the LA anatomical structures in all patients. Anatomical PV antrum accuracy was high, and the majority of PV segments needed no manual correction before proceeding to PVI.

Catheter ablation for patients with atrial fibrillation and heart failure: insights from the swedish heart failure registry

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): DFG (Deutsche Forschungsgemeinschaft) to G.O.

Aims

To investigate the association between catheter ablation and mortality as well as hospitalization for heart failure (HF) in patients with atrial fibrillation (AF) and HF across the ejection fraction (EF) spectrum in a contemporary cohort.

Methods

Between 2005 and 2019, patients with first-time catheter ablation for AF (ablation group) compared to only medical treated AF patients (medical therapy group) were identified from the Swedish Heart Failure Registry. The primary outcome (all-cause mortality/first HF hospitalization) was assessed by cox regression models in a 1:2 propensity score (PS) matched cohort and pre-specified EF subgroups (preserved EF [HFpEF] [EF≥50%], mildly reduced EF [HFmrEF] [EF 40% to 49%], reduced EF [HFrEF] [EF<40%]) of this cohort.

Results

452 patients in the ablation and 43766 patients in the medical therapy group were identified. After PS matching, 437 patients in the ablation group were compared to 874 patients in the medical therapy group. Over the entire follow-up, catheter ablation was associated with a lower risk of the primary outcome (Hazard ratio [HR] 0.71 [95%CI, 0.59-0.85]) and first cardiovascular (CV) hospitalization (HR 0.85 [95%CI, 0.72-0.99]) in PS matched analysis. Results were consistent across all EF subgroups. In HFpEF patients, catheter ablation was associated with a significantly lower risk of recurrent HF hospitalization (Incidence rate ratio (IRR) 0.17 [95%CI, 0.07-0.42]).

Conclusion

In this nationwide study, catheter ablation was associated with a significant lower risk of the primary outcome (all-cause mortality/first HF hospitalization) in HF patients with AF. This study advocates catheter ablation as a potent treatment option for AF in HF patients across all EF subgroups, including HFpEF.

Effect of internet-delivered cognitive behavioral therapy on quality of life in patients with symptomatic atrial fibrillation

Background

Many patients with atrial fibrillation (AF) experience severe or disabling symptoms and suffer from impaired quality of life (QoL). AF symptoms are often not sufficiently alleviated by current treatments. Symptom preoccupation (fear of AF episodes, hypervigilance towards cardiac symptoms, worry about complications, avoidance of physical and social activities) plays an important role in AF disability and can be targeted by cognitive behavioural therapy (CBT). This is the first randomized controlled trial (RCT) evaluating internet-delivered CBT in patients with AF.

Methods

We randomized patients to 10 weeks of CBT or routine care with AF-education (EDU) only. Inclusion criteria were ECG documented paroxysmal AF (≥1 episode/month); AF-care according to ESC guidelines; symptoms ≥EHRA IIb. Exclusion criteria were recent or planned ablation and severe medical or psychiatric illness. CBT was delivered over the internet by clinical psychologists. Main components were exposure to cardiac-related physical sensations and reduction of AF-related avoidance behavior. Patients were evaluated at baseline, post-CBT and 3 months (3M) post-CBT. The primary endpoint was AF-specific QoL (AFEQT) at 3M. Secondary endpoints were symptom preoccupation (CAQ), symptom frequency (SCL), symptom severity (SCL), general QoL (WHODAS) and AF-specific healthcare (AFSS) (abbreviations: see table legend). AF burden was measured by 5-day continuous ECG recording. After 3M, patients in the EDU group were offered CBT. The CBT group was further evaluated at 6M and 12M.

Results

127 patients (age 65.4±8.3; 58% female; AF duration 5.6±6.1 years) were randomized to CBT (n=65) or EDU (n=62). CBT significantly improved AF-specific QoL. The AFEQT score was 62.5±16.7 at baseline and increased by 21.0 in the CBT group compared to 6.0 in the EDU group resulting in an 15.0 points improvement (95% CI: 10.1–19.8; P<.001). CBT also significantly improved the secondary outcomes (table). Results were sustained 12 months after treatment (AFEQT; figure). The results from ECG monitoring (AF burden) are currently being analyzed.

Conclusion

Internet delivered CBT significantly improved AF-specific QoL in patients with symptomatic paroxysmal AF already receiving routine AF care. The magnitude of QoL improvement was comparable to that obtained in recent rhythm control trials and the effects were sustained over 12 months. AF-specific CBT delivered via the internet has the potential to improve the well-being of a large group of patients who do not sufficiently improve from current treatment methods. Our data support the integration of psychological evaluation and treatment in a multifactorial approach to AF management.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was supported by grants from theSwedish Research Council (2016-01379), RegionStockholm (ALF project). Change in AFEQT score over study periodBetween group improvements

Low incidence of major complications after the first six hours post-atrial fibrillation ablation – same-day discharge safe and feasible in most patients

Background/Introduction

Catheter ablation of atrial fibrillation (AF) is associated with a complication risk. It is common practice to monitor patients overnight post-procedurally which is resource craving.

Purpose

To evaluate the incidence of procedural complications related to catheter ablation of AF to assess the potential feasibility and safety of same day discharge in a large cohort.

Methods

We performed an analysis of prospectively collected data of complications of all patients staying overnight after undergoing AF ablation between 2001 and 2020 at a tertiary centre. By studying medical records, we analysed complications occurring intraprocedurally until six hours post-ablation, and between six hours post-ablation until discharge the day after ablation procedure (up to 24 hours post-procedure).

Results

In 5414 AF ablations we identified a total of 108 (2.0%) major complications occurring intraprocedural or until discharge the day after procedure. Most major complications occurred early and were detected intraprocedurally or within six hours after completed procedure (n=96, 1.8%). Twelve (0.2%) major complications occurred between six hours post-ablation and until discharge the day after procedure. The most common of these were congestive heart failure (n=6) and transient ischemic attack (TIA, n=4). In addition, there were 61 (1.1%) minor complications which occurred in this time span. Factors independently associated with major complications intraprocedurally or within 24 hours were age (p=0.046), body mass index (BMI) ≥30 kg/m2 (p=0.009), significant valvular disease (p=0.001), cardiomyopathy (p<0.001), prior stroke or TIA (p=0.014), first time procedure vs. repeat procedure (p=0.013), cryoablation vs. radiofrequency (p<0.001) and procedure duration (p<0.001).

Conclusion

Very few complications occurred between six hours and until discharge after ablation of atrial fibrillation. Therefore, same-day discharge may be a safe option for a large proportion of patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Region Stockholm funding

Cryoablation as standard treatment of atrial flutter: a prospective, 2-center study (CASTAF)

BACKGROUND

Cryoablation (CRYO) of cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) has been shown to be non-inferior to radiofrequency ablation (RF) in terms of ablation success and is associated with less pain. However, procedural time has been significantly longer with CRYO compared to RF. A possible explanation for this could be that operators had less experience with CRYO than with RF. The purpose of this study was to test the hypothesis that in the hands of experienced operators, cryoablation of CTI-dependent AFL is effective with procedure-time similar to what is reported for RF.

METHODS

This prospective 2-center study included 184 patients with CTI-dependent AFL - median age 66 years (range 28-83), 159 men (86%). Cryoablation was performed using a 9 F, 8 mm tip catheter (Freezor MAX, Medtronic, Inc, MN, USA). Ablation endpoint was bidirectional CTI-block. Pain was evaluated with a visual analogue scale (VAS 0-10). All operators had experience of at least 25 previous CTI-ablations with CRYO.

RESULTS

The acute success rate was 89%. Procedural time including an observation period of 30 min, was 115 ± 36 min which is similar to procedural times for RF in previous studies. Fluoroscopy time was 11 ± 9 min. Cryoablation was perceived as almost pain- free by the patients, VAS (mean) 1.8 ± 1.2. Success rate at 12-month follow-up (FU) was 88% in patients with primary success. No major adverse events occurred.

CONCLUSIONS

Cryoablation of CTI-dependent AFL is effective, with a low level of procedure-related pain. In experienced hands, the procedure time in this prospective non-randomised trial seems to be in the level of reported procedure times for RF. The long-term relapse rate appears to be higher than for RF.

Immediate versus staged revascularisation in multivessel coronary disease: an updated meta-analysis

Background

Percutaneous coronary interventions (PCIs) are often aimed at the culprit vessel in acute coronary syndromes (ACSs) followed by revascularisation of other stenoses later in the index hospitalisation or shortly after discharge. PCI delay of non-culprit coronary vessels stenoses is supported by lower contrast fluid use and thrombocyte aggregation. Distinct coronary interventions increase the risk of both non- and coronary artery complications, e.g. acute abdominal and periphery artery bleeding, suggesting undertaking all PCIs at the same time.

Purpose

To assess the effect on mortality and re-myocardial infarction (MI) of immediate versus staged revascularisation in multivessel coronary disease, with the latter constrained to initial PCI of the culprit coronary vessel.

Methods

The syntax of “randomised controlled trial (RCT) & acute coronary syndrome & complete revascularisation” was undertaken in PubMed.

Clinical characteristics were gathered at the index hospitalisation. The intervention scenario was acute coronary syndrome or not.

Meta-analyses calculated relative risk (RR) reductions on outcomes of 1) mortality and 2) re-MI. Meta-regression assessed linear difference between interventional treatment benefits and baseline characteristics.

Results

A total of 148 studies was found. Of those, 8 was found eligible for further analyses and their baseline characteristics are shown in Table 1.

Comparison of immediate versus staged revascularisation on mortality was nonsignificant (RR, 1.19; 95% CI: 0.78–1.81, p=0.43) (Figure 1). The impact of Immediate vs staged revascularisation on re-MI was also nonsignificant (RR, 0.83; 95% CI: 0.44–1.55, p=0.56). Meta-regression found no associations between the outcomes and study characteristics (not shown).

Conclusion

The intervention of immediate compared to staged revascularisation assessed on outcomes of all-cause mortality and re-MI were nonsignificant.

Figure 1

Funding Acknowledgement

Type of funding source: None

Sinus heart rate post pulmonary vein ablation and long-term risk of recurrences

Aim

To investigate the association of sinus heart rate pre- and post-ablation and recurrence rates in patients undergoing catheter ablation for atrial fibrillation.

Methods

Between January 2012 and December 2017, data of 482 patients undergoing their first pulmonary vein isolation (PVI) were included. All patients were followed-up for 12 months and were screened for any atrial tachyarrhythmia. Sinus heart rate measurements were recorded before (PRE), directly post ablation (POST) and 3 months post ablation (3M).

Results

In the total study population, the mean resting sinus heart rate at PRE (mean 57.9 bpm (95% CI, 57.1–58.7 bpm)) increased by over 10 bpm to POST (mean 69.4 bpm (95% CI, 68.5–70.3 bpm); p<0.001) followed by a slight decrease at 3M (mean 67.3 bpm (95% CI, 66.4–68.2 bpm)) but still remaining higher compared to PRE (p<0.001). This pattern was observed in patients with and without recurrences at PRE, POST and 3M respectively (both p<0.001). However, only at 3M, there was a significant difference in mean heart rate being lower in patients with compared to patients without recurrences (p=0.031). In this regard, patients with a heart rate ≥60 bpm at 3M and a heart rate change ≥11 bpm (PRE to 3M) had a favorable outcome in terms of recurrences compared to the remaining patients (HR 0.61 (95% CI, 0.44–0.84), p=0.002 and HR 0.55 (95% CI, 0.40–0.76), p<0.001, respectively). These variables remained independently associated in multivariable analysis.

Conclusion

Our study confirms the impact of PVI on cardiac autonomic function with a significant heart increase post-ablation. A heart rate ≥60bpm at 3M and a heart rate change ≥11 bpm (PRE to 3M) are associated with a favorable outcome in terms of recurrences.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German Research Foundation

Long-term outcome of patients with invasive electrophysiology procedure related cardiac tamponade

Aims

Iatrogenic cardiac tamponades are a rare but dreaded complication of invasive electrophysiology procedures (EPs). Their long-term impact on clinical outcomes is unknown. This study analyzed the risk of death or serious cardiovascular events in patients suffering from EP related cardiac tamponade requiring pericardiocentesis during long-term follow-up.

Methods and results

Out of 19997 invasive EPs at our university hospital between January 1998 and September 2018, all patients with EP related periprocedural cardiac tamponade were identified (n=60) and matched (1:3 ratio) to a control group (n=180). After a follow-up of 5 years, the composite primary end point - death from any cause, acute myocardial infarction, TIA/stroke and hospitalization for heart failure – occurred in significantly more patients in the tamponade than in the control group (12 patients (20.0%) vs 19 patients (10.6%); Hazard ratio (HR) 2.53 (95% CI, 1.15–5.58); p=0.021). This was mainly driven by a higher incidence of TIA/stroke in the tamponade than in the control group (HR 3.75 (95% CI, 1.01–13.97); p=0.049). Death from any cause, acute myocardial infarction and hospitalization for heart failure did not show a significant difference between the groups. Hospitalization for pericarditis occurred in significantly more patients in the tamponade than in the control group (HR 36.0 (95% CI, 4.68–276.86); p=0.001).

