Hemodynamic monitoring by intracardiac impedance measured by cardiac resynchronization defibrillators: Evaluation in a controlled clinical setting (BIO.Detect HF II study)

BackgroundIn patients with cardiac resynchronization therapy defibrillators (CRT-Ds), intracardiac impedance measured by dedicated CRT-D software may be used to monitor hemodynamic changes. We investigated the relationship of hemodynamic parameters assessed by intracardiac impedance and by echocardiography in a controlled clinical setting.MethodsThe study enrolled 68 patients (mean age, 66 ± 9 years; 74% males) at 12 investigational sites. The patients had an indication for CRT-D implantation, New York Heart Association class II/III symptoms, left ventricular ejection fraction 15%–35%, and a QRS duration ≥150 ms. Two months after a CRT-D implantation, hemodynamic changes were provoked by overdrive pacing. Intracardiac impedance was recorded at rest and at four pacing rates ranging from 10 to 40 beats/min above the resting rate. In parallel, echocardiography measurements were performed. We hypothesized that a mean intra-individual correlation coefficient (r_mean) between stroke impedance (difference between end-systolic and end-diastolic intracardiac impedance) measured by CRT-D and the aortic velocity time integral (i.e., stroke volume) determined by echocardiography would be significantly larger than 0.65.ResultsThe hypothesis was evaluated in 40 patients with complete data sets. The r_mean was 0.797, with a lower confidence interval bound of 0.709. The study hypothesis was met (p = 0.007). A stepwise reduction of stroke impedance and stroke volume was observed with increasing heart rate.ConclusionsIntracardiac impedance measured by implanted CRT-Ds correlated well with the aortic velocity time integral (stroke volume) determined by echocardiography. The impedance measurements bear potential and are readily available technically, not requiring implantation of additional material beyond standard CRT-D system.     

Congenitally Corrected Transposition of Great Arteries with Severe Rhythm Disturbances

Within recent years, much scientific attention has been devoted to adults with congenital heart disease (CHD) and probable complications. Congenitally corrected transposition of the great arteries (CCTGA) is a rare, complex form of congenital heart defects. CCTGA is characterized by atrioventricular (AV) and ventriculoarterial (VA) discordance and, hence, by a physiologically normal direction of blood flow. The development of complete AV block and global ventricular dysfunction has been identified as the cause of cardiac death. Although the development of arrhythmias represents a major cause of morbidity and mortality in patients with CHD, the account of all implantations of pacemakers and implantable cardioverter defibrillators (ICD) is less than one percent. This paper presents a case of CCTGA with severe rhythm disorders, discusses probable treatment options, and offers indications of ICD implantation in patients with CHD.     

Wearable cardioverter-defibrillator (life-vest): A feasible bridging treatment in adult congenital heart disease

BackgroundWearable cardioverter-defibrillators (WCDs) are currently used in patients at temporarily heightened risk for sudden cardiac death (SCD) who are temporarily unable to receive an implantable cardioverter-defibrillator (ICD). WCD can safely record and terminate life-threatening arrhythmias through a non-invasive electrode-based system. The current clinical indications for WCD use are varied and keep evolving as experience with this technology increases.MethodsWe reviewed and explored the data behind indications for WCD use and discuss its usefulness in congenital heart disease (CHD) patients.ResultsWe considered 8 consecutive patients (mean age 35.25 years, range 18–51 years, average duration of WCD use 4 months, range 3–6 months) with complex CHD, in which a WCD was used between June 2018 and January 2022. No sustained ventricular arrhythmias requiring shocks were recorded in the observation period. No inappropriate shocks were recorded. All the patients showed a good compliance and a very high mean wear time per day (21.2 ± 1 h a day). Four patients implanted a permanent device (3 CRT-D, 1 ICD), three underwent cardiac surgery at the end of the WCD period and one is still on the waiting list for the operation.ConclusionsLarger trial could confirm the possible conceivable benefit from an extended use of the WCD in certain populations with complex CHD as in our case series, especially in patients with life-treating ventricular arrhythmias waiting for surgery for residual cardiac defects or in the early phases following the surgical/hemodynamic interventions, patients with tachycardiomyopathy expected to improve after the arrhythmias are removed and patients awaiting implantation of an ICD at high risk due to active infection.     

Use of a novel pacing mode to achieve biventricular pacing in a patient with recurrent atrial lead dislodgement after CRT-D implantation

Cardiac resynchronization therapy device (CRT-P and CRT-D) implantation has increased tremendously with increasing operator experience, eligible patients and expansion of indications. Refinements in devices and algorithms now aid physicians to improve biventricular pacing and optimize CRT. We report a case in which an interesting device program was used to achieve biventricular pacing after repeated dislodgement of the atrial lead in a patient implanted with CRT-D.     

Cardiac resynchronization therapy pacemakers versus defibrillators in older non-ischemic cardiomyopathy patients

Introduction

With the recent publication of the negative DANISH trial, the mortality benefit of the implantable cardioverter-defibrillator (ICD) has been put in question in patients with non-ischemic cardiomyopathy (NICM). Because a majority of patients in DANISH receive cardiac resynchronization therapy (CRT) devices, we investigated in the present study the survival of recipients of CRT pacemakers (CRT-P) versus CRT ICDs (CRT-D) in a cohort of older (≥75 years) NICM patients at our institution.

Occupational challenges of young adult patients with congenital heart disease

Background

Despite improved survival of adults with congenital heart disease (CHD), higher rates of unemployment and work-related problems are seen, especially among younger adults. This study was performed to gain insight into current barriers and facilitating experiences at work among young adult patients with CHD.

Methods

This qualitative study consisted of semi-structured face-to-face interviews, based on a self-constructed model from several existing models, which were held among outpatients with CHD from a large tertiary referral centre. Verbatim transcribed audio-taped data were analysed using a directed model-based content analysis approach.

Results

Fifteen patients had been interviewed when data saturation was reached. Work was important for all participants. Several barriers and facilitating factors were identified. Barriers were mostly on physical aspects and lack of opportunities for recovery. Important facilitating factors were good relationships with colleagues and employer and having sufficient opportunities for recovery. Most of these factors are also seen among patients with other chronic diseases, but with a different priority.

Conclusion

This is the first study that has identified qualitative factors at work of young adult CHD patients. Work is important to them. Challenges are dealing with the physical barriers and getting enough support from colleagues. Specific coaching or a tailored group intervention could thereby be helpful. Future research should aim at the aetiology of problems and identifying patients who would benefit most from specific coaching.     

Transvenous pacing in complex post-operative congenital heart disease guided by angiography: A case report

Transvenous pacing in patients with postoperative complex congenital heart disease (CHD) can be challenging and pose technical challenges to lead placement because of the complex anatomy, distortions produced by the surgical procedures, and the altered relationship of cardiac chambers. We describe the utility of angiography for transvenous dual chamber pacemaker implantation in a post-operative complex congenital heart disease.     

New developments in adult congenital heart disease

Congenital heart disease (CHD) affects 0.8% of live births and over the past decades technical improvements and large-scale repair has led to increased survival into adulthood of over 95% of the new-born. A new group of patients, those who survived their congenital heart defect, has emerged but late complications including heart failure, pulmonary hypertension (PH), arrhythmias, aneurysms and endocarditis appeared numerous, with a huge impact on mortality and morbidity. However, innovations over the past years have changed the landscape of adult CHD dramatically. In the diagnostic process important improvements have been made in the use of MRI, biomarkers, e‑health concepts and 3D visualisation of anatomy. Care is now concentrated in specialised centres, with a continuous emphasis on education and the introduction of weekly multidisciplinary consultations on diagnosis and intervention. Surgery and percutaneous intervention have been refined and new concepts applied, further reducing the burden of the congenital malformations. Research has matured from case series to global networks. Currently, adults with CHD are still facing high risks of early mortality and morbidity. By global collaboration and continuous education and development and innovation of our diagnostic and therapeutic arsenal, we will improve the perspectives of these young patients.

     

Long-term results of implantation of bioengineered and drug-eluting stents in patients with coronary heart disease: comparative characteristics of predictors of poor prognosis

The purpose of the investigation was to study the morphological and clinical characteristics affecting the long-term prognosis after implantation of bioengineered and drug-eluting stents in patients with coronary heart disease (CHD). The investigation covered 2362 patients with CHD. Genous bioengineered stents were implanted in 316 patients; Cypher rapamycin-eluting stents were in 2046 patients. The independent poor factor for complications was discontinuation of antiaggregatory therapy due to surgical interventions of different types in the drug-eluting stent group and stenting of extensive stenoses in the bioengineered stent group.     

Epidemiology of adult congenital heart disease: demographic variations worldwide

The population of adults with a congenital heart defect (CHD) is increasing, due to improved survival after cardiac surgery. To accommodate the specialised care for these patients, a profound interest in the epidemiology of CHD is required. The exact size of the current population of adults with CHD is unknown, but the best available evidence suggests that currently overall prevalence of CHD in the adult population is about 3000 per million. Regional differences in CHD prevalence have been described, due to both variations in incidence and in mortality. Knowledge of demographic variations of CHD may lead to new aetiological insights and may be useful for preventive therapies. Socioeconomic status, education, urbanisation, climatological factors, ethnicity and patient-related factors, such as comorbidity, lifestyle and healthcare-seeking behaviour, may play a role in CHD incidence and mortality. The higher risk of several major cardiac outcomes in males with CHD might well explain at least partly the increased mortality rate in men. Regional differences in quality of life among CHD patients have been reported and although methodological differences may play a role, sociocultural differences warrant further attention. Socioeconomic outcomes in CHD patients, such as lower education, more unemployment and less relationships, might have a different impact on quality of life in different cultures. To gain more insight into demographic differences around the world large international multicentre studies on the epidemiology of CHD are needed.     

Post-hoc analysis on the CD14 C(-260)T promoter polymorphism and coronary heart disease

Functional C(-260)--> T polymorphism in the promoter of the CD14 gene has been reported to be associated with coronary heart disease (CHD). The functional role of the polymorphism, however, is still a matter of debate, since several studies have not proved its effect on clinical outcomes associated with atherosclerosis. Cardiovascular-related morbidity and mortality was assessed in a post-hoc approach four years after baseline characterization of patients (male/female n = 36/32) with angiographically proven coronary heart disease. CD14 C(-260)--> T promoter genotype was determined at baseline. Seventeen out of 20 CHD patients with non-lethal cardiovascular events carried at least one T-allele. CD14 T-260 allele carriers have a 3.59-fold (95 % confidence interval: 1.11-6.75) increased risk for non-lethal cardiovascular events (Kaplan-Meier plot: log rank test p = 0.029). All patients with lethal outcomes (n = 6) were also T-allele carriers. Multivariate logistic regression analysis among CHD patients including age, established risk factors and the C(-260)--> T polymorphism as covariates and non-lethal events as a dependent variable confirmed the independent prospective effect of the T-allele on cardiovascular outcomes in this subset. Further evidence is provided for the role of CD14 C(-260)--> T promoter polymorphism as a genetic susceptibility marker of atherosclerosis in patients with an advanced clinical course of the disease. Due to the small sample size and post-hoc character of the study large-scale prospective studies that monitor patients with proven CHD are needed to confirm these findings.     

Cardiac Pacing and Defibrillation in Children and Young Adults

The population of children and young adults requiring a cardiac pacing device has been consistently increasing. The current generation of devices are small with a longer battery life, programming capabilities that can cater to the demands of the young patients and ability to treat brady and tachyarrhythmias as well as heart failure. This has increased the scope and clinical indications of using these devices. As patients with congenital heart disease (CHD) comprise majority of these patients requiring devices, the knowledge of indications, pacing leads and devices, anatomical variations and the technical skills required are different than that required in the adult population. In this review we attempt to discuss these specific points in detail to improve the understanding of cardiac pacing in children and young adults.     

Mechanically induced electrical storm as a complication of cardiac resynchronization therapy: A case report

BackgroundCardiac resynchronization therapy (CRT) has been shown to improve both the functional status and mortality of heart failure patients with left bundle branch block. Multiple recent studies suggest several mechanisms for proarrhythmia associated with CRT device.Case summaryA 51-year-old male with symptomatic non-ischemic cardiomyopathy and no previous history of ventricular arrhythmias underwent placement of a biventricular cardioverter-defibrillator. The patient developed sustained monomorphic ventricular tachycardia (VT) soon after implantation. The VT recurred despite reprogramming to right ventricular only pacing. The electrical storm resolved only after a subsequent discharge from the defibrillator caused inadvertent dislodgement of the coronary sinus lead. No recurrent VT occurred throughout 10-years follow up after urgent coronary sinus lead revision.DiscussionWe describe the first reported case of mechanically induced electrical storm due to the physical presence of the CS lead in a patient with a new CRT-D device. It is important to recognize mechanical proarrhythmia as a potential mechanism of electrical storm, as it may be intractable to device reprogramming. Urgent coronary sinus lead revision should be considered. Further studies on this mechanism of proarrhythmia are needed.     

国产雷帕霉素药物洗脱支架在冠心病介入治疗中疗效评价

目的:观察国产雷帕霉素药物洗脱支架在冠心病介入治疗中有效性及安全性。方法:2010年1月至2010年12月我院心血管内科收治并行国产雷帕霉素药物洗脱支架(Firebird支架)置入术患者124例,收治并行进口雷帕霉素药物洗脱支架(Cypher^TM支架)置入术患者167例,于不同支架置入患者中各随机选68例,命名为国产组与进口组。术后1年、5年分别随访两组,观察两组患者支架置入后在不同时间段不良心血管事件发生情况及冠脉造影复查结果。结果:两组患者不良事件比较,国产组术后1年随访结果与术后5年随访结果比较,差异无统计学意义(P0.05);进口组术后1年随访结果与术后5年随访结果比较,差异无统计学意义(P0.05);国产组术后5年随访结果与进口组术后5年随访结果比较,差异无统计学意义(P0.05)。两组患者冠脉造影复查结果比较,差异无统计学意义(P0.05)。结论:国产雷帕霉素药物洗脱支架在冠脉介入治疗中具有安全性和有效性,与进口雷帕霉素药物洗脱支架比较无明显差异,值得临床推广应用。     

Early detection and treatment of hyperlipidemia: physician practices in Canada.

We surveyed primary care physicians in Canada to determine their current practices regarding the detection and treatment of hyperlipidemia in asymptomatic adults 20 years of age or more and to determine the role of selected patient characteristics (age, sex and the presence of coronary heart disease [CHD] risk factors) in their management decisions. The self-administered questionnaire was completed by 428 of 804 family physicians and general practitioners. The proportion of physicians who reported having tested at least 50% of their adult patients varied from 29% to 85% and was related to the number of CHD risk factors present and the patient''s age. The proportion of respondents who reported starting dietary or drug therapy among patients with a cholesterol level of 6.2 mmol/L or less increased as the number of CHD risk factors increased and was not related to patient age or sex. According to the factors examined our results suggest that primary care physicians in Canada select patients for screening and treatment mainly on the basis of CHD risk factors present and that their approach is more conservative than that recommended by the Canadian and US consensus conferences.     

Decentralization of Care for Adults with Congenital Heart Disease in the United States: A Geographic Analysis of Outpatient Surgery

Background

Guidelines recommend that adults with congenital heart disease (CHD) undergo noncardiac surgery in regionalized centers of expertise, but no studies have assessed whether this occurs in the United States. We hypothesized that adults with CHD are less likely than children to receive care at specialized CHD centers.

Methods

Using a comprehensive state ambulatory surgical registry (California Ambulatory Surgery Database, 2005–2011), we calculated the proportion of adult and pediatric patients with CHD who had surgery at a CHD center, distance to the nearest CHD center, and distance to the facility where surgery was performed.

Results

Patients with CHD accounted for a larger proportion of the pediatric population (n = 11,254, 1.0%) than the adult population (n = 10,547, 0.07%). Only 2,741 (26.0%) adults with CHD had surgery in a CHD center compared to 6,403 (56.9%) children (p<0.0001). Adult CHD patients who had surgery at a non-specialty center (11.9±15.4 miles away) lived farther from the nearest CHD center (37.9±43.0 miles) than adult CHD patients who had surgery at a CHD center (23.2±28.4 miles; p<0.0001). Pediatric CHD patients who had surgery at a non-specialty center (18.0±20.7 miles away) lived farther from the nearest CHD center (35.7±45.2 miles) than pediatric CHD patients who had surgery at a CHD center (22.4±26.0 miles; p<0.0001).

Conclusions

Unlike children with CHD, most adults with CHD (74%) do not have outpatient surgery at a CHD center. For both adults and children with CHD, greater distance from a CHD center is associated with having surgery at a non-specialty center. These results have significant public health implications in that they suggest a failing to achieve adequate regional access to specialized ACHD care. Further studies will be required to evaluate potential strategies to more reliably direct this vulnerable population to centers of expertise.