Predictors of long-term prognosis based on measurements achieved after 9-week hybrid telerehabilitation in heart failure patients – a subanalyis of the TELEREH-HF RCT

Background

Predicting prognosis in heart failure (HF) is of major importance.

The purpose of the study was to define predictors influencing long-term cardiovascular mortality or HF hospitalization (“composite outcome”) based on clinical status and measurements obtained after the 9-week hybrid comprehensive telerehabilitation (HCTR) programme.

Methods

This analysis is based on TELEREH-HF multicenter, randomized trial that enrolled 850 HF patients (NYHA I-III; left ventricular ejection fraction [LVEF]≤40%). Patients were randomized 1:1 to 9-week HCTR plus usual care (development sample) or usual care only (validation sample) and followed for 12–24 months for development of the composite.

Results

The predictors of our composite were: non-ischaemic etiology of HF, diabetes, higher serum level of: N-terminal prohormone of brain natriuretic peptide, creatinine, and high-sensitivity C-Reactive Protein; low carbon dioxide output at peak exercise, high minute ventilation and breathing frequency at maximum effort in cardiopulmonary test; increase of delta of average heart rate in 24h-ECG Holter monitoring, lower LVEF and patients' non-adherence to HCTR. The model discrimination C-index=0.795 and decreased to 0.755 on validation (Table 1). The 2-year risk of the composite was 48% in the top tertile versus 5% in the bottom tertile (Figure 1).

Conclusion

Risk factors collected at the end of the 9-week telerehabilitaion period did an excellent job in stratifying patients based on their 2-year risk of the composite outcome. Patients in the top tertile had an almost ten-fold higher risk compared to patients in the bottom tertile. Adherence to treatment but not peakVO2 or quality of life were significantly associated with the outcome.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Centre for Research and Development, Warsaw, Poland

Prognostic Impact of Hybrid Comprehensive Telerehabilitation Regarding Diastolic Dysfunction in Patients with Heart Failure with Reduced Ejection Fraction—Subanalysis of the TELEREH-HF Randomized Clinical Trial

Aims: The objective of the study was to evaluate the effects of individually prescribed hybrid comprehensive telerehabilitation (HCTR) implemented at patients’ homes on left ventricular (LV) diastolic function in heart failure (HF) patients. Methods and results: The Telerehabilitation in Heart Failure Patients trial (TELEREH-HF) is a multicenter, prospective, randomized (1:1), open-label, parallel-group, controlled trial involving HF patients assigned either to HCTR involving a remotely monitored home training program in conjunction with usual care (HCTR group) or usual care only (UC group). The patient in the HCTR group underwent a 9-week HCTR program consisting of two stages: an initial stage (1 week) conducted in hospital and the subsequent stage (eight weeks) of home-based HCTR five times weekly. Due to difficulties of proper assessment and differences in the evaluation of diastolic function in patients with atrial fibrillation, we included in our subanalysis only patients with sinus rhythm. Depending on the grade of diastolic dysfunction, patients were assigned to subgroups with mild diastolic (MDD) or severe diastolic dysfunction (SDD), both in HCTR (HCTR-MDD and HCTR-SDD) and UC groups (UC-MDD and UC-SDD). Changes from baseline to 9 weeks in echocardiographic parameters were seen only in A velocities in HCTR-MDD vs. UC-MDD; no significant shifts between groups of different diastolic dysfunction grades were observed after HCTR. All-cause mortality was higher in UC-SDD vs. UC-MDD with no difference between HCTR-SDD and HCTR-MDD. Higher probability of HF hospitalization was observed in HCTR-SDD than HCTR-MDD and in UC-SDD than UC-MDD. No differences in the probability of cardiovascular mortality and hospitalization were found. Conclusions: HCTR did not influence diastolic function in HF patients in a significant manner. The grade of diastolic dysfunction had an impact on mortality only in the UC group and HF hospitalization over a 12–24-month follow-up in HCTR and UC groups.

Relationships between physical capacity and depression in heart failure patients undergoing hybrid comprehensive telerehabilitation vs usual care results of the TELEREH-HF randomized clinical trial

Introduction

The novel hybrid comprehensive telerehabilitation (HCTR) consisting of telecare (with psychological telesupport), telerehabilitation and remote monitoring of cardiovascular implantable electronic devices might be an option to improve both physical capacity and depressive symptoms.

Purpose

The aim of the study was to investigate the influence of HCTR on depressive symptoms and physical capacity in heart failure (HF) patients in comparison with usual care (UC) alone.

Methods

The present analysis formed part of a multicenter, randomized trial that enrolled 850 HF patients (New York Heart Association class I–III, left ventricular ejection fraction ≤40%). Patients were randomized 1:1 to HCTR plus UC or UC only. Patients underwent either an HCTR program (1 week in hospital and 8 weeks at home; exercise training 5 times weekly) or UC with observation. The psychological intervention in the HCTR group included supportive psychological counseling via mobile phone. The Beck Depression Inventory II (BDI II) score (cut point for depression ≥14) was used to assess depression and the physical capacity was measured by peak oxygen consumption (peak VO2). Measurements were made before and after a 9-week intervention (HCTR group)/ observation (UC group).

Results

Both groups were comparable in terms of demographic, clinical characteristics and medical therapy. In HCTR group at entry 23% of the sample (n=88/382) obtaining BDI-II scores ≥14 vs 27.5% (n=107/389) in UC group. The BDI II score at study entry was 9.8±6.6 and after intervention was 9.2±6.6, p=0.016 (HCTR group) vs at entry 10.6±8.2 and after observation 10.0±8.3, p=0.022 (UC group). There were no significant differences between groups regarding ΔBDI II score p=0.992. There was a significant improvement in physical capacity assessed by peak VO2 only in the HCTR group, both in patients with (p=0.033) and without (p<0.001) depression (Table 1). These beneficial effects have not been observed in UC group.

Conclusions

In heart failure patients, HCTR provided similar reduction of depressive symptoms as UC. Hybrid comprehensive telerehabilitation resulted in a significant improvement in physical capacity both in patients with and without depression.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The National Centre for Research and Development, Warsaw, Poland.

Assessment of ECG during hybrid comprehensive telerehabilitation in heart failure patients – subanalysis of the TELEREHabilitation in heart failure patients – TELEREH-HF randomized clinical trial

Background

Exercise training in heart failure (HF) patients (pts) should be monitored to ensure patients safety. That is why we use ECG telemonitoring during hybrid comprehensive telerehabilitation (HCTR).

Purpose

Assessment of frequency of cardiac arrhythmias during telerehabilitation in HF patients.

Methods

The present analysis formed part of TELEREH-HF multicenter, randomized (1:1), controlled trial that enrolled 850 HF pts with New York Heart Association class I, II, or III and left ventricular ejection fraction (LVEF) of 40% or less. Patients were randomized 1:1 to 9 week HCTR plus usual care or usual care only. This subanalysis focuses on 386 pts (aged 62±11 years, LVEF 31±7%) randomized to HCTR based on Nordic walking training 5 times/week. HCTR was tele-monitored with an EHO mini device adjusted to record 16-second fragments of ECG (from three precordial leads) and to transmit the data via mobile phone network to the monitoring center. The timing of automatic ECG recording were pre-set and coordinated with exercise training.

Results

In all, 16622 HCTR sessions were registered and 66488 ECGs transmitted fragments were evaluated (four 16-second recording per patient per one session were recorded). A sinus rhythm was present in 320 (83%) pts, permanent atrial fibrillation in 66 (17%) pts. Assessment of ECG during HCTR procedure is presented in Table 1.

Conclusions

Telerehabilitation in heart failure patients is safe without evidence for symptomatic cardiac arrhythmias requiring discontinuation of training.

Non-sustained ventricular tachycardia and paroxysmal atrial fibrillation episodes were rare but have required adjustment of the telerehabilitation regimen.

The most common arrhythmias were ventricular and supraventricular premature beats.

These arrhythmias did not result in any changes in rehabilitation and therapy regimens.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The National Centre for Research and Development, Warsaw, Poland.

Pacemaker-Based Cardiac Neuromodulation Therapy in Patients With Hypertension: A Pilot Study

Background In prior unblinded studies, cardiac neuromodulation therapy (CNT) employing a sequence of variably timed short and longer atrioventricular intervals yielded sustained reductions of systolic blood pressure (SBP) in patients with hypertension. The effects of CNT on SBP were investigated in this double-blind randomized pilot study. Methods and Results Eligible patients had daytime ambulatory SBP (aSBP) ≥130 mm Hg and office SBP ≥140 mm Hg despite taking ≥1 antihypertensive medication, and an indication for a dual-chamber pacemaker. Patients underwent Moderato device implantation, which was programmed as a standard pacemaker during a 1-month run-in phase. Patients whose daytime aSBP was ≥125 mm Hg at the end of this period were randomized (1:1, double blind) to treatment (CNT) or control (CNT inactive). The primary efficacy end point was the between-group difference of the change in 24-hour aSBP at 6 months. Of 68 patients initially enrolled and who underwent implantation with the Moderato system, 47 met criteria for study continuation and were randomized (26 treatment, 21 control). The mean age was 74.0±8.7 years, 64% were men, left ventricular ejection fraction was 59.2%±5.7%, and aSBP averaged 141.0±10.8 mm Hg despite the use of 3.3±1.5 antihypertensive medications; 81% had isolated systolic hypertension. Six months after randomization, aSBP was 11.1±10.5 mm Hg (95% CI, -15.2 to -8.1 mm Hg) lower than prerandomization in the treatment group compared with 3.1±9.5 mm Hg (-7.4 to 1.2 mm Hg) lower in controls, yielding a net treatment effect of 8.1±10.1 mm Hg (-14.2 to -1.9 mm Hg) (P=0.012). There were no Moderato device- or CNT-related adverse events. Conclusions CNT significantly reduced 24-hour aSBP in patients with hypertension with a clinical indication for a pacemaker. The majority of patients had isolated systolic hypertension, a particularly difficult group of patients to treat. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02837445.

Antiarrhythmic effect of 9-week hybrid cardiac telerehabilitation - subanalysis of the TELEREHabilitation in Heart Failure patients - TELEREH-HF randomized clinical trial

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The National Centre for Research and Development, Warsaw, Poland.

Background. Cardiac rehabilitation is a component of heart failure (HF) management but its effect on ventricular arrhythmias is not well recognized.

Purpose. We analyzed the antiarrhythmic effect of a 9-week hybrid cardiac telerehabilitation (HCTR) and its influence on long term cardiovascular mortality in HF patients taken from the TELEREH-HF trial.

Methods. We evaluated the presence of non-sustained ventricular tachycardia (nsVT) and frequent premature ventricular complexes ≥10 beats/hour (PVCs ≥10) with 24-hour ECG monitoring at the baseline and after 9-week HCTR or usual care (UC) of 773 HF patients (NYHA I-III, LVEF ≤ 40%).

Results. Among 143 patients with nsVT, arrhythmia subsided in 30.8% after HCTR, similarly among 165 patients randomized to UC who had nsVT 34.5% did not show them after 9 weeks (p = 0.481). There was no significant difference in the decrease in PVC ≥10 over 9 weeks between randomization arms (14.9% vs. 17.8%, respectively p = 0.410). Functional response for HCTR (Δ peak oxygen consumption [pVO2] in cardiopulmonary exercise test >2.0 ml/kg/min) did not affect occurrence of arrhythmias. The multivariable analysis of the entire population did not identify HCTR as an independent factor determining improvement in terms of nsVT or PVCs >10.  However, only in the HCTR group, the achievement of the antiarrhythmic effect significantly reduced the cardiovascular mortality in 2 years follow-up (Logrank p = 0.0009) (Figure).

Conclusions. Significant improvement in physical capacity after 9 weeks of HCTR did not correlate with the antiarrhythmic effect in terms of  incidence of nsVT or PVCs ≥10. An antiarrhythmic effect after the 9-week HCTR affected long term cardiovascular mortality in HF patients. Abstract Figure

Effects of a 9-Week Hybrid Comprehensive Telerehabilitation Program on Long-term Outcomes in Patients With Heart Failure: The Telerehabilitation in Heart Failure Patients (TELEREH-HF) Randomized Clinical Trial

Importance

Guidelines recommend exercise training as a component of heart failure management. There are large disparities in access to rehabilitation, and introducing hybrid comprehensive telerehabilitation (HCTR) consisting of remote monitoring of training at patients' homes might be an appealing alternative.

Objective

To assess whether potential improvements in quality-of-life outcomes after a 9-week HCTR intervention in patients with heart failure translate into improvement in clinical outcomes during extended 12 to 24 months of follow-up, compared with usual care.

Design, Setting, and Participants

The Telerehabilitation in Heart Failure Patients (TELEREH-HF) trial is a multicenter, prospective, open-label, parallel-group randomized clinical trial that enrolled 850 patients with heart failure up to 6 months after a cardiovascular hospitalization with New York Heart Association levels I, II, or III and left ventricular ejection fraction of 40% or less. Patients from 5 centers in Poland were randomized 1:1 to HCTR plus usual care or usual care only and followed up for 14 to 26 months after randomization.

Interventions

During the first 9 weeks, patients underwent either an HCTR program (1 week in hospital and 8 weeks at home) or usual care with observation. The HCTR intervention encompassed telecare, telerehabilitation, and remote monitoring of implantable devices. No intervention occurred in the remaining study period.

Main Outcomes and Measures

The percentage of days alive and out of the hospital from randomization through the end of follow-up at 14 to 26 months.

Results

A total of 850 patients were enrolled, with 425 randomized to the HCTR group (377 male patients [88.7%]; mean [SD] age, 62.6 [10.8] years) and 425 randomized to usual care (376 male patients [88.5%]; mean [SD] age, 62.2 [10.2] years). The HCTR intervention did not extend the percentage of days alive and out of the hospital. The mean (SD) days were 91.9 (19.3) days in the HCTR group vs 92.8 (18.3) days in the usual-care group, with the probability that HCTR extends days alive and out of the hospital equal to 0.49 (95% CI, 0.46-0.53; P = .74) vs usual care. During follow-up, 54 patients died in the HCTR arm and 52 in the usual-care arm, with mortality rates at 26 months of 12.5% vs 12.4%, respectively (hazard ratio, 1.03 [95% CI, 0.70-1.51]). There were also no differences in hospitalization rates (hazard ratio, 0.94 [95% CI, 0.79-1.13]). The HCTR intervention was effective at 9 weeks, significantly improving peak oxygen consumption (0.95 [95% CI, 0.65-1.26] mL/kg/min vs 0.00 [95% CI, -0.31 to 0.30] mL/kg/min; P < .001) and quality of life (Medical Outcome Survey Short Form-36 questionnaire score, 1.58 [95% CI, 0.74-2.42] vs 0.00 [95% CI, -0.84 to 0.84]; P = .008), and it was well tolerated, with no serious adverse events during exercise.

Conclusions and Relevance

In this trial, the positive effects of a 9-week program of HCTR in patients with heart failure did not lead to the increase in percentage of days alive and out of the hospital and did not reduce mortality and hospitalization over a follow-up period of 14 to 26 months.

Trial Registration

ClinicalTrials.gov identifier: NCT02523560.

Heart failure patients' adherence to hybrid comprehensive telerehabilitation and its impact on prognosis based on data from TELEREH-HF randomized clinical trial

Background

Adherence to treatment guidelines in heart failure (HF) patients (pts) is of major prognostic importance, but thorough implementation of guidelines in routine care remains insufficient. Introducing hybrid comprehensive telerehabilitation (HCTR) consisting of telecare, telerehabilitation and remote monitoring of implantable devices might be an option to improve adherence to recommendation and can affect the prognosis. Purpose to investigate the association of adherence to HCTR with mortality and hospitalization. Methods The present analysis formed part of TELEREH-HF multicenter, randomized trial that enrolled 850 HF pts (NYHA I-III,LVEF≤40%). Patients were randomized 1:1 to HCTR plus usual care or usual care only and followed up for 14 to 26 months. During the first 9 weeks, pts underwent either an HCTR (1 week in hospital and 8 weeks at home) or usual care. This analysis focuses on pts randomized to HCTR. Adherent pts were those who adhered both to the number of training sessions prescribed and to the duration of the prescribed cycle by at least80%; non-adherent pts, were those who adhered&lt;20% to the prescribed number of training sessions and their duration. The remaining pts were classified as partially adherent.

Results

There were 350 (88.4%) adherent pts, 39 (9.8%) partially adherent pts and 7 (1.8%) non-adherent pts. There were 54 deaths during follow-up in the HCTR arm. Non-adherence or partial adherence was associated with statistically significantly higher risk of cardiovascular (CV) mortality (hazard ratio (HR) = 2.62, p=0.021); all-cause mortality or HF hospitalization (HR=1.71, p=0.038); CV mortality or HF hospitalization (HR=1.89, p=0.014).

Conclusion

The adherence to HCTR was very high. Adherence to HCTR was associated with improved prognosis for CV mortality.

Kaplan-Meier Probability of CV Mortality

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Centre for Research and Development, Warsaw, Poland

Quality of life in heart failure patients undergoing hybrid comprehensive telerehabilitation versus usual care results of TELEREH-HF randomized clinical trial

Background

Heart failure (HF) is a clinical syndrome associated with physical capacity impairment and poor quality of life (QoL). The hybrid comprehensive telerehabilitation (HCTR) consisting of telecare, telerehabilitation and homemonitoring of implantable devices might be an option to improve QoL. Purpose to investigate the influence of HCTR on various facets of QoL in HF pts in comparison to usual care (UC).

Methods

The present analysis formed part of TELEREH-HF multicenter, randomized trial that enrolled 850 HF pts (NYHA I-III, LVEF≤40%). Patients were randomized 1:1 to HCTR plus UC or UC. Patients underwent either an HCTR (1 week in hospital and 8 weeks at home) or UC with observation. The psychology telecare had a form of supportive psychotherapy via phone. The Short Form 36 Questionnaire was used to assess QoL. Measurements were made before and after intervention/observation.

Results

HCTR group showed significant improvement in overall QoL, physical domain, and 4 areas of QoL (physical functioning [PF], role functioning related to physical state, general health, vitality). A significant positive change in QoL in UC group was observed in vitality and social functioning. There were significant differences in QoL after intervention/observation between groups. Results showed higher improvement in HCTR for overall QoL, physical domain and 3 areas of QoL (PF, role functioning related to physical state and bodily pain [BP]), Table 1.

Conclusion

In comparison to UC, HCTR resulted in significant improvement in overall QoL, physical domain and 3 specific areas of QoL: PF, role functioning related to physical state and BP.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Centre for Research and Development, Warsaw, Poland

10-year outcomes of triple-site versus standard cardiac resynchronization therapy randomized trial (TRUST CRT)

Background

Triple-Site versus Standard Cardiac Resynchronization Therapy Randomized Trial (TRUST CRT) was initiated in 2009 to verify the hypothesis whether triple-site (single right, double left) cardiac resynchronization therapy (CRT) may be superior to conventional, biventricular resynchronization in patients with advanced heart failure.

Objectives

To report 6-month outcomes and 10-year survival in TRUST CRT.

Methods

100 consecutive patients with moderate to severe heart failure, ejection fraction of 35% or less, electrical and mechanical dyssynchrony, were randomly assigned in a 1:1 fashion to triple-site CRT defibrillator (TRIV) or to conventional CRT-D. The primary objective evaluated response-rate, defined as the 6-month's combined end point of alive status, freedom from hospitalization for heart failure or heart transplantation, relative≥10% increase in ejection fraction, ≥10% in peak oxygen consumption, and ≥10% in 6-minute walking distance. The secondary objective was to assess the occurrence of major adverse cardiovascular events (hospitalization for exacerbated heart failure requiring modification of pharmacotherapy, heart transplant or death) at month 6 and during remote observation.

Results

At month 6, the response-rate was higher in triple-site than conventional CRT-D group (51.1 vs. 26.5%, P=0.014). There were 2 deaths or heart failure events in the triple-site group (4%) as compared with 8 in the group assigned to conventional CRT-D (16%). A triple-site resynchronization resulted in 12% absolute risk reduction for secondary end point (hazard ratio 0.25; 95 percent confidence interval, 0.05 to 1.17, P=0.056, in comparison with the conventional CRT-D group). After 10 years of observation (median follow up of 7.1 years; range: 1.2–10.4) 57 patients (58.2%) died: 24 (53.3%) in the triple-site group, 31 (60.8%) in the conventional group (P=0.46) and 2 patients with and ICD (failed CRT implantation) [Figure].

Conclusions

In patients with advanced heart failure, triple-site resynchronization combined with an ICD did not result in better survival than conventional resynchronization therapy in a median observation of 7.1 years.

Figure 1

Funding Acknowledgement

Type of funding source: None

Ferritin as a potential biomarker of efficacy of treatment of atrial fibrillation - preliminary report

BACKGROUND

Complex mechanisms of responsible for originating and maintaining of atrial fibrillation (AF) are involved in pathophysiology of this arrhythmia. Inflammation substantially contribute to arrhythmic remodelling of atrial tissue.The aim of the present study is to assess an applicability of ferritin and high sensitive C-reactive protein (hs-CRP) as biomarkers of atrial fibrillation and their usefulness in evaluation of efficacy of cryoablation.

MATERIALS AND METHODS

The study population consisted of 40 patients who underwent first AF cryoablation procedure. The whole follow-up time was for 6 months. The efficacy of cryoablation was defined as lack of episodes of AF longer than 30 s reported either in patient's medical documentation or present in standard or Holter ECG records. Concentrations of hs-CRP (latex method ) and ferritin (immunochemical method) were determined in standard way in hospital laboratory.

RESULTS

The recurrence of atrial fibrillation during follow-up was detected in 7 of 40 patients (efficacy 82.5%). Basal concentrations of hs-CRP and ferritin were significantly higher in patients who underwent ablation during AF. Ablation resulted in an increase of either hs-CRP or ferritin concentrations. After seven days, both hs-CRP and ferritin concentrations returned to basal level. The trend toward the higher concentration of hs-CRP was observed in AF recurrence subgroup in 30th and the 90th day after the procedure. Ferritin concentrations were significantly higher in recurrence subgroup after 30 and 90 days.

CONCLUSION

Our results suggest that the evaluation of ferritin serum level can be a potential tool for assessment of AF treatment efficacy.

Prognostic value of collagen turnover biomarkers in cardiac resynchronization therapy: A subanalysis of the TRUST CRT randomized trial population

BACKGROUND

A substantial proportion of patients do not respond to cardiac resynchronization therapy (CRT). Various echocardiographic and biochemical markers including collagen turnover biomarkers were suggested to predict CRT results. However, pathological significance of collagen turnover biomarkers in CRT remains controversial.

OBJECTIVE

The aim of the present study was to evaluate the relationship between levels of collagen turnover biomarkers (amino-terminal propeptide of procollagen type I and amino-terminal propeptide of procollagen type III [PIIINP]), N-terminal of the prohormone brain natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein, and matrix metalloproteinases (metalloproteinase-2 and metalloproteinase-9) and echocardiographic response to CRT and clinical outcomes.

METHODS

The study population consisted of patients enrolled in the Triple Site Versus Standard Cardiac Resynchronization Therapy trial. Blood samples were obtained before implantation of a CRT with defibrillator. The levels of PIIINP, amino-terminal propeptide of procollagen type I, metalloproteinase-2, and metalloproteinase-9 were determined using commercially available ELISA kits. High-sensitivity C-reactive protein and NT-proBNP levels were determined in a standard way.

RESULTS

Samples were collected from 74 of 100 enrolled patients. The multivariate logistic regression analysis demonstrated that low PIIINP levels (odds ratio [OR] 3.56; 95% confidence interval [CI] 1.23-10.24; P = .017) and baseline ejection fraction (OR 2.14; 95% CI 1.11-4.11; P = .02) were favorably associated with echocardiographic response. PIIINP and NT-proBNP levels appeared to be independent predictors of all-cause mortality (PIIINP: OR 3.11; 95% CI 1.21-7.89; P = .033; NT-proBNP: OR 2.05; 95% CI 1.11-4.96; P = .039) and risk of major cardiac adverse event (PIIINP: OR 3.56; 95% CI 1.53-9.15; P = .007; NT-proBNP: OR 4.51; 95% CI 1.75-11.6; P = .001). PIIINP levels showed significant additive value in predicting mortality as compared with NT-proBNP levels, but they were not superior to ejection fraction in predicting response. Survival analysis with cutoff values identified by receiver operating characteristic analysis confirmed a significant benefit associated with low baseline PIIINP levels.

CONCLUSION

Low PIIINP levels are associated with favorable echocardiographic response and long-term survival in CRT recipients.

Transseptal versus transaortic approach for radiofrequency ablation in patients with cardioverter-defibrillator and electrical storm

PURPOSE

Radiofrequency current ablation (RFCA) of ventricular tachycardia (VT) is usually performed using a retrograde transaortic approach. We compared the mapping accuracy, procedural course, safety, and results of VT ablation using transseptal and transaortic route.

METHODS

Twenty-one consecutive patients with ischemic cardiomyopathy and history of electrical storm underwent RFCA with electro-anatomic mapping system. In six patients, ablation was performed with transseptal approach (transseptal group); in 15, retrograde approach to the left ventricle was used (retrograde group).

RESULTS

The endocardial surface of the left ventricle was similarly accessible in both methods. Less detailed maps of interventricular septum were constructed with the use of transseptal approach. The RFCA success rate was similar in the transseptal and retrograde groups (83 vs. 80%, p = NS). The median procedural time was 112 min in transseptal vs. 145 min in the retrograde group; radiation exposure was 200 vs. 67 mGy, respectively (both p < 0.05), and fluoroscopy time was 22 vs.16 min (p = NS). During the 3-month follow-up, VT recurrence occurred in one patient in the transseptal group and in three patients in the retrograde group (p = NS).

CONCLUSIONS

Transseptal approach is an accurate, safe, feasible, and effective method of RF ablation in patients with malignant, recurrent ventricular arrhythmias. However, limited access to the septal regions with the use of this method has to be remembered. Transseptal approach may be considered as an alternative to the transaortic route in patients with contraindication to the latter.

Triple-site biventricular pacing in patients undergoing cardiac resynchronization therapy: a feasibility study

AIMS

To evaluate implantation safety and efficiency of triple-site (double left-single right) cardiac resynchronization therapy (CRT) and to assess the outcome of this procedure.

METHODS AND RESULTS

Twenty-six patients with New York Heart Association (NYHA) class III-IV, left ventricular ejection fraction (EF) < or = 35%, and QRS > or = 120 ms underwent triple-site CRT. Procedural course and complications were analysed. NYHA class, QRS duration, echocardiographic parameters, peak oxygen consumption (VO(2)max), and 6 min walking distance (6MWD) were assessed at baseline and after 3 months. Responders were defined by survival, by no re-hospitalization for heart failure, and by >10% EF, VO(2)max, and 6MWD increase. Implantation was successful in 22 patients (84.6%). Procedure duration (199.1 min) and fluoroscopy time (38.7 min) were higher than in standard procedures. Two clinically silent coronary sinus dissections occurred intra-operatively; one phrenic nerve stimulation and one pocket infection were observed during follow-up. After 3 months of CRT, a significant reduction (P < 0.05) of NYHA class, increment of VO(2)max, 6MWD, EF, and improvement of indices of dyssynchrony were observed. Response rate in the studied group was 95.4%.

CONCLUSION

Triple-site resynchronization appears to be a safe and efficient treatment method, with high response rate. Further studies are needed to evaluate the role of this pacing mode in CRT.

Genetic and environmental correlation and path coefficient analysis of fruit yield per bush and other traits in black currants (Ribes nigrum L.)

Twenty-five F1 hybrid families of black currants (Ribes nigrum L.) originating from diallel crosses of five cultivars were assessed. Phenotypic correlation coefficient between full-sib family means (rFS), genetic correlation coefficient between full-sib family expected values (rG) and the environmental correlation were estimated on the basis of two years of observations for 12 quantitative characteristics studied. Evident repeatability of correlations in both years was proved. A considerable consistency between the values of genetic and phenotypic correlation coefficients was also observed. Coefficients of phenotypic and environmental correlation were significant for many pairs of traits. Most of the significant environmental correlation coefficients were found for the same pairs of characteristics for which phenotypic correlation coefficients were significant. This shows that genetic and environmental factors affected similar traits. Fruit yield expressed the largest number of significant correlations with other traits. Path coefficient analysis indicated that plant and berry size were the main factors influencing directly fruit yield in both years. It was proved that the number and length of one-year-old shoots via bush size had very large indirect effects on fruit yield per plant.