Development and Validation of Predictive Models of Cardiac Mortality and Transplantation in Resynchronization Therapy

Background

30-40% of cardiac resynchronization therapy cases do not achieve favorable outcomes.

Objective

This study aimed to develop predictive models for the combined endpoint of cardiac death and transplantation (Tx) at different stages of cardiac resynchronization therapy (CRT).

Methods

Prospective observational study of 116 patients aged 64.8 ± 11.1 years, 68.1% of whom had functional class (FC) III and 31.9% had ambulatory class IV. Clinical, electrocardiographic and echocardiographic variables were assessed by using Cox regression and Kaplan-Meier curves.

Results

The cardiac mortality/Tx rate was 16.3% during the follow-up period of 34.0 ± 17.9 months. Prior to implantation, right ventricular dysfunction (RVD), ejection fraction < 25% and use of high doses of diuretics (HDD) increased the risk of cardiac death and Tx by 3.9-, 4.8-, and 5.9-fold, respectively. In the first year after CRT, RVD, HDD and hospitalization due to congestive heart failure increased the risk of death at hazard ratios of 3.5, 5.3, and 12.5, respectively. In the second year after CRT, RVD and FC III/IV were significant risk factors of mortality in the multivariate Cox model. The accuracy rates of the models were 84.6% at preimplantation, 93% in the first year after CRT, and 90.5% in the second year after CRT. The models were validated by bootstrapping.

Conclusion

We developed predictive models of cardiac death and Tx at different stages of CRT based on the analysis of simple and easily obtainable clinical and echocardiographic variables. The models showed good accuracy and adjustment, were validated internally, and are useful in the selection, monitoring and counseling of patients indicated for CRT.     

Innovations in the Development of Cardiac Resynchronization Therapy Devices with Defibrillation Capability—the Boston Scientific Experience

Cardiac resynchronization therapy (CRT) has been clinically proven to improve symptoms, exercise capacity, and quality of life and promote reduction in ventricular dimensions. When combined with a defibrillator (CRT-D), significant reductions in all-cause mortality alone and in combination with cause-specific hospitalization have also been demonstrated. We trace Boston Scientific Corporation’s experience in the development of CRT-D devices from the first human implant worldwide 10 years ago using transthoracic lead technology, through the clinical studies that led to regulatory approval using transvenous leads and pulse generators with features specifically designed for heart failure patients. We conclude with innovations for CRT-D that are currently under study.     

动态优化AV/VV间期心脏再同步化治疗慢性心力衰竭的中远期疗效

目的 观察动态优化AV/VV间期心脏再同步化治疗（CRT）慢性心力衰竭的中远期疗效。方法 19例心衰晚期患者接受CRT治疗,分别于植入前、植入术后1周、3、6及12个月在心脏彩超指导下优化AV/VV间期治疗,同时观察心腔结构、二尖瓣返流、主动脉瓣射血速度时间积分（AVTI）、心电图以及测定血浆脑钠肽（BNP）水平等,评价其血流动力学改变。结果 动态优化下最佳优化AV间期120～180 ms （158.33±19.46 ms）之间和VV间期4～28 ms （15.83±7.12 ms）之间临床症状改善,6分钟步行距离由255.71±21.58 m增加至397.37±11.35 m（P0.001）,QRS时限由138.79±16.06 ms降至105.53±8.80 ms（P<0.05）。植入后左心室舒张期末内径（LVEDD）较植入前明显缩小（73.53±9.41 mm比54.11±3.41;P<0.05）,左心室射血分数（LVEF）较植入前明显提高（31%±3%比58%±6%;P<0.01）;AVTI由14.69±1.48优化后增加至20.52±1.18（P<0.05）,血浆BNP水平由植入前的1069.02±501.85 ng/L降至81.26±31.51 ng/L（P<0.05）。结论 动态优化AV/VV间期可以改善患者的血流动力学,提高CRT对慢性心力衰竭患者中远期疗效。     

慢性充血性心力衰竭心脏再同步化治疗研究进展

心电学异常往往合并心衰共存于心肌病患者中 ,异常的心电顺序使心脏收缩和舒张不协调 ,从而损害心功能。近来短期和长期研究发现应用心脏起搏可使心脏活动再同步、改善心功能、提高生活质量和生存率 ,认为心脏再同步化疗法是严重心衰合并心电学异常患者的一种理想的非药物辅助治疗选择。其潜在的机制包括 :心脏整体活动的再同步化 ,拮抗神经内分泌活性、逆转心脏重塑 ,抗心律失常等。该方法有严格的适应证 ,可根据患者情况选择不同的方法。文章综述了心脏失同步化的病理生理及心脏再同步化治疗相关临床试验、显效机制、技术关键及存在的问题     

Remoção Percutânea de Eletrodos de Estimulação Cardíaca Artificial em um Único Centro Sul-Americano

Background:In the last decade, the number of cardiac electronic devices has risen considerably and consequently the occasional need for their removal. Concurrently, the transvenous lead removal became a safe procedure that could prevent open-heart surgery.Objective:The primary objective of this study was to describe the successful performance and the complication rates of pacemaker removals in a Brazilian public hospital. Our secondary aim was to describe the variables associated to successes and complications.Methods:A retrospective case series was conducted in patients submitted to pacemaker removal in a Brazilian public hospital from January 2013 to June 2018. Removal, explant, extraction, success and complication rates were defined by the 2017 Heart Rhythm Society Guideline. Categorical variables were compared using x² or Fisher''s tests, while continuous variables were compared by unpaired tests. A p-value of 0.05 was considered statistically significant.Results:Cardiac device removals were performed in 61 patients, of which 51 were submitted to lead extractions and 10 to lead explants. In total, 128 leads were removed. Our clinical success rate was 100% in the explant group and 90.2% in the extraction one (p=0.58). Major complications were observed in 6.6% patients. Procedure failure was associated to older right ventricle (p=0.05) and atrial leads (p=0,04). Procedure duration (p=0.003) and need for blood transfusion (p<0,001) were associated to more complications.Conclusion:Complications and clinical success were observed in 11.5% and 91.8% of the population, respectively. Removal of older atrial and ventricular leads were associated with lower success rates. Longer procedures and blood transfusions were associated with complications.     

顽固性心力衰竭的治疗进展

近半个世纪来,药物治疗心力衰竭取得很大进展,尽管目前的治疗改善了心力衰竭患者的生存质量,降低其病死率,但顽固性心力衰竭患者预后仍很差,本文就顽固性心力衰竭的治疗进展做一述评。     

Temporal Variation in the Prognosis and Treatment of Advanced Heart Failure - Before and After 2000

Background

The treatment of heart failure has evolved in recent decades suggesting that survival is increasing.

Objective

To verify whether there has been improvement in the survival of patients with advanced heart failure.

Methods

We retrospectively compared the treatment and follow-up data from two cohorts of patients with systolic heart failure admitted for compensation up to 2000 (n = 353) and after 2000 (n = 279). We analyzed in-hospital death, re-hospitalization and death in 1 year of follow-up. We used Mann-Whitney U test and chi-square test for comparison between groups. The predictors of mortality were identified by regression analysis through Cox proportional hazards model and survival analysis by the Kaplan-Meier survival analysis.

Results

The patients admitted until 2000 were younger, had lower left ventricular impairment and received a lower proportion of beta-blockers at discharge. The survival of patients hospitalized before 2000 was lower than those hospitalized after 2000 (40.1% vs. 67.4%; p<0.001). The independent predictors of mortality in the regression analysis were: Chagas disease (hazard ratio: 1.9; 95% confidence interval: 1.3-3.0), angiotensin-converting-enzyme inhibitors (hazard ratio: 0.6; 95% confidence interval: 0.4-0.9), beta-blockers (hazard ratio: 0.3; 95% confidence interval: 0.2-0.5), creatinine ≥ 1.4 mg/dL (hazard ratio: 2.0; 95% confidence interval: 1.3-3.0), serum sodium ≤ 135 mEq/L (hazard ratio: 1.8; 95% confidence interval: 1.2-2.7).

Conclusions

Patients with advanced heart failure showed a significant improvement in survival and reduction in re-hospitalizations. The neurohormonal blockade, with angiotensin-converting-enzyme inhibitors and beta-blockers, had an important role in increasing survival of these patients with advanced heart failure.     

A New Tissue Doppler Index to Predict Cardiac Death in Patients with Heart Failure

Background

It has been shown that a new tissue Doppler index, E/(E''×S''), including the ratio between early diastolic transmitral and mitral annular velocity (E/E''), and the systolic mitral annular velocity (S''), has a good accuracy to predict left ventricular filling pressure.

Objectives

We investigated the value of E/(E''×S'') to predict cardiac death in patients with heart failure.

Methods

Echocardiography was performed in 339 consecutive hospitalized patients with heart failure, in sinus rhythm, after appropriate medical treatment, at discharge and after one month. Worsening of E/(E''×S'') was defined as any increase of baseline value. The end point was cardiac death.