Conclusion

Patients with EP related cardiac tamponade are at higher risk for cerebrovascular events during the first two weeks and hospitalization for pericarditis during the first months after index procedure. Despite the increased risk for early complications tamponade patients have a good long-term prognosis without increased risk for mortality or other serious cardiovascular events.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German Research Foundation

3053High mortality in atrial fibrillation patients suffering ischemic stroke, intracranial hemorrhage or a gastrointestinal bleed and associations with the preceding antithrombotic treatment

Background

Anticoagulation treatment reduces the risk of stroke but increases the risk of bleeding in atrial fibrillation (AF) patients. There is little data on survival after a stroke or a severe bleed.

Objective

To analyze 90-day mortality in AF patients after an ischemic stroke, an intracranial hemorrhage (ICH) or a gastrointestinal bleed (GIB) and assess associations with the type of antithrombotic treatment preceding the event.

Methods

From the Stockholm Healthcare database (n=2.3 million inhabitants) we selected all AF patients suffering from an ischemic stroke, an intracranial bleed, or a severe GIB requiring acute hospital care between July 2011 and August 2018 and assessed 90-day mortality rates. We assessed current use of warfarin, non-vitamin K oral anticoagulants (NOAC), or antiplatelet agents at the time of the event. We used a Cox regression to calculate adjusted hazard ratios (aHRs), adjusting for components of the Charlson Comorbidity Index, the CHADsVASc score, the HAS-BLED score, comedication, and year of inclusion, for the association between treatment preceding the event and mortality. In addition, we performed log-rank tests in propensity score matched cohorts.

Results

Of 105 313 patients with AF, 6 017 were included after an ischemic stroke, 3 006 after an ICH, and 4 291 after a GIB. 90-day mortality rates were 25.1%, 31.6% and 16.2%, respectively. Patients suffering from an ischemic stroke were the oldest at 81.6±9.8 (S.D:) years of age followed by patients suffering from an ICH (80.2±9.8 years) or a GIB (78.7±10.5 years). A large proportion of patients suffering ischemic stroke (72%) had no anticoagulant treatment preceding the event. After ICH, there was a significantly increased risk of mortality in warfarin compared to NOAC treated patients after adjusting for confounders (aHR: 1.36 CI: 1.04–1.78). Patients receiving antiplatelets or no treatment had significantly higher mortality rates than patients on NOAC treatment, both after an ischemic stroke and a GIB, but there was no significant difference between warfarin and NOACs (aHR 0.84 CI: 0.63–1.12 after ischemic stroke, aHR 0.91 CI: 0.66–1.25 after GIB). Propensity score matched analyses yielded similar results.

Survival curves after event

Conclusion

Mortality rates are high in AF patients suffering from an ischemic stroke, an ICH, or a GIB. NOAC treatment was associated with a lower 90-day mortality after ICH than warfarin, but no such difference was found after ischemic stroke or GIB. After ischemic stroke and GIB, mortality rates were higher in antiplatelet treated and untreated patients compared to NOAC treated patients.

Acknowledgement/Funding

Swedish Heart Lung Foundation

P6334Daily body weight in patients with chronic heart failure: improved diagnostic value by analysing prolonged time intervals

Background

Daily body weight (BW) is a mainstay in the management of patients with chronic heart failure (HF). Guidelines recommend to take action if BW increases more than 2kg within 3 days. However, the evidence behind the 2kg/3d rule is unclear and studies have shown poor diagnostic performance of this algorithm.

Purpose

To assess the diagnostic value of different BW thresholds and time intervals to alert for imminent HF decompensation.

Methods

We studied 184 patients with HF (age 71±10 yr, EF 26±11%). 43% had been hospitalized for HF during the preceding year. They were assessed by daily BW using digital scales with direct data transfer to a central data base. The mean follow-up was 286 days.

