Cardiac Resynchronization Device Implantation Research Articles

Assessment of the Impact of Cardiac Implantable Electronic Devices on Patients' Quality of Life.

Assessing the quality of life serves as a crucial metric during various therapeutic or surgical procedures. The rise in cardiac electronic device implantations in recent years underscores the significance of evaluating the quality of life among such patients. We conducted a study focusing on the quality of life of 438 patients with cardiac implantable electronic devices (cardiac pacemakers, cardioverter-defibrillators, cardiac resynchronization therapy devices). These patients were diagnosed with sick sinus syndrome, high-degree atrioventricular (AV) block, or severe heart failure (New York Heart Association (NYHA) classes III- IV (NYHA III-IV)), with left ventricular ejection fraction (LVEF) ≤ 35%, with/without complete left bundle branch block (QRS ≥ 130 μs), or with a history of ventricular tachycardia/ventricular fibrillation. The study utilized the EuroQol 5-Dimension 5-level (EQ-5D-5L) questionnaire and the EQ visual analog scale, which patients completed both prior to cardiac device implantation and during six post-implantation follow-up visits. The analysis of the research findings was conducted using the IBM SPSS Statistics software program (Armonk, NY). Cardiac pacemaker implantation in patients with sick sinus syndrome and high-grade AV block demonstrated significant and highly reliable positive effects on quality of life concerning mobility, self-care, and usual activity. Similarly, cardiac resynchronization device implantation in individuals with severe heart failure with reduced LVEF and wide QRS showed significant positive effects in these areas. However, cardioverter-defibrillator implantation did not yield positive effects on these modules.Regarding pain/discomfort, neither pacemaker nor cardiac resynchronization device implantation resulted in improved quality of life, while there was a somewhat positive effect observed in the cardioverter-defibrillator group. In terms of anxiety/depression, pacemaker implantation in patients with sick sinus syndrome and high-degree AV block had a significant and highly reliable positive impact on quality of life. Additionally, relatively positive impacts were noted at various periods following cardioverter-defibrillator and cardiac resynchronization device implantations. Cardiac implantable electronic devices play a crucial role not only in saving lives but also in positively impacting the quality of life of patients when appropriately selected.

Preoperative Prediction of Optimal Method and Site of Left Ventricular Electrode Implantation

We present a clinical case of cardiac resynchronization device implantation in a patient with a zone of late left ventricular activation in the area of the anterior coronary sinus vein, which, however, was unsuitable for endovascular implantation and stable electrode placement in it. This anatomical feature was diagnosed at the outpatient stage using a noninvasive mapping technique. Using this approach, we were able to understand that an epicardial electrode implantation, instead of traditional endovascular implantation of the left ventricular electrode through the coronary sinus vein, is indicated for the patient. Targeted implantation of an epicardial electrode in the area of interest on the epicardial surface of the left ventricle in the basal part of the anterolateral wall allowed achieving a complete clinical response to resynchronization therapy.

Nuances of Cardiac Resynchronization Therapy in Patients with Dilated Cardiomyopathy and Atrial Fibrillation (a Clinical Case)

Dilated cardiomyopathy (DCM) is a steadily developing disease characterized by progressive chronic heart failure (CHF) resistant to drug therapy. Cardiac resynchronization therapy (CRT) significantly improves the prognosis in these patients if they have indications for implantation of resynchronization devices. The article presents a clinical case of successful implantation of a cardioversion-defibrillation cardiac resynchronization device in a patient suffering from DCM in combination with permanent atrial fibrillation (AF). The nuances of ventricular rate control and the role of the catheter procedure for modifying the atrioventricular junction are discussed.

Six-Year Outcome after Valve Replacement and Resynchronization Therapy in TGA Patient

Patients with complete transposition of the great arteries (TGA) treated by the Senning procedure have a higher risk of developing heart failure due to: a) additional work load of the systemic (morphologic right) ventricle (sRV), b) arrhythmias, mainly caused by surgical implications at the atria as well as c) worsening of systemic tricuspid regurgitation. We present a unique case of a female patient who developed all these complications, who was successfully treated and was able to carry out a twin pregnancy. This breakthrough approach was based on: 1. detecting reversibility potential of myocardial systolic dysfunction in a severe valvular lesion combined with continuous systemic afterload settings and permanent tachyarrhythmia, and 2. prevention of subsequently iatrogenic worsening of systemic ventricular function due to permanent pacing. Surgical replacement of systemic tricuspid valve (sTV) and cardiac resynchronization device (CRT) implantation after nodal ablation resulted in recovering of the systolic function and a positive remodeling of the sRV. The reversal of a further decline in systolic function was achieved by permanent arrhythmia control, synchronous pacing with epicardial leads of CRT, sTV replacement as well as echocardiographic monitoring during pregnancy to determine the right time for delivery. Two years after delivery, the patient remains in NYHA Class I.