Results

During the follow-up period (35.2 ± 8.8 months), cardiac death occurred in 51 patients (15%). The optimal cut-off value for the initial E/(E''×S'') to predict cardiac death was 2.83 (76% sensitivity, 85% specificity). At discharge, 252 patients (74.3%) presented E/(E''×S'') ≤ 2.83 (group I) and 87 (25.7%) presented E/(E''×S'') > 2.83 (group II), respectively. Cardiac death was significantly higher in group II than in group I (38 deaths, 43.7% vs 13 deaths, 5.15%, p < 0.001). By multivariate Cox regression analysis, including variables that affected outcome in univariate analysis, E/(E''×S'') at discharge was the best independent predictor of cardiac death (hazard ratio = 3.09, 95% confidence interval = 1.81-5.31, p = 0.001). Patients with E/(E''×S'') > 2.83 at discharge and its worsening after one month presented the worst prognosis (all p < 0.05).

Conclusions

In patients with heart failure, the E/(E''×S'') ratio is a powerful predictor of cardiac death, particularly if it is associated with its worsening.     

Stratification of the Risk of Sudden Death in Nonischemic Heart Failure

Despite significant therapeutic advancements, heart failure remains a highly prevalent clinical condition associated with significant morbidity and mortality. In 30%-40% patients, the etiology of heart failure is nonischemic. The implantable cardioverter-defibrillator (ICD) is capable of preventing sudden death and decreasing total mortality in patients with nonischemic heart failure. However, a significant number of patients receiving ICD do not receive any kind of therapy during follow-up. Moreover, considering the situation in Brazil and several other countries, ICD cannot be implanted in all patients with nonischemic heart failure. Therefore, there is an urgent need to identify patients at an increased risk of sudden death because these would benefit more than patients at a lower risk, despite the presence of heart failure in both risk groups. In this study, the authors review the primary available methods for the stratification of the risk of sudden death in patients with nonischemic heart failure.     

Predictors of Conversion from Radial Into Femoral Access in Cardiac Catheterization

Background

Fewer bleeding complications and early ambulation make radial access a privileged route for cardiac catheterization. However, transradial (TR) approach is not always successful, requiring its conversion into femoral access.

Objectives

To evaluate the rate of conversion from radial into femoral access in cardiac catheterization and to identify its predictors.

Methods

Prospective dual-center registry, including 7632 consecutive patients undergoing catheterization via the radial access between Jan/2009 and Oct/2012. We evaluated the incidence of conversion into femoral access and its predictors by logistic regression analysis.

Results

The patients’ mean age was 66 ± 11 years, and 32% were women. A total of 2969 procedures (38.4%) were percutaneous coronary interventions (PCI), and the most used first intention arterial access was the right radial artery (97.6%). Radial access failure rate was 5.8%. Independent predictors of conversion from radial into femoral access were the use of short introducer sheaths (OR 3.047, CI: 2.380-3.902; p < 0.001), PCI (OR 1.729, CI: 1.375-2.173; p < 0.001), female sex (OR 1.569, CI: 1.234-1.996; p < 0.001), multivessel disease (OR 1.457, CI: 1.167-1.819; p = 0.001), body surface area (BSA) ≤ 1.938 (OR 1.448, CI: 1.120-1.871; p = 0.005) and age > 66 years (OR 1.354, CI: 1.088-1.684; p = 0.007).

Conclusion

Transradial approach for cardiac catheterization has a high success rate and the need for its conversion into femoral access in this cohort was low. Female sex, older age, smaller BSA, the use of short introducer sheaths, multivessel disease and PCI were independent predictors of conversion into femoral access.     

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio are Predictors of Heart Failure

Background

Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are inflammatory markers used as prognostic factors in various diseases. The aims of this study were to compare the PLR and the NLR of heart failure (HF) patients with those of age-sex matched controls, to evaluate the predictive value of those markers in detecting HF, and to demonstrate the effect of NLR and PLR on mortality in HF patients during follow-up.

Methods

This study included 56 HF patients and 40 controls without HF. All subjects underwent transthoracic echocardiography to evaluate cardiac functions. The NLR and the PLR were calculated as the ratio of neutrophil count to lymphocyte count and as the ratio of platelet count to lymphocyte count, respectively. All HF patients were followed after their discharge from the hospital to evaluate mortality, cerebrovascular events, and re-hospitalization.

Results

The NLR and the PLR of HF patients were significantly higher compared to those of the controls (p < 0.01). There was an inverse correlation between the NLR and the left ventricular ejection fraction of the study population (r: -0.409, p < 0.001). The best cut-off value of NLR to predict HF was 3.0, with 86.3% sensitivity and 77.5% specificity, and the best cut-off value of PLR to predict HF was 137.3, with 70% sensitivity and 60% specificity. Only NLR was an independent predictor of mortality in HF patients. A cut-off value of 5.1 for NLR can predict death in HF patients with 75% sensitivity and 62% specificity during a 12.8-month follow-up period on average.

Conclusion

NLR and PLR were higher in HF patients than in age-sex matched controls. However, NLR and PLR were not sufficient to establish a diagnosis of HF. NLR can be used to predict mortality during the follow-up of HF patients.     

Association of Aortic Valve Sclerosis with Previous Coronary Artery Disease and Risk Factors

Background

Aortic valve sclerosis (AVS) is characterized by increased thickness, calcification and stiffness of the aortic leaflets without fusion of the commissures. Several studies show an association between AVS and presence of coronary artery disease.

Objective

The aim of this study is to investigate the association between presence of AVS with occurrence of previous coronary artery disease and classical risk factors.

Methods

The sample was composed of 2,493 individuals who underwent transthoracic echocardiography between August 2011 and December 2012. The mean age of the cohort was 67.5 ± 15.9 years, and 50.7% were female.

Results

The most frequent clinical indication for Doppler echocardiography was the presence of stroke (28.8%), and the most common risk factor was hypertension (60.8%). The most prevalent pathological findings on Doppler echocardiography were mitral valve sclerosis (37.1%) and AVS (36.7%). There was a statistically significant association between AVS with hypertension (p < 0.001), myocardial infarction (p = 0.007), diabetes (p = 0.006) and compromised left ventricular systolic function (p < 0.001). Conclusion: Patients with AVS have higher prevalences of hypertension, stroke, hypercholesterolemia, myocardial infarction, diabetes and compromised left ventricular systolic function when compared with patients without AVS. We conclude that there is an association between presence of AVS with previous coronary artery disease and classical risk factors.     

Mortality by Heart Failure and Ischemic Heart Disease in Brazil from 1996 to 2011

Background

Circulatory system diseases are the first cause of death in Brazil.

Objective

To analyze the evolution of mortality caused by heart failure, by ischemic heart diseases and by ill-defined causes, as well as their possible relations, in Brazil and in the geoeconomic regions of the country (North, Northeast, Center-West, South and Southeast), from 1996 to 2011.

Methods

Data were obtained from DATASUS and death declaration records with codes I20 and I24 for acute ischemic diseases, I25 for chronic ischemic diseases, and I50 for heart failure, and codes in chapter XIII for ill-defined causes, according to geoeconomic regions of Brazil, from 1996 to 2011.

Results

Mortality rates due to heart failure declined in Brazil and its regions, except for the North and the Northeast. Mortality rates due to acute ischemic heart diseases increased in the North and Northeast regions, especially from 2005 on; they remained stable in the Center-West region; and decreased in the South and in the Southeast. Mortality due to chronic ischemic heart diseases decreased in Brazil and in the Center-West, South and Southeast regions, and had little variation in the North and in the Northeast. The highest mortality rates due to ill-defined causes occurred in the Northeast until 2005.

Conclusions

Mortality due to heart failure is decreasing in Brazil and in all of its geoeconomic regions. The temporal evolution of mortality caused by ischemic heart diseases was similar to that of heart failure. The decreasing number of deaths due to ill-defined causes may represent the improvement in the quality of information about mortality in Brazil. The evolution of acute ischemic heart diseases ranged according to regions, being possibly confused with the differential evolution of ill-defined causes.     

Aortic Counterpulsation Therapy in Patients with Advanced Heart Failure: Analysis of the TBRIDGE Registry

Background

The use of aortic counterpulsation therapy in advanced heart failure is controversial.

Objectives

To evaluate the hemodynamic and metabolic effects of intra-aortic balloon pump (IABP) and its impact on 30-day mortality in patients with heart failure.

Methods

Historical prospective, unicentric study to evaluate all patients treated with IABP betwen August/2008 and July/2013, included in an institutional registry named TBRIDGE (The Brazilian Registry of Intra-aortic balloon pump in Decompensated heart failure - Global Evaluation). We analyzed changes in oxygen central venous saturation (ScvO₂), arterial lactate, and use of vasoactive drugs at 48 hours after IABP insertion. The 30-day mortality was estimated by the Kaplan-Meier method and diferences in subgroups were evaluated by the Log-rank test.

Results

A total of 223 patients (mean age 49 ± 14 years) were included. Mean left ventricle ejection fraction was 24 ± 10%, and 30% of patients had Chagas disease. Compared with pre-IABP insertion, we observed an increase in ScvO₂ (50.5% vs. 65.5%, p < 0.001) and use of nitroprusside (33.6% vs. 47.5%, p < 0.001), and a decrease in lactate levels (31.4 vs. 16.7 mg/dL, p < 0.001) and use of vasopressors (36.3% vs. 25.6%, p = 0.003) after IABP insertion. Thirty-day survival was 69%, with lower mortality in Chagas disease patients compared without the disease (p = 0.008).

Conclusion

After 48 hours of use, IABP promoted changes in the use of vasoactive drugs, improved tissue perfusion. Chagas etiology was associated with lower 30-day mortality. Aortic counterpulsation therapy is an effective method of circulatory support for patients waiting for heart transplantation.