To decrease day-to-day variability, BW was analysed based on a daily moving average over 3 days. We retrospectively calculated the sensitivity and false-positive rate of BW thresholds at 1.5, 2.0, 2.5, 3.0 and 3.5 kg and time intervals between 2 and 30 days. Threshold crossings occurring within 30 days prior to a hospitalization for decompensated HF were deemed a positive alert.

Results

The sensitivity of 2kg/3d was poor (13%). Prolonging the time interval of weight changes markedly improved sensitivity. Increasing the weight threshold decreased the false positive rate. Greatest sensitivity (60%) was achieved using a 14 day interval at a weight threshold of 1.5 kg. However, this was associated with a high rate of false alerts (3.1 per patient/year). A weight threshold of 3.5 kg resulted in excellent specificity (0.3 false alerts per patient/year), however sensitivity was low (20%, 20 day time interval).

Conclusion

Monitoring daily BW using a 2kg/3d algorithm is associated with poor diagnostic performance. Generally, by analyzing stable trends over time (moving average) and using prolonged time intervals, BW monitoring with digital scales can achieve a clinically meaningful diagnostic performance. This new approach to BW monitoring may improve early detection of imminent HF decompensation.

P4426Prolonged troponin t elevation in male and female master athletes after long-distance running

Background

Troponin levels may be elevated after long-distance running, probably due to increased membrane permeability of cardiomyocytes. It is believed that elevated troponin post exercise, in contrast to acute coronary syndromes, normalize within 24 (−48) hours. This phenomenon has been mainly studied in young and elite athletes. However, participation in endurance exercise is increasingly popular among elderly and recreational sportsmen.

Purpose

To assess troponin levels in master athletes before and up to 7 days after long-distance running.

Method

We studied 97 participants (56 males and 41 females, matched for age) in the world's largest cross-country race (30 km, Lidingöloppet). They were ≥45 years (53±5 years). Baseline evaluation included a physical exam, blood pressure, BMI, NT-proBNP and an ECG. Blood tests were taken at baseline, immediately after as well as 1d, 4d and 7d after the race, including high sensitive troponin T (TnT), creatinine and high sensitive CRP. Elevated TnT was defined as ≥15 ng/l.

Results

After the race TnT had increased from 5±3 ng/l at baseline to 46±32 ng/l (range 11–180; p<0.0001). TnT was still significantly elevated at day 1 (16±16ng/l, range 4–106; p<0.0001) and day 4 (8±8 ng/l, range 4–63; p<0.01) with a borderline increase at day 7 (6±3; range 4–22; p=0.062). Both men and women showed a significant TnT increases at day 1 and day 4. Elevated TnT above the diagnostic threshold for myocardial infarction was observed in 96% (post race), 34% (day 1), 9% (day 4) and 3% (day 7). Males had generally higher TnT levels. At day 1, elevated TnT levels were present in 39% of males and 17% of females while all subjects with elevated TnT at day 4 and day 7 were male.

Conclusion

TnT is elevated in the vast majority of male and female master athletes after participation in a 30 km cross country race. To our knowledge, this is the first report showing that TnT levels can be still significantly elevated four days after endurance running. Prolonged TnT values above the diagnostic threshold for myocardial infarction were predominantly seen in males. Our findings are relevant to the clinical management of patients with increased troponin values after endurance exercise.

Acknowledgement/Funding

Hjärt och lungfonden (Swedish heart- and lung fund). Governmental grants.

P3120Prevention of heart failure in treatments with trastuzumab and anthracyclines: a meta-analysis

Background

Trastuzumab and anthracyclines are conventional chemotherapies used in breast cancer. Unfortunately, they are associated with a decrease in left ventricular function potentially leading to heart failure (HF). In order to prevent this, randomised controlled trials (RCTs) assess the preventive effect of concomitant beta-blocker (BB), angiotensin receptor blocker (ARB) and angiotensin converting enzyme inhibitor (ACEI) therapy during chemotherapy.

Purpose

To assess the preventive effect of BB, ARB or ACEIs on left ventricular ejection fraction (LVEF) during trastuzumab and anthracycline treatment in patients without HF.

Methods

Our primary outcomes were the effect of BBs or ARB/ACEIs during 1) trastuzumab and 2) anthracycline treatment.

Secondary outcomes were the distinct effects of 1) BBs and 2) ARB/ACEIs in either trastuzumab or anthracycline treatments.

Through the search term “(RCTs), prevention, cancer chemotherapy and cardiotoxicity” in PubMed, studies were selected, excluding those without randomising to a BB, ARB/ACEI and a placebo control group during chemotherapy.

Means of the LVEF and the standard deviation (SD) post-chemotherapy were applied.

Meta-analyses estimated the standardised mean difference (SMD) in the LVEF.

Heterogeneity was calculated as the I2.

Results

A total of 7 studies (Table 1) were included in the analysis. Between 93 and 100% were woman. Age varied from 41 to 51 years. Treatment time varied from 12 to 52 weeks.

Concomitant BB or ARB/ACEI therapy during trastuzumab treatment was not associated with the LVEF, significantly (Fig. 1A; p=0.07). Oppositely, in the anthracycline regime the LVEF remained significant higher in the concomitant BB and ARB/ACEI groups as compared to controls (Fig. 1B).

BB and ARB/ACEI separation in the analysis showed both to influence the LVEF positively independent of chemotherapy (P=0.03 & p=0.005).

Table 1 Study reference Year Chemotherapies Preventive drugs Pituskin et al., “Multidisciplinary Approach to Novel Therapies in Cardio-Oncology Research (MANTICORE 101-Breast): A Randomized Trial for the Prevention of Trastuzumab-Associated Cardiotoxicity.” 2017 Trastuzumab Perindopril. bisoprolol Gulati et al., “Prevention of Cardiac Dysfunction during Adjuvant Breast Cancer Therapy (PRADA).” 2016 Trastuzumab Candesartan, metoprolol Boekhout et al., “Angiotensin II-Receptor Inhibition With Candesartan to Prevent Trastuzumab-Related Cardiotoxic Effects in Patients With Early Breast Cancer: A Randomized Clinical Trial.” 2016 Trastuzumab Candesartan Janbabai et al., “Effect of Enalapril on Preventing Anthracycline-Induced Cardiomyopathy.” 2017 Anthracycline Enalapril Nabati et al., “Cardioprotective Effects of Carvedilol in Inhibiting Doxorubicin-Induced Cardiotoxicity.” 2017 Anthracycline Carvedilol Tashakori Beheshti et al., “Carvedilol Administration Can Prevent Doxorubicin-Induced Cardiotoxicity: A Double-Blind Randomized Trial.” 2016 Anthracycline Carvedilol Kaya et al., “Protective Effects of Nebivolol against Anthracycline-Induced Cardiomyopathy: A Randomized Control Study.” 2013 Anthracycline Nebivolol

Figure 1

Conclusions

Concomitant BB and ARB/ACEI therapy both favoured maintenance of the LVEF during trastuzumab and anthracyclines regimens as compared to controls.

Cardiac resynchronization therapy: a breakthrough in heart failure management

Heart failure is now considered an epidemic. In patients with heart failure, electrical and mechanical dyssynchrony, evident primarily as prolongation of the QRS-complex on the surface electrocardiogram, is associated with detrimental effects on the cardiovascular system at several levels. In the past 10 years, studies have demonstrated that by stimulating both cardiac ventricles simultaneously, or almost simultaneously [cardiac resynchronization therapy (CRT)], the adverse effects of dyssynchrony can be overcome. Here, we provide a comprehensive overview of different aspects of CRT including the rationale behind and evidence for efficacy of the therapy. Issues with regard to gender effects and patient follow-up as well as a number of unresolved concerns will also be discussed.

[Schwannoma of the nasal cavity: a case report]

Schwannomas of the nasal cavity and paranasal sinuses are quite rare, with 4% occurring in this location. Most of them are benign and do not recur when totally removed by surgery. It is very important to distinguish between schwannoma and primary benign neurofibroma. Neurofibromas are lesions having the possibility for malignant transformation and recurrence. A case of schwannoma in the nasal cavity is reported, and the diagnostic and therapeutic procedures, as well as recommendations from the literature, are described. The histological and immunohistochemical features are discussed in detail to draw a distinction between schwannoma and neurofibroma. In cases of intranasal and paranasal lesions, the existence of a schwannoma must be considered. Differentiating between schwannoma and neurofibroma is important for estimating the risk of malignant transformation and recurrence.

Continuous haemodynamic monitoring during withdrawal of diuretics in patients with congestive heart failure

AIMS

Right heart pressure parameters can be recorded continuously with the help of an implanted haemodynamic monitor. The aim of this study was to investigate the usefulness of the device in adjusting diuretic medication in patients with chronic congestive heart failure, and to evaluate the response of right ventricular pressure to increased volume load induced by diuretic withdrawal.

METHODS AND RESULTS

Four patients with stable congestive heart failure were implanted with an implantable haemodynamic monitor. Furosemide, the only diuretic used, was reduced by 50% the first week, withdrawn completely for the second week and then reinstituted in the initial dose. Right ventricular systolic and diastolic pressure, pulse pressure, dP/dt, estimated diastolic pulmonary artery pressure and heart rate were sampled continuously. Patients were evaluated by body weight, NYHA class, serum creatinine, serum brain natriuretic peptide, the 6 min walk test, quality of life and echocardiography on days 0, 7, 14 and 21. We observed significant changes in right ventricular pressure parameters in parallel with clinical signs and symptoms of worsening heart failure, such as increased body weight, a shorter walking distance and impaired quality of life. Moreover elevated levels of brain natriuretic peptide and lower creatinine levels were observed.

CONCLUSION

Haemodynamic changes due to increased volume load can be detected with an implantable haemodynamic monitor. Such data provide useful information for tailoring an optimal diuretic dose in patients with congestive heart failure.

Reduction of hospital days by biventricular pacing

The health care costs for heart failure are substantial. Studies indicate that hospital treatment constitutes 65-75% of these. The aim of this study was to assess total and heart failure related hospital days as well as safety and efficacy of biventricular pacing in 16 patients with severe heart failure and delayed intraventricular conduction (QRS duration >150 ms). They were implanted with a biventricular pacemaker and followed by NYHA class, 6-min walk test and quality of life for a mean of 291+/-76 days. Total number of hospital days and the need for hospitalisations were monitored. Thirteen responders improved by at least one functional class. After 6 months of pacing the 6-min walk test improved from 375+/-83 m to 437+/-73 m (P<0.001) and Minnesota Living with Heart Failure quality of life score from 41+/-19 to 24+/-17 (P<0.001) compared to baseline. The need for hospital care decreased significantly after biventricular pacing. The total number of hospital days in all patients was 253 the year before compared to 45 the year after biventricular pacing (P<0.01). For heart failure related hospital days the corresponding figures were 183 and 39 days, respectively (P<0.01). Biventricular pacing improved 13/16 patients with severe heart failure and wide QRS complexes in this open study. The improvement resulted in a reduced need for hospital care.

[Biventricular pacing as a new therapeutic method in heart failure. An alternative for patients with intraventricular conduction disorders]

Patients with severe heart failure often have interventricular conduction disturbances indicated by wide QRS complexes. The resulting uncoordinated contraction pattern leads to impaired systolic and diastolic function which might be overcome by a new technique, biventricular pacing. The first Swedish clinical trial is reported, an open study where 13 out of 16 patients improved in terms of functional class, walking test and quality of life after six months of treatment. The number of hospital days was markedly reduced after pacemaker implantation.

Differential sensitivity of three sublines of the rat Dunning prostate tumor system R3327 to radiation and/or local tumor hyperthermia

To better understand the relationship of the growth characteristics of tumor tissues and their response to ionizing radiation alone and in combination with local tumor hyperthermia, we compared three different tumor sublines of the Dunning rat prostate carcinoma R3327. This report includes results obtained with the anaplastic AT1 subline (volume doubling time 5.2 days), the moderately differentiated mucin-secreting HI subline (volume doubling time about 9 days) and the well-differentiated, hormone-dependent H subline (volume doubling time about 17 days). The effects of single doses of photons (10 to 40 Gy) with and without local tumor hyperthermia (35 min immersion at 43.5 degrees C) were quantified by growth delay. The time to reach five times the volume at the time of treatment after 30 Gy alone was found to be 56.0, 134.9 and 184.0 days for the R3327-AT1, HI and H tumors, respectively. The R3327-H tumor was more radiosensitive than the AT1 or HI subline. Five of nine R3327-H tumors were controlled locally with a single dose of photons (40 Gy). Local tumor hyperthermia alone induced growth delay in both differentiated tumors, while the anaplastic tumor subline did not respond. Combined treatment modalities with heat applied directly after irradiation revealed isoeffective thermal enhancement ratios for 30 Gy which decreased from 1.59 for the AT1 tumor and 1.42 for the HI tumor to 1.23 in the well-differentiated subline R3327-H.