The extent of the raphe in bicuspid aortic valves is associated with aortic regurgitation and aortic root dilatation

Background

The clinical course of bicuspid aortic valves (BAVs) is variable. Data on predictors of aortopathy and valvular dysfunction mainly focus on valve morphology.

Aim

To determine whether the presence and extent of the raphe (fusion site of valve leaflets) is associated with the degree of aortopathy and valvular dysfunction in patients with isolated BAV and associated aortic coarctation (CoA).

Methods

Valve morphology and aortic dimensions of 255 BAV patients were evaluated retrospectively by echocardiography.

Results

BAVs with a complete raphe had a significantly higher prevalence of valve dysfunction (especially aortic regurgitation) than BAVs with incomplete raphes (82.9 vs. 66.7 %, p = 0.01). Type 1A BAVs (fusion of right and left coronary leaflets) and complete raphe had larger aortic sinus diameters compared with the rest of the population (37.74 vs. 36.01, p = 0.031). Patients with CoA and type 1A BAV had significantly less valve regurgitation (13.6 vs. 55.8 %, p < 0.001) and smaller diameters of the ascending aorta (33.7 vs. 37.8 mm, p < 0.001) and aortic arch (25.8 vs. 30.2 mm, p < 0.001) than patients with isolated BAV.

Conclusions

Type 1A BAV with complete raphe is associated with more aortic regurgitation and root dilatation. The majority of CoA patients have incomplete raphes, associated with smaller aortic root diameters and less valve regurgitation.     

Cardiopulmonary exercise test predicts sustained ventricular arrhythmias in chronic heart failure

Background

The cardiopulmonary exercise test (CPX) is an affordable tool for risk prediction in patients with chronic heart failure (CHF). We aimed to determine the role of CPX parameters in predicting the risk of incidence of sustained ventricular arrhythmias (SVA) in CHF.

Methods

Sixty-one consecutive patients with CHF enrolled in the Daunia Heart Failure Registry underwent CPX and were followed for 327 ± 247 days. Clinical follow-up was performed every month and anticipated in case of re-hospitalisation for cardiac disease. Incidence of SVA was evaluated by direct clinical examination (ECG, ambulatory ECG).

Results

Patients with episodes of SVA (N 14) showed lower values of pVO2 and PetCO2, and higher values of VE/VCO2, VE/VCO2 slope, and VE%. After correction for age, gender, diabetes, ischaemic heart disease and left ventricular ejection fraction, peak VO2 (hazard ratio (HR) 0.68, 95 % confidence interval (CI) 0.51–0.91, p < 0.05), VE% (HR 1.38, 95 % CI 1.04–1.84, p < 0.05), VE/VCO2 (HR 1.38, 95 % CI 1.04–1.82, p < 0.05), VE/VCO2 slope (HR 1.77, 95 % CI 1.31–2.39, p < 0.01), PetCO2 (HR 0.66, 95 % CI 0.50–0.88, p < 0.01) were found as predictors of SVA. At Kaplan-Meier analysis, lower event-free rates were found in subjects with peak VO2 values below median (log rank p < 0.05), values of VE/VCO2 above mean (p < 0.05), higher VE/VCO2 slope tertiles (p <0.05), and values of PetCO2 below median (p < 0.05).

Conclusions

CPX provides prognostic independent information for risk of SVA in subjects with CHF.     

Benefits of an open access echocardiography service: a Dutch prospective cohort study

Background

Open access echocardiography has been evaluated in the United Kingdom, but hardly in the Netherlands. The echocardiography service of the SHL-Groep in Etten-Leur was set up independently from the regional hospitals. Cardiologists not involved in the direct care of the participating patients evaluated the echocardiograms taken by ultrasound technicians.

Aims

We estimated the reduction in the number of referrals to regional cardiologists, the adherence of the general practitioners (GPs) to the advice of the evaluating cardiologist, GPs’ opinion on the benefit of the echocardiography service and GPs’ adherence to the diagnostic protocol advocated in the Dutch clinical guideline for heart failure.

Methods

A prospective cohort study was performed. Patients were included from April 2011 to April 2012 (N = 155). Data from application forms (N = 155), echocardiography results (N = 155) and telephone interviews with GPs (N = 138) were analysed.

Results

GPs referred less patients to the cardiologist than they would have done without echocardiography available (92 % vs. 34 %, p < 0.001). They treated more patients by themselves (62 % vs. 10 %, p < 0.001). Most GPs (81 %) followed the advice presented on the echocardiogram result. Most GPs (82 %) found the service had clinical benefit for the patient. Sixty two percent of echocardiography requests met the criteria of the Dutch clinical guideline for heart failure.

Conclusion

Open access echocardiography saved referrals to the cardiology department, saved time, and enabled GPs to treat more patients by themselves. Adherence to diagnostic guidelines for heart failure was suboptimal.     

Treatment with atorvastatin is associated with a better prognosis in chronic heart failure with systolic dysfunction: results from The Daunia Heart Failure Registry

Background

Few works have evaluated the effect of statins on left ventricular dysfunction in patients with chronic heart failure (CHF), by using tissue Doppler imaging (TDI). We therefore aimed to investigate whether atorvastatin treatment may influence prognosis and myocardial performance evaluated by TDI in subjects with CHF.

Methods

Five hundred thirty-two consecutive CHF outpatients enrolled in a local registry, the Daunia Heart Failure Registry, were prospectively analysed. 195 patients with CHF and left ventricular ejection fraction (LVEF) ≤40 %, either in treatment with atorvastatin (N: 114) or without statins (N: 81), underwent TDI examination. Adverse events were evaluated during follow-up.

Results

The atorvastatin group showed a lower incidence of adverse events (cardiac death: 0 % vs 7 %, p < 0.01), and better TDI performance (E/E’ 15 ± 5.7 vs 18 ± 8.3, p < 001) than controls. Ischaemic CHF patients in treatment with atorvastatin also showed a lower incidence of adverse events (death: 10 % vs 26 %, p < 0.05; sustained ventricular arrhythmias: 5 % vs 19 %, p < 0.05, cardiac death: 0 vs 8 %, p < 0.05) and better TDI performance (E/E’ ratio: 15.00 ± 5.68 vs 19.72 ± 9.14, p < 0.01; St: 353.70 ± 48.96 vs 303.33 ± 68.52 msec, p < 0.01) than controls. The association between atorvastatin and lower rates of cardiac death remained statistically significant even after correction in a multivariable analysis (RR 0.83, 95 % CI 0.71–0.96, p < 0.05 in CHF with LVEF ≤40 %; RR 0.77, 95 % CI 0.62–0.95, p < 0.05 in ischaemic CHF with LVEF ≤40 %).

Conclusions

Treatment with atorvastatin in outpatients with systolic CHF is associated with fewer cardiac deaths, and a better left ventricular performance, as assessed by TDI.     

Statins Do Not Reduce Atrial Fibrillation After Cardiac Valvular Surgery: A Single Centre Observational Study

Introduction

Statins may theoretically reduce postoperative atrial fibrillation (AF) in patients after cardiac valvular surgery due to preservation of endothelial function and anti-ischaemic, anti-inflammatory and anti-remodelling effects.

Methods

Two hundred seventy-two patients who underwent cardiac workup and subsequently cardiac valvular surgery without AF and concomitant coronary artery bypass grafting (CABG) at our hospital were selected. Preoperative drug use and postoperative AF were recorded. AF was defined as any episode of AF longer than 10 s. In addition, results from echocardiography and blood samples were retrieved.

Results

Baseline characteristics were as follows: mean age was 65 ± 11 years, 142 (52%) patients were male, 189 (70%) had undergone aortic valve surgery and the mean left ventricular ejection fraction was 57 ± 12%. Statins were used by 79 patients (29%). Statin users, more often, had a prior percutaneous coronary intervention (25% vs 9%, p < 0.001) or CABG (24% vs 4%, p < 0.001), diabetes mellitus (22% vs 5%, p < 0.001) and more often used β-blockers (51% vs 24%, p < 0.001). Patients in the non-statin group more often had surgery on more than one valve (10% vs 3%, p = 0.043) and had a higher cholesterol level (222 ± 48 vs 190 ± 43 mg/dl, p < 0.001). Postoperative AF occurred in 54% (43/79) of the patients with and in 55% (106/193) of the patients without statins (p = 0.941). There was also no difference in the timing of onset of AF or duration of hospital stay.

Conclusion

In this observational study, statin use was not associated with a reduced incidence of AF in patients after cardiac valvular surgery.     

Predictors of outcome after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy. Special interest for the septal coronary anatomy

Background

Alcohol septal ablation (ASA) provides symptomatic relief in most but not all patients with hypertrophic obstructive cardiomyopathy (HOCM). Therefore we investigated predictors of outcome after ASA.

Methods

Clinical, echocardiographic, angiographic and procedural characteristics were analysed in 113 consecutive patients. Successful ASA was defined as NYHA ≤ 2 with improvement of at least 1 class combined with a resting gradient < 30 mmHg and provoked gradient < 50 mmHg at 4-month follow-up.

Results

In 37 patients ASA was not successful. In multivariate analysis, baseline gradient (OR 1.06 (1.01–1.11) per 5 mmHg, p = 0.024) and distance to the ablated septal branch (OR 1.09 (1.03–1.16) per mm, p = 0.004) were predictors of unsuccessful outcome. The combined presence of a non-ablated septal branch and a distance ≥ 19 mm to the ablated branch was a predictor of unsuccessful outcome (OR 5.88 (2.06–16.7), p < 0.001).

Conclusions

Baseline gradient and a greater distance from the origin of the left anterior descending artery to the ablated septal branch combined with a non-ablated proximal septal branch are associated with an unsuccessful outcome after ASA.     

The risk of ventricular arrhythmias in a Dutch CRT population: CRT-defibrillator versus CRT-pacemaker

Background

Patients eligible for cardiac resynchronisation therapy (CRT) have an indication for primary prophylactic implantable cardioverter defibrillator (ICD) therapy. However, response to CRT might influence processes involved in arrhythmogenesis and therefore change the necessity of ICD therapy in certain patients.

Method

In 202 CRT-defibrillator patients, the association between baseline variables, 6-month echocardiographic outcome (volume response: left ventricular end-systolic volume decrease < ≥15 % and left ventricular ejection fraction (LVEF) ≤ >35 %) and the risk of first appropriate ICD therapy was analysed retrospectively.

Results

Fifty (25 %) patients received appropriate ICD therapy during a median follow-up of 37 (23–52) months. At baseline ischaemic cardiomyopathy (hazard ratio (HR) 2.0, p = 0.019) and a B-type natriuretic peptide level > 163 pmol/l (HR 3.8, p < 0.001) were significantly associated with the risk of appropriate ICD therapy. After 6 months, 105 (52 %) patients showed volume response and 51 (25 %) reached an LVEF > 35 %. Three (6 %) patients with an LVEF > 35 % received appropriate ICD therapy following echocardiography at ± 6 months compared with 43 patients (29 %) with an LVEF ≤ 35 % (p = 0.001). LVEF post-CRT was more strongly associated to the risk of ventricular arrhythmias than volume response (LVEF > 35 %, HR 0.23, p = 0.020).

Conclusion

Assessing the necessity of an ICD in patients eligible for CRT remains a challenge. Six months post-CRT an LVEF > 35 % identified patients at low risk of ventricular arrhythmias. LVEF might be used at the time of generator replacement to identify patients suitable for downgrading to a CRT-pacemaker.     

Prevalence of psychological distress in elderly hypertension patients in primary care

Background

Recent guidelines on cardiovascular disease prevention advocate the importance of psychological risk factors, as they contribute to the risk of developing cardiovascular disease. However, most previous research on psychological distress and cardiovascular factors has focused on selected populations with cardiovascular disease.

Aim

The primary aim was to determine the prevalence of depression, anxiety, and Type D personality in elderly primary care patients with hypertension. Secondary aim was to examine the relation between elevated systolic blood pressure and depression, anxiety, and Type D personality.

Design and Setting

A cross-sectional study in primary care practices located in the south of the Netherlands.

Method

Primary care hypertension patients (N = 605), between 60 and 85 years (45 % men, mean age = 70 ± 6.6), were recruited for this study. All patients underwent a structured interview including validated self-report questionnaires to assess depression (PHQ-9), anxiety (GAD-7), and Type D personality (DS14) as well as blood pressure assessment.

Results and Conclusion

Depression was prevalent in 5 %, anxiety in 5 %, and Type D personality in 8 %. None of the distress measures were associated with elevated systolic blood pressure of >160 mmHg (all p-values >0.05). This study showed no relation between psychological distress and elevated systolic blood pressure in elderly primary care patients with hypertension.     

Out-of-hospital cardiac arrest: the prospect of E-CPR in the Maastricht region

Aim

The current outcome of out-of-hospital cardiac arrest (OHCA) patients in the Maastricht region was analysed with the prospect of implementing extracorporeal cardiopulmonary resuscitation (E-CPR).

Methods

A retrospective analysis of adult patients who were resuscitated for OHCA during a 24-month period was performed.

Results

195 patients (age 66 [57–75] years, 82 % male) were resuscitated for OHCA by the emergency medical services and survived to admission at the emergency department. Survival to hospital discharge was 46.2 %. Notable differences between non-survivors and survivors were observed and included: age (70 [58–79] years) vs. (63 [55–72] years, p = 0.01), chronic heart failure (18 vs. 7 %, p = 0.02), shockable rhythm (67 vs. 99 %, p < 0.01), and return of spontaneous circulation (ROSC) at departure from the site of the arrest (46 vs. 99 %, p < 0.01) and on arrival to the emergency department (43 vs. 98 %, p < 0.01), respectively. Acute coronary syndrome was diagnosed in 32 % of non-survivors vs. 59 % among survivors, p < 0.01. Therapeutic hypothermia was provided in non-survivors (20 %) vs. survivors (43 %), p < 0.01. Percutaneous coronary intervention (PCI) was performed in 14 % of non-survivors while 52 % of survivors received PCI (p < 0.01). No statistical significance was observed in terms of gender, witnessed arrest, bystander CPR, or automated external defibrillator deployed among the cohort. At hospital discharge, moderately severe neurological disability was present in six survivors.

Conclusion

These observations are compatible with the notion that a shockable rhythm, ROSC, and post-arrest care improve survival outcome. Potentially, initiating E-CPR in the resuscitation phase in patients with a shockable rhythm and no ROSC might serve as a bridge to definite treatment and improve survival outcome.     

Plasma levels of alpha-1-antichymotrypsin are elevated in patients with chronic heart failure,but are of limited prognostic value

Background

There is increasing interest in utilising novel markers of cardiovascular disease risk in patients with chronic heart failure (HF). Recently, it was shown that alpha-1-antichymotrypsin (ACT), an acute-phase protein and major inhibitor of cathpesin G, plays a role in the pathophysiology of HF and may serve as a marker for myocardial distress.

Objective

To assess whether ACT is independently associated with long-term mortality in chronic HF patients.

Methods

ACT plasma levels were categorised into quartiles. Survival times were analysed using Kaplan-Meier curves and Cox proportional hazards regression, without and with correction for clinically relevant risk factors, including sex, age, duration of HF, kidney function (MDRD), ischaemic HF aetiology and NT-proBNP.

Results

Twenty healthy individuals and 224 patients (mean age 71 years, 72 % male, median HF duration 1.6 years) with chronic HF were included. In total, 159 (71 %) patients died. The median survival time was 5.3 (95 % CI 4.5–6.1) years. ACT was significantly elevated in patients (median 433 μg/ml, IQR 279–680) in comparison with controls (median 214 μg/ml, IQR 166–271; p < 0.001). Cox regression analysis demonstrated that ACT was not independently related to long-term mortality in chronic HF patients (crude HR = 1.03, 95 % CI 0.75–1.41, p = 0.871; adjusted HR = 1.12, 95 % CI 0.78–1.60, p = 0.552), which was confirmed by Kaplan-Meier curves.

Conclusion

ACT levels are elevated in chronic HF patients, but no independent association with long-term mortality can be established.     

Incidence of lead dislodgement,malfunction and perforation during the first year following device implantation

Background

The number of cardiac rhythm device implantations has been growing fast due to expanding indications and ageing of the population. Complications of implantation were rare in the trials. However, these involved small numbers and selected patients. Prospective real-life data are necessary to assess cardiac device implantation procedure-related risks.

Objective

To determine the incidence and predictors of lead-related re-intervention in a Dutch high-volume teaching hospital.

Methods

Data from all patients who underwent cardiac rhythm device implantation between January 2010 and December 2011 were collected in a prospective registry. At least 1 year of follow-up regarding re-intervention was available for all patients. Lead-related reasons for re-intervention were categorised into lead dislodgement, malfunctioning or perforation.

Results

One thousand nine hundred twenty-nine devices including 3909 leads were implanted. In 595 patients (30.8 %) a CRT-D/P was implanted. Lead-related re-intervention was necessary in 86 (4.4 %) patients; it was more common in younger and male patients, and due to either lead dislodgement (66 %), malfunctioning (20 %) or perforation (18 %). Coronary sinus lead dislodgement or malfunctioning was 1.4 %. Right atrial dislodgement (1.9 %, p < 0.001) or ICD lead dislodgement (1.8 %, p = 0.002) was more common than right ventricular dislodgement (0.3 %). The incidence of lead malfunctioning was higher (0.8 %) in ICD leads. An apical position of the right ventricular lead and lateral wall position of the right atrial lead were related to cardiac perforation.

Conclusions

The incidence of lead-related re-intervention was comparable with the literature. The majority of re-interventions were due to lead dislodgements, particularly with right atrial and ICD leads. Re-intervention due to coronary sinus lead dislodgement was rare.     

Ethnic differences in ventricular hypertrabeculation on cardiac MRI in elite football players

Purpose

Left ventricular (LV) trabeculation may be more pronounced in ethnic African than in Caucasian (European) athletes, leading to possible incorrect diagnosis of left ventricular non-compaction cardiomyopathy (LVNC). This study investigates ethnic differences in LV hypertrabeculation amongst elite athletes with cardiac magnetic resonance (CMR) and electrocardiography (ECG).

Methods

38 elite male football (soccer) players (mean age 23.0, range 19–34 years, 28/38 European, 10/38 African) underwent CMR and ECG. Hypertrabeculation was assessed using the ratio of non-compacted to compacted myocardium (NC/C ratio) on long-axis and short-axis segments. ECGs were systematically rated.

Results

No significant differences were seen in ventricular volumes, wall mass or E/A ratio, whereas biventricular ejection fraction (EF) was significantly lower in African athletes (European/African athletes LVEF 55/50 %, p = 0.02; RVEF 51/48 %, p = 0.05). Average NC/C ratio was greater in African athletes but only significantly at mid-ventricular level (European/African athletes: apical 0.91/1.00, p = 0.65; mid-ventricular 0.89/1.45, p < 0.05; basal 0.40/0.46, p = 0.67). ECG readings demonstrated no significant group differences, and no correlation between ECG anomalies and hypertrabeculation.

Conclusions

A greater degree of LV hypertrabeculation is seen in healthy African athletes, combined with biventricular EF reduction at rest. Recognition of this phenomenon is necessary to avoid misdiagnosis of LVNC.     

Patients with heart failure with preserved ejection fraction and low levels of natriuretic peptides

Aims

Heart failure with preserved ejection fraction (HFpEF) is common and its management remains difficult. B-type natriuretic peptide (BNP) levels are used to diagnose heart failure, and as an entry criterion for inclusion into trials. We investigated a population of HFpEF patients who had been randomised into a study based on clinical parameters, and compared those with low BNP levels to those with elevated BNP levels.

Methods

We examined patients who had been enrolled in the Coordinating study evaluating Outcomes of Advising and Counselling in Heart Failure (COACH), with preserved left ventricular ejection fraction (LVEF ≥ 40 %), and compared those with low BNP (< 100 pg/ml; n = 30) to those with elevated BNP (≥ 100 pg/ml; n = 127). Baseline characteristics, comorbidities, biomarkers, quality of life, and outcome parameters (hospitalisations and death) were compared between the groups. To validate our findings, we repeated all analyses for NT-proBNP (< 300 pg/ml and ≥ 300 pg/ml).

Results

Patients were similar with regard to most clinical characteristics (including age, sex, and LVEF), biomarkers, and comorbidities. In contrast, patients with a low BNP had higher body mass index levels (31 kg/m² vs. 27 kg/m²; p < 0.01) and lower cardiac troponin I (9 pg/ml vs. 15 pg/ml; p = 0.02). In addition, these patients were less frequently prescribed diuretics and beta-blockers. No differences in quality of life, heart failure related symptoms and the primary and secondary outcomes were observed between these groups. These observations were confirmed for NT-proBNP.

Conclusion

Among the patients with clinically diagnosed HFpEF, those with low BNP are strikingly similar to those with elevated BNP levels, except for BMI, which was significantly higher in these patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s12471-016-0816-8) contains supplementary material, which is available to authorized users.     

Exercise related ventricular arrhythmias are related to cardiac fibrosis in hypertrophic cardiomyopathy mutation carriers

Aims

Hypertrophic cardiomyopathy (HCM) is a frequent cause of sudden cardiac death (SCD) due to exercise-related ventricular arrhythmias (ERVA); however the pathological substrate is uncertain. The aim was to determine the prevalence of ERVA and their relation with fibrosis as determined by cardiac magnetic resonance imaging (CMR) in carriers of an HCM causing mutation.

Methods

We studied the prevalence and origin of ERVA and related these with fibrosis on CMR in a population of 31 HCM mutation carriers.

Results

ERVA occurred in seven patients (23%) who all showed evidence of fibrosis (100% ERVA(+) vs. 58% ERVA(-), p = 0.04). No ventricular tachycardia or ventricular fibrillation occurred. In patients with ERVA, the extent of fibrosis was significantly larger (8 ± 4% vs. 3 ± 4%, p = 0.02). ERVA originated from areas with a high extent of fibrosis or regions directly adjacent to these areas.

Conclusions

ERVA in HCM mutation carriers arose from the area of fibrosis detected by CMR; ERVA seems closely related to cardiac fibrosis. Fibrosis as detected by CMR should be evaluated as an additional risk factor to further delineate risk of SCD in carriers of an HCM causing mutation.     

The ethnicity-specific association of biomarkers with the angiographic severity of coronary artery disease

Background

Risk factor burden and clinical characteristics of patients with coronary artery disease (CAD) differ among ethnic groups. We related biomarkers to CAD severity in Caucasians, Chinese, Indians and Malays.

Methods

In the Dutch-Singaporean UNICORN coronary angiography cohort (n = 2033) we compared levels of five cardiovascular biomarkers: N-terminal pro-brain natriuretic peptide (NTproBNP), high-sensitivity C-reactive protein (hsCRP), cystatin C (CysC), myeloperoxidase (MPO) and high-sensitivity troponin I (hsTnI). We assessed ethnicity-specific associations of biomarkers with CAD severity, quantified by the SYNTAX score.

Results

Adjusted for baseline differences, NTproBNP levels were significantly higher in Malays than in Chinese and Caucasians (72.1 vs. 34.4 and 41.1 pmol/l, p < 0.001 and p = 0.005, respectively). MPO levels were higher in Caucasians than in Indians (32.8 vs. 27.2 ng/ml, p = 0.026), hsTnI levels were higher in Malays than in Caucasians and Indians (33.3 vs. 16.4 and 17.8 ng/l, p < 0.001 and p = 0.029) and hsTnI levels were higher in Chinese than in Caucasians (23.3 vs. 16.4, p = 0.031). We found modifying effects of ethnicity on the association of biomarkers with SYNTAX score. NTproBNP associated more strongly with the SYNTAX score in Malays than Caucasians (β 0.132 vs. β 0.020 per 100 pmol/l increase in NTproBNP, p = 0.032). For MPO levels the association was stronger in Malays than Caucasians (β 1.146 vs. β 0.016 per 10 ng/ml increase, p = 0.017). Differing biomarker cut-off levels were found for the ethnic groups.

Conclusion

When corrected for possible confounders we observe ethnicity-specific differences in biomarker levels. Moreover, biomarkers associated differently with CAD severity, suggesting that ethnicity-specific cut-off values should be considered.     

Haemolysis as a first sign of thromboembolic event and acute pump thrombosis in patients with the continuous-flow left ventricular assist device HeartMate II

Background

Despite advances in pump technology, thromboembolic events/acute pump thrombosis remain potentially life-threatening complications in patients with continuous-flow left ventricular assist devices (CF-LVAD). We sought to determine early signs of thromboembolic event/pump thrombosis in patients with CF-LVAD, which could lead to earlier intervention.

Methods

We analysed all HeartMate II recipients (n = 40) in our centre between December 2006 and July 2013. Thromboembolic event/pump thrombosis was defined as a transient ischaemic attack (TIA), ischaemic cerebrovascular accident (CVA), or pump thrombosis.

Results

During median LVAD support of 336 days [IQR: 182–808], 8 (20 %) patients developed a thromboembolic event/pump thrombosis (six TIA/CVA, two pump thromboses). At the time of the thromboembolic event/pump thrombosis, significantly higher pump power was seen compared with the no-thrombosis group (8.2 ± 3.0 vs. 6.4 ± 1.4 W, p = 0.02), as well as a trend towards a lower pulse index (4.1 ± 1.5 vs. 5.0 ± 1.0, p = 0.05) and a trend towards higher pump flow (5.7 ± 1.0 vs. 4.9 ± 1.9 L m, p = 0.06).The thrombosis group had a more than fourfold higher lactate dehydrogenase (LDH) median 1548 [IQR: 754–2379] vs. 363 [IQR: 325–443] U/L, p = 0.0001). Bacterial (n = 4) or viral (n = 1) infection was present in 5 out of 8 patients. LDH > 735 U/L predicted thromboembolic events/pump thrombosis with a positive predictive value of 88 %.

Conclusions

In patients with a CF-LVAD (HeartMate II), thromboembolic events and/or pump thrombosis are associated with symptoms and signs of acute haemolysis as manifested by a high LDH, elevated pump power and decreased pulse index, especially in the context of an infection.     

Assessment of LV ejection fraction using real-time 3D echocardiography in daily practice: direct comparison of the volumetric and speckle tracking methodologies to CMR

Aims

This study is the first to directly compare two widely used real-time 3D echocardiography (RT3DE) methods of cardiac magnetic resonance imaging (CMR) and assess their reproducibility in experienced and less experienced observers.

Methods

Consecutive patients planned for CMR underwent RT3DE within 8 h of CMR with Philips (volumetric method) and Toshiba Artida (speckle tracking method). Left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV) and end-systolic volume (LVESV) were measured using RT3DE, by four trained observers, and compared with CMR values.

Results

Thirty-five patients were included (49.7 ± 15.7 years; 55 % male), 30 (85.7 %) volumetric and 27 (77.1 %) speckle tracking datasets could be analysed. CMR derived LVEDV, LVESV and LVEF were 198 ± 58 ml, 106 ± 53 ml and 49 ± 15 %, respectively. LVEF derived from speckle tracking was accurate and reproducible in all observers (all intra-class correlation coefficients (ICC) > 0.86). LVEF derived from the volumetric method correlated well to CMR in experienced observers (ICC 0.85 and 0.86) but only moderately in less experienced observers (ICC 0.58 and 0.77) and was less reproducible in these observers (ICC = 0.55). Volumes were significantly underestimated compared with CMR (p < 0.001).

Conclusion

This study demonstrates that both RT3DE methodologies are sufficiently accurate and reproducible for use in daily practice. However, experience importantly influences the accuracy and reproducibility of the volumetric method, which should be considered when introducing this technique into clinical practice.     

Feasibility of TEE-guided stroke risk assessment in atrial fibrillation—background, aims, design and baseline data of the TIARA pilot study

Background

Antithrombotic management in atrial fibrillation (AF) is currently based on clinical characteristics, despite evidence of potential fine-tuning with transoesophageal echocardiography (TEE). This open, randomised, multicentre study addresses the hypothesis that a comprehensive strategy of TEE-based aspirin treatment in AF patients is feasible and safe.

Methods

Between 2005 and 2009, ten large hospitals in the Netherlands enrolled AF patients with a moderate risk of stroke. Patients without thrombogenic TEE characteristics were randomised to aspirin or vitamin K antagonists (VKA). The primary objective is to show that TEE-based aspirin treatment is safe compared with VKA therapy. The secondary objective tests feasibility of TEE as a tool to detect echocardiographic features of high stroke risk. This report compares randomised to non-randomised patients and describes the feasibility of a TEE-based approach.

Results

In total, 310 patients were included. Sixty-nine patients were not randomised because of non-visualisation (n = 6) or TEE risk factors (n = 63). Compared with non-randomised patients, randomised patients (n = 241) were younger (65 ± 11 vs. 69 ± 9 years, p = 0.004), had less coronary artery disease (9 vs. 20%, p = 0.018), previous TIA (1.7 vs. 7.2%, p = 0.029), AF during TEE (25 vs. 54%, p < 0.001), mitral incompetence (55 vs. 70%, p = 0.038), VKA use (69 vs. 82%, p = 0.032), had a lower mean CHADS₂ score (1.2 ± 0.6 vs. 1.6 ± 1.0, p = 0.004), and left ventricular ejection fraction (59 ± 8 vs. 56 ± 8%, p = 0.016).

Conclusions

This study shows that a TEE-based approach for fine-tuning stroke risk in AF patients with a moderate risk for stroke is feasible. Follow-up data will address the safety of this TEE-based approach.     

Characteristics of cardiac device infections in the Isala Hospital; a large volume tertiary care cardiology centre

Aims

To determine the frequency, characteristics and risk factors of cardiac device infections in the Isala Hospital.

Methods

We retrospectively studied all patients who underwent cardiac device procedures performed in the cardiac catheterisation lab and the operating room from 2010 to 2012. All patients who developed a cardiac device infection were reviewed for its characteristics.

Results

31/2026 patients developed a cardiac device infection (1.5 %). One (3.2 %) patient died within 30 days of hospitalisation. Device infection rates for procedures in the catheterisation lab and operating room were similar (p = 0.60). Positive cultures were present in 27/31 (87 %) cases. These consisted predominantly of micro-organisms that are part of the skin flora (84 %). The mean time between device procedure and infection was 14 ± 21 months (range 0–79). Cardiac device infection was significantly associated with device revision, (65 % were revisions in patients with device infection vs. 30 % revisions in patients without device infection, p = 0.011) and placement of a left ventricular lead in pacemaker implantations (59 % of patients with vs. 51 % of patients without device infection, p < 0.001).

Conclusion

The frequency of cardiac device infection was 1.5 % with a mortality of 3.2 % within 30 days, which is lower compared with other registries. Cardiac device infections were associated with device revisions and placement of left ventricular leads in pacemaker implantations.     

Prognostic value of microvolt T-wave alternans in a real-world ICD population. Twente ICD Cohort Studie (TICS)

Introduction

Survival benefit from ICD implantation is relatively low in primary prevention patients. Better patient selection is important to maintain maximum survival benefit while reducing the number of unnecessary implants. Microvolt T-wave alternans (MTWA) is a promising risk marker. In this study, we aimed to evaluate the predictive value of MTWA in ICD patients.

Methods and results

This study was a substudy of the Twente ICD Cohort Study (TICS). Patients with ischaemic or non-ischaemic left ventricular dysfunction who received an ICD following current ESC guidelines were eligible for inclusion. Exercise-MTWA was performed and classified as non-negative or negative. The primary endpoint was the composite of mortality and appropriate shock therapy. Analysis was performed in 134 patients (81 % male, mean age 62 years, mean ejection fraction 26.5 %). MTWA was non-negative in 64 %. There was no relation between non-negative MTWA testing and mortality and/or appropriate shock therapy (all p-values >0.15). Due to clinical conditions, 24 % were ineligible for testing. These patients experienced the highest risk for mortality (p < 0.01).

Conclusion

Non-negative MTWA testing did not predict mortality and/or appropriate shock therapy. Furthermore, MTWA testing is not feasible in a large percentage of patients. These ineligible patients experience the highest risk for mortality.