Strategies to Reduce Radiation Exposure in Electrophysiology and Interventional Cardiology

Clinical diagnosis sometimes involves the use of medical instruments that employ ionizing radiation. However, ionizing radiation exposure is a workplace hazard that goes undetected and is detrimental to patients and staff in the catheterization laboratory. Every possible effort should be made to reduce the amount of radiation, including scattered radiation. Implementing radiation dose feedback may have a role in reducing exposure. In medicine, it is important to estimate the potential biologic effects on, and the risk to, an individual. In general, implantation of cardiac resynchronization devices is associated with one of the highest operator exposure doses due to the proximity of the operator to the radiation source. All physicians should work on the principle of as low as reasonably achievable. Methods for reducing radiation exposure must be implemented in the catheterization laboratory. In this article, we review the available tools to lower the radiation exposure dose to the operator during diagnostic, interventional, and electrophysiological cardiac procedures.

New opportunities for assessing the optimal positioning of a multipolar left ventricular electrode for resynchronization therapy

Heart failure and left bundle branch block is a common disease in the modern world. Cardiac resynchronization therapy is used to correct this condition, but some patients have no positive clinical effect from its use. One of the reasons for the lack of response to therapy is not the optimal position of the left ventricular electrode. In this clinical case we presented the experience of using myocardial perfusion scintigraphy to determine the optimal position of the left ventricular electrode.A 60-year-old patient, who was admitted to the center with symptoms of heart failure and signs of complete left bundle branch block, underwent an implantation of the cardiac resynchronization system. Both intraoperative data and the data of preliminary myocardial scintigraphy were used to select the site of implantation of the left ventricular electrode. A significant improvement in the patient’s condition, evaluated after 6 months after the implantation of the device, allowed us to conclude that the use of myocardial perfusion scintigraphy with standard methods of ultrasound diagnosis can increase the efficiency of implantation of cardiac resynchronization devices and a response to the therapy.Received 2 October 2019. Revised 20 December 2019. Accepted 23 December 2019.Funding: The work is supported by a grant of the President of the Russian Federation for young scientists No. МД-2893.2018.7.Conflict of interest: Authors declare no conflict of interest.

A Novel and Practical Method of Performing Atrioventricular Nodal Ablation via a Superior Approach in Patients with Refractory Atrial Fibrillation Undergoing Cardiac Resynchronization Device Implantation.

Atrioventricular node (AVN) ablation is a strategy to manage patients with drug-refractory atrial fibrillation (AF) and heart failure in whom cardiac resynchronization therapy (CRT) device implantation has been prescribed. This study describes a practical method to perform these two procedures using the same surgical site. Twenty-seven patients were indicated for AVN ablation and concurrent CRT device implantation while presenting with AF and rapid ventricular response (RVR) refractory to medical therapy. After placement of the right and left ventricular leads, a third puncture was made in the axillary vein to obtain access to perform the ablation. After hand-injecting contrast media through a RAMP™ (Abbott Laboratories, Chicago, IL, USA) sheath positioned in the right atrial cavity, the anatomical area corresponding to the AVN was identified using fluoroscopy cine runs obtained in the right anterior oblique and left anterior oblique projections. The adequate site for ablation was confirmed by the bipolar recording of a His-bundle deflection at the tip of the ablation catheter. Radiofrequency energy was delivered to achieve complete heart block. Subsequently, device implant was completed. The method was successfully applied in 27 consecutive cases, achieving permanent complete heart block in all patients. The mean radiofrequency time to achieve heart block was 110 seconds ± 43 seconds. The average procedural time including AVN ablation and device implant was 87 minutes ± 21 minutes. The images obtained with the hand-injected contrast media provided adequate information to readily identify the anatomical area corresponding to the AVN with 100% accuracy. This study suggests that ablation of the AVN can be safely and effectively accomplished via a superior approach in patients undergoing a CRT device implant.

Safety of cardiac resynchronization device implantation — retrospective analysis from high-volume centre

Aims: Cardiac resynchronization therapy (CRT) is a treatment dedicated to patients suffering from heart failure and asynchrony of systole typically due to left bundle branch block (LBBB). The aim of this study is to analyse the safety of CRT device implantation in a large single-centre group. Methods and results: The retrospective analysis of 198 patients hospitalized in the Department of Cardiology, dr A. Jurasz University Hospital no 1 in Bydgoszcz, who underwent CRT devices implantations in two consecutive years (2015–2016) has been performed. Out of 198 patients, 136 underwent implantation of CRT de novo and 62 exchange of the device. Studied procedures included implantations of 121 (89.0%) cardiac resynchronization therapy defibrillators (CRT-D) and 15 (11.0%) cardiac resynchronization therapy pacemakers (CRT-P) de novo, as procedures of exchange were excluded from statistical analysis. Collected data included: reported complications, patients’ basic clinical characteristics, comorbidities and details of implantