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Pereira SC, Antonio PS, Rigueira J, Almeida AG. Multiple complications of a well-known disease: a case report of acquired Gerbode defect after bicuspid aortic valve endocarditis. Eur Heart J Case Rep 2023; 7:ytad286. [PMID: 37501715 PMCID: PMC10371048 DOI: 10.1093/ehjcr/ytad286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/05/2023] [Accepted: 06/22/2023] [Indexed: 07/29/2023]
Abstract
Background Infective endocarditis is a rare but serious disease with high morbidity and mortality due to its potential life-threatening complications. Gerbode defect is an anomalous connection between the left ventricle and the right atrium that can be either congenital or acquired, with previous rare reports following abscess formation in infective endocarditis. Case summary A 27-year-old woman presented in hospital with Janeway lesions, stroke, splenic and hepatic abscesses, and transient complete auriculoventricular block. Bicuspid aortic valve infective endocarditis to methicillin-sensitive Staphylococcus aureus and acquired Gerbode defect were diagnosed. After intravenous antibiotics and aortic valve replacement, the patient was discharged without sequelae. Discussion Bicuspid aortic valve patients have a higher risk of infective endocarditis than the general population. Infective endocarditis may present with multiple complications, including systemic embolization and local perivalvular lesions. Acquired Gerbode defect is a rare complication of infective endocarditis where transoesophageal echocardiography plays an important role for small shunt detection before surgical intervention.
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Affiliation(s)
| | - Pedro Silverio Antonio
- Cardiology Division, Heart and Vessels Department, Centro Hospitalar Universitário de Lisboa Norte, E.P.E., Av. Prof. Egas Moniz MB, 1649-028, Lisbon, Portugal
| | - Joana Rigueira
- Cardiology Division, Heart and Vessels Department, Centro Hospitalar Universitário de Lisboa Norte, E.P.E., Av. Prof. Egas Moniz MB, 1649-028, Lisbon, Portugal
- Cardiovascular Centre of the University of Lisbon (CCUL), CAML, Lisbon School of Medicine, University of Lisbon, Av. Prof. Egas Moniz MB, 1649-028, Lisbon, Portugal
| | - Ana G Almeida
- Cardiology Division, Heart and Vessels Department, Centro Hospitalar Universitário de Lisboa Norte, E.P.E., Av. Prof. Egas Moniz MB, 1649-028, Lisbon, Portugal
- Cardiovascular Centre of the University of Lisbon (CCUL), CAML, Lisbon School of Medicine, University of Lisbon, Av. Prof. Egas Moniz MB, 1649-028, Lisbon, Portugal
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Brito J, Rigueira J, Rodrigues T, Aguiar-Ricardo I, Santos R, Nunes-Ferreira A, Cunha N, Pereira S, Antonio PS, Morais P, Alves Silva P, Valente Silva B, Pinto FJ, Almeida AG. Mitral valve prolapse: American versus European guidelines - which one is better. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
According to the most recent recommendations of AHA, mitral valve prolapse (MVP) is defined as systolic displacement of the mitral leaflet into the left atrium (LA) of at least 2 mm from the mitral annular plane. The ESC recommendations define MVP, flail and billowing, according to the location of the leaflet tips in relation to the coaptation plan. Differences in outcomes considering these classifications are not established.
Purpose
To evaluate the differences in clinical presentation and outcomes of MVP considering AHA and ESC classifications.
Methods
Single-center retrospective study of consecutive patients with MVP (defined according to the AHA classification) documented in transthoracic echocardiogram between January 2014 and October 2019. Demographic, clinical, echocardiographic and electrocardiographic data were collected. The results were obtained using Chi-square and ANOVA tests.
Results
We included 247 patients (mean age 62.9 ± 18 years, 61% males) according to AHA classification; considering the ESC classification: 147 (59%) had prolapse, 30 (12%) flail and 67 (39%) billowing.
In comparison to patients with flail and billowing, patients with MVP had less cordae rupture (p = 0.02). Prolapse was associated with better survival (p = 0.037) and was an independent predictor of survival (OR = 0.372, CI95% [0.148-0.935], p = 0.035) Patients with flail were older in comparison to the ones with prolapse and billowing (71 ± 14 vs 63 ± 17 vs 60 ± 21 years, respectively, p = 0.022). Patients with flail were mostly men (80%, p = 0.028), with more significant mitral regurgitation (p = 0.003) and higher NYHA class (p = 0.018). They also had higher systolic pulmonary artery pressure (SPAP) (48 ± 23 vs 38 ± 18 vs 36 ± 12mmHg, p = 0.015) and higher values of LV mass and posterior wall thickness (144 ±32 vs 125 ± 44 vs 114 ± 37g/m2, p = 0.005 and 11 ± 1,5 vs 10 ± 1,7 vs 9 ± 1.9 mm, p = 0.009, respectively). Women had more billowing (p = 0.04) than prolapse and flail.
Conclusion
The ESC classification adds information to the AHA classification in what concerns to clinical presentation and prognosis of mitral valve prolapse, so both classifications should be used in daily practice.
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Affiliation(s)
- J Brito
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - J Rigueira
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - T Rodrigues
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - I Aguiar-Ricardo
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - R Santos
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - A Nunes-Ferreira
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - N Cunha
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - S Pereira
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - PS Antonio
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - P Morais
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - P Alves Silva
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - B Valente Silva
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - FJ Pinto
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
| | - AG Almeida
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
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Honarbakhsh S, Providencia R, Garcia-Hernandez J, Martin CA, Hunter RJ, Lim WY, Kirkby C, Graham AJ, Sharifzadehgan A, Waldmann V, Marijon E, Munoz-Esparza C, Lacunza J, Gimeno-Blanes JR, Ankou B, Chevalier P, Antonio N, Elvas L, Castelletti S, Crotti L, Schwartz P, Scanavacca M, Darrieux F, Sacilotto L, Mueller-Leisse J, Veltmann C, Vicentini A, Demarchi A, Cortez-Dias N, Antonio PS, de Sousa J, Adragao P, Cavaco D, Costa FM, Khoueiry Z, Boveda S, Sousa MJ, Jebberi Z, Heck P, Mehta S, Conte G, Ozkartal T, Auricchio A, Lowe MD, Schilling RJ, Prieto-Merino D, Lambiase PD. A Primary Prevention Clinical Risk Score Model for Patients With Brugada Syndrome (BRUGADA-RISK). JACC Clin Electrophysiol 2020; 7:210-222. [PMID: 33602402 DOI: 10.1016/j.jacep.2020.08.032] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/13/2020] [Accepted: 08/14/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The goal of this study was to develop a risk score model for patients with Brugada syndrome (BrS). BACKGROUND Risk stratification in BrS is a significant challenge due to the low event rates and conflicting evidence. METHODS A multicenter international cohort of patients with BrS and no previous cardiac arrest was used to evaluate the role of 16 proposed clinical or electrocardiogram (ECG) markers in predicting ventricular arrhythmias (VAs)/sudden cardiac death (SCD) during follow-up. Predictive markers were incorporated into a risk score model, and this model was validated by using out-of-sample cross-validation. RESULTS A total of 1,110 patients with BrS from 16 centers in 8 countries were included (mean age 51.8 ± 13.6 years; 71.8% male). Median follow-up was 5.33 years; 114 patients had VA/SCD (10.3%) with an annual event rate of 1.5%. Of the 16 proposed risk factors, probable arrhythmia-related syncope (hazard ratio [HR]: 3.71; p < 0.001), spontaneous type 1 ECG (HR: 3.80; p < 0.001), early repolarization (HR: 3.42; p < 0.001), and a type 1 Brugada ECG pattern in peripheral leads (HR: 2.33; p < 0.001) were associated with a higher risk of VA/SCD. A risk score model incorporating these factors revealed a sensitivity of 71.2% (95% confidence interval: 61.5% to 84.6%) and a specificity of 80.2% (95% confidence interval: 75.7% to 82.3%) in predicting VA/SCD at 5 years. Calibration plots showed a mean prediction error of 1.2%. The model was effectively validated by using out-of-sample cross-validation according to country. CONCLUSIONS This multicenter study identified 4 risk factors for VA/SCD in a primary prevention BrS population. A risk score model was generated to quantify risk of VA/SCD in BrS and inform implantable cardioverter-defibrillator prescription.
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Affiliation(s)
| | - Rui Providencia
- The Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Jorge Garcia-Hernandez
- Farr Institute of Health Informatics Research, University College London, London, United Kingdom
| | - Claire A Martin
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Ross J Hunter
- The Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Wei Y Lim
- The Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Claire Kirkby
- The Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Adam J Graham
- The Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Ardalan Sharifzadehgan
- Cardiology Department, European Georges Pompidou Hospital, Paris, France; Paris Descartes University, Paris, France; Paris Cardiovascular Research Center (INSERM U970), Paris, France
| | - Victor Waldmann
- Cardiology Department, European Georges Pompidou Hospital, Paris, France; Paris Descartes University, Paris, France; Paris Cardiovascular Research Center (INSERM U970), Paris, France
| | - Eloi Marijon
- Cardiology Department, European Georges Pompidou Hospital, Paris, France; Paris Descartes University, Paris, France; Paris Cardiovascular Research Center (INSERM U970), Paris, France
| | - Carmen Munoz-Esparza
- Inherited Cardiac Disease Unit, University Hospital Virgen Arrixaca, Murcia, Spain
| | - Javier Lacunza
- Inherited Cardiac Disease Unit, University Hospital Virgen Arrixaca, Murcia, Spain
| | | | - Benedicte Ankou
- Rhythmology Department, Hôpital Cardiovasculaire Louis Pradel, Claude Bernard University, Lyon, France
| | - Philippe Chevalier
- Rhythmology Department, Hôpital Cardiovasculaire Louis Pradel, Claude Bernard University, Lyon, France
| | - Nátalia Antonio
- Cardiology Department, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Luís Elvas
- Cardiology Department, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Silvia Castelletti
- Cardiology Department, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Lia Crotti
- Laboratory of Cardiovascular Genetics, Center for Cardiac Arrhythmias of Genetic Origin, IRCCS Istituto Auxologico, Italiano, Milan, Italy
| | - Peter Schwartz
- Laboratory of Cardiovascular Genetics, Center for Cardiac Arrhythmias of Genetic Origin, IRCCS Istituto Auxologico, Italiano, Milan, Italy
| | - Mauricio Scanavacca
- Arritmia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Francisco Darrieux
- Arritmia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Luciana Sacilotto
- Arritmia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Christian Veltmann
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | | | - Nuno Cortez-Dias
- Department of Cardiology, Santa Maria University Hospital, Lisbon Academic Medical Centre and Cardiovascular Centre of the University of Lisbon, Faculty of Medicine, Lisbon, Portugal
| | - Pedro Silverio Antonio
- Department of Cardiology, Santa Maria University Hospital, Lisbon Academic Medical Centre and Cardiovascular Centre of the University of Lisbon, Faculty of Medicine, Lisbon, Portugal
| | - João de Sousa
- Department of Cardiology, Santa Maria University Hospital, Lisbon Academic Medical Centre and Cardiovascular Centre of the University of Lisbon, Faculty of Medicine, Lisbon, Portugal
| | - Pedro Adragao
- Cardiology Department, Santa Cruz Lisboa Hospital, Lisbon, Portugal
| | - Diogo Cavaco
- Cardiology Department, Santa Cruz Lisboa Hospital, Lisbon, Portugal
| | | | | | | | | | | | - Patrick Heck
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Sarju Mehta
- Addenbroke's Hospital, Cambridge, United Kingdom
| | - Giulio Conte
- Cardiac Electrophysiology Unit, Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Tardu Ozkartal
- Cardiac Electrophysiology Unit, Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Angelo Auricchio
- Cardiac Electrophysiology Unit, Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Martin D Lowe
- The Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | | | - David Prieto-Merino
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Pier D Lambiase
- The Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom.
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Aguiar-Ricardo I, Nunes-Ferreira A, Rigueira J, Rdrigues T, Cunha N, Antonio PS, Morais P, Pereira SC, Bernardes A, Santos I, Magalhaes A, Neves H, Pinto FJ, De Sousa J, Marques P. P1166Women as candidates for CRT: Are they less but better? Europace 2020. [DOI: 10.1093/europace/euaa162.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Women have been under-represented in trials of cardiac resynchronization therapy (CRT). Most available data suggest that CRT has a greater clinical benefit in women than in men. However, further studies are needed to investigate the exact reasons for these results.
Purpose
To compare the prognostic impact and response rate of CRT in women and man.
Methods
Prospective study, single-center study that included pts undergoing CRT implant from 2015 to 2019. Clinical and echocardiographic evaluation were made before CRT implant and between 6-12 months post-implant. Pts with EF elevations≥10% or LV end-systolic volume (ESV) reductions≥15% were classified as responders. Patients with EF elevations ≥ 20% or ESV reductions≥30% were classified as super-responders. All the parameters were compared between women and man. Prognostic impact of CRT was evaluated as total mortality by the Cox regression and Kaplan-Meier methods.
Results
From 2015-2019, 561 patients were submitted to CRT implant with a follow-up duration of 18.9 ± 15.8 months. From these 148 (26.4%) were female (mean age 72.2 ± 10 years, 22.4% ischemic, LVEF < 30% in 70.2%). The cardiovascular risk factors and comorbidities were similar in both populations (women and men). In the female group, dilated cardiomyopathy was more frequent than in men (71% vs 50.8%, p < 0.01), with ischemic heart disease being the second most frequent etiology of heart failure.
The frequency of LBBB was similar in both groups (63.9% in women and 57.0% in men, p = NS) however the QRS duration was higher in women (164 ± 17 vs 160 ± 24, p = 0.017). The baseline mean EF was similar (30.5 ± 10.3ms in women and 30.3 ± 11.4ms in men) but the ESV was lower (109.7 ± 59.9 vs 138.4 ± 64.6, p < 0.001).
The prevalence of complications and need for surgical revision were similar in both groups.
The rate of CRT responders was similar in both groups, although tendentially higher in women (64.3% in women vs 55.2% in men, p = NS). On the other hand, super-responder rate was statistically significant (38% in women vs 25.1% in men, p = 0.004). The long-term survival was similar in both groups.
Conclusion
The rate of super-responders was higher in women than in men. This may be explained by the higher prevalence of dilated cardiomyopathy in this subgroup of patients and by the fact that women have smaller hearts and a larger QRS duration at baseline, most likely to have a real LBBB. Long-term mortality of CRT was not gender related
Abstract Figure. Long-term survival by gender
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Affiliation(s)
- I Aguiar-Ricardo
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - A Nunes-Ferreira
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - J Rigueira
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - T Rdrigues
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - N Cunha
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - P S Antonio
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - P Morais
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - S C Pereira
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - A Bernardes
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - I Santos
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - A Magalhaes
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - H Neves
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - F J Pinto
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - J De Sousa
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - P Marques
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
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Nunes Ferreira A, Antonio PS, Aguiar-Ricardo I, Rodrigues T, Rigueira J, Agostinho JR, Santos R, Pereira S, Bernardes A, Santos I, Pinto FJ, De Sousa J, Marques P. 864A modified snare technique improves left ventricular lead implant success and response rate to cardiac resynchronization therapy. Europace 2020. [DOI: 10.1093/europace/euaa162.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Left ventricular (LV) lead placement is often the most challenging aspect of cardiac resynchronization therapy (CRT) device implantation, with a failure rate up to 10% due to complex coronary anatomies.
Purpose
To evaluate the efficacy of a modified snare technique in the LV lead implantation in cases of standard technique failure and to evaluate its impact in the response rate to CRT.
Methods
A prospective study was conducted of patients indicated for a CRT implant. When LV lead delivery to the target vessel failed using standard techniques, a modified snare technique was implemented, using a secondary coronary sinus delivery sheath introduced through the same venous puncture. Patients were evaluated every 6 months. Efficacy was quantified by long-term surgical intervention rates. Patients were evaluated with transthoracic echocardiography before CRT implant and between 6-12 months post-implant. Patients with ejection fraction (EF) elevation ≥ 10% or LV end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. Time to surgical revision and mortality were evaluated by the Cox regression and Kaplan-Meier methods.
Results
From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). The standard LV implant technique failed in 94 cases (16.6%), of which the modified snare technique was successful in 92 (97.9%) with LV lead implant in a lateral vein in 94.7% of cases. Baseline clinical characteristics were similar between patients who implanted LV lead with snare vs standard technique (p = NS). The 4-year surgical intervention rate was lower with the modified snare implant technique than with the standard technique (3.2% vs. 10.2%, HR 0.26, 95% CI 0.08-0.84, p < 0.05), with a relative risk reduction of 74% and a number needed to treat to prevent one surgical intervention of 14. The intervention rate was also lower regarding LV lead implant failure or dislodgement rates (0% vs. 5.3%, p < 0.05). Major complications were similar between groups.
In addition, the response rate to CRT was higher in the modified snare technique than in the standard approach (71.1% vs 55.0%, p < 0.05). In patients who implanted the LV lead with the snare technique, EF increased from 28.1 ± 8.2% to 36.1 ± 11.1% (p < 0.05) and LV ESV decreased from 127.8 ± 64.0mL to 99.8 ± 61.1mL (p = 0.01).
The super-response rate was similar between groups (33.3% vs 27.8%, p = NS).
Conclusion
For challenging coronary sinus anatomies that preclude LV lead placement by standard methods, this modified snare alternative was effective, with significantly lower surgical intervention rates and a higher response rate to resynchronization therapy. This higher than expected response rate with the snare technique, evaluated by remodeling criteria, may be explained by the implant of LV lead in the desired target lateral vein.
Abstract Figure.
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Affiliation(s)
- A Nunes Ferreira
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - P S Antonio
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - I Aguiar-Ricardo
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - T Rodrigues
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - J Rigueira
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - J R Agostinho
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - R Santos
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - S Pereira
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - A Bernardes
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - I Santos
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - F J Pinto
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - J De Sousa
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - P Marques
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
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6
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Aguiar Ricardo I, Nunes-Ferreira A, Rigueira J, Rodrigues T, Cunha N, Antonio PS, Morais P, Pereira SC, Bernardes A, Santos I, Magalhaes A, Neves H, Pinto FJ, De Sousa J, Marques P. P541Cardiac resynchronization therapy: left or non-left bundle branch block? That is the question. Europace 2020. [DOI: 10.1093/europace/euaa162.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Cardiac resynchronization therapy (CRT) is associated with reduced mortality and improved quality of life in patients (pts) with low ejection fraction (EF) and conduction delays. Patients with left bundle branch block (LBBB) seem to be the ones who benefit the most from CRT and there is controversy about its efficacy in patients with non-LBBB.
Purpose
To compare the prognostic impact and the response rate to CRT in patients with LBBB and non-LBBB.
Methods
Prospective single-center study of patients who implanted CRT between 2015 and 2019. Clinical, electrocardiographic and echocardiographic evaluations were made before CRT implant and between 6-12 months post-implant. Patients with EF elevation ≥ 10% or left ventricle end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. All the parameters were compared between patients with or without LBBB. Prognostic impact of resynchronization therapy was evaluated by comparing total mortality using the Cox regression and Kaplan-Meier methods.
Results
From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). From these patients, 59% had LBBB (69% males, mean age 71.6 ± 10.8 years, 34.5% ischemic, EF < 30% in 65.5%). The cardiovascular risk factors and comorbidities were similar in both populations (with and without LBBB), except for diabetes which was more frequent in non-LBBB patients (33% vs 50.6%, p = 0.007). Mean duration of QRS was similar between LBBB vs non-LBBB patients (163 ± 19ms vs 160 ± 22ms, p = NS) and baseline ejection fraction was also equivalent (29.8 ± 13.6% vs 27.9 ± 8.9%).
The prevalence of complications and surgical revisions were similar in both groups.
The response rate according to left ventricle remodelling criteria was higher in LBBB pts (65.9% vs 49.1%, p < 0.05), but the super-responders were similar in both groups (32.5% vs 26.4% p = NS).
The 4-year survival rate of patients with LBBB and non-LBBB was similar (86.5% vs 85.3%).
Conclusion
In our population the response rate to CRT was higher in LBBB pts. However, and despite the actual controversy about the efficacy of CRT in non-LBBB, the long-term mortality was similar in patients with or without LBBB.
Abstract Figure. lon-term survival
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Affiliation(s)
- I Aguiar Ricardo
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - A Nunes-Ferreira
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - J Rigueira
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - T Rodrigues
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - N Cunha
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - P S Antonio
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - P Morais
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - S C Pereira
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - A Bernardes
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - I Santos
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - A Magalhaes
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - H Neves
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - F J Pinto
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - J De Sousa
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
| | - P Marques
- Santa Maria University Hospital/CHULN, CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Cardiology, Lisbon, Portugal
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7
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Nunes Ferreira A, Antonio PS, Aguiar-Ricardo I, Rodrigues T, Cunha N, Santos RP, Rigueira J, Bernardes A, Santos I, Goncalves S, Pinto FJ, De Sousa J, Marques P. P578Multipoint pacing in cardiac resynchronization therapy - how to improve remodeling criteria and its impact in quality of life. Europace 2020. [DOI: 10.1093/europace/euaa162.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Despite the reduction in mortality and hospitalization rates, resynchronization therapy still has 30-40% of non-responders. Several studies are ongoing to evaluate if novel programming techniques such as multipoint pacing (MPP) increase the conversion rate of non-responder to responder to CRT. However, there is still lack of information about conversion to super-responders and the impact in quality of life of MPP.
Purpose
To evaluate the impact of MPP in conversion to super-responders and its impact in the quality of life of patients.
Methods
Randomized clinical trial of non-AF patients with indication for CRT and who implanted the Quartet™ quadripolar left ventricle (LV) lead. After implant, CRTs were programmed on biventricular pacing according to the latest activated area for 6 months. After a 6-month follow-up, patients were randomized in a 1:1 fashion to MPP ON or MPP OFF. MPP was programmed with the two widest spaced LV electrodes and with a LV1-LV2 to LV2-RV delay of 5ms. Patients were followed-up for 12 months with a 6-month evaluation of NTproBNP, echocardiographic remodeling criteria (LV end systolic volume (ESV) and LV ejection fraction), and quality of life (QoL) evaluated by EQ-5D, Minnesota Living with Heart Failure (MLWHF) questionnaire and 6-minute walk test (6MWT).
Results
76 patients were included in this trial, 62 with a completed 12-month follow-up (average age 67.2 ± 10.2 years old, 32.3% female gender, dilated cardiomyopathy in 77.4%). Among these patients, 24 were randomized to MPP ON, 28 to MPP OFF. Six patients died and 4 were lost to follow-up. Baseline clinical and echocardiographic characteristics were similar between groups (p = NS).
At 6 months, the overall response rate (reduction in ESV≥15%) was 75%. At twelve months, patients randomized to MPP ON had a super-response rate (reduction in ESV≥30%) higher than patients with MPP OFF (75% vs 39.3%, p = 0.01).
Between 6-12 months, patients assigned to MPP ON had a higher reduction in ESV (93.4 ± 52.3mL to 82.1 ± 40.5mL, p = 0.04) and an improvement in LVEF (38.3 ± 9.8% to 45.1 ± 11.1%, p < 0.01) compared to patients with MPP OFF (92.2 ± 47.3mL to 95.4 ± 47.5mL, p = NS; 37.1 ± 12.0% to 40.2 ± 9.2%, p = NS). Additionally, QoL of patients with MPP ON improved during follow up (EQ-5D 78.3% to 86.3%, p < 0.01; MLWHF 12.1 to 6.6, p = 0.03, 6MWT 316m to 239m, p = NS; NTproBNP 1608 ± 2450pg/mL to 775 ± 914pg/mL, p = NS) and was unchanged in MPP OFF patients (76.6% to 74.2%; MLWHF 12.7 to 12.7; 6MWT 338m to 299m, NTproBNP 1112 ± 1442pg/mL to 1383 ± 2118pg/mL, for all p = NS).
Conclusion
In our population, patients with CRT programmed with MPP ON, when compared to MPP OFF, had an improvement in the super-response rate and in quality of life. These results may be consequence from a more favorable reverse remodeling due to MPP, with a higher reduction in the LV end systolic volume.
Abstract Figure.
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Affiliation(s)
- A Nunes Ferreira
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - P S Antonio
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - I Aguiar-Ricardo
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - T Rodrigues
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - N Cunha
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - R P Santos
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - J Rigueira
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - A Bernardes
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - I Santos
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - S Goncalves
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - F J Pinto
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - J De Sousa
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
| | - P Marques
- Cardiology Department, Santa Maria University Hospital (CHULN), CAML, CCUL, Lisbon School of Medicine, Universidade de Lisboa, Portugal, Lisboa, Portugal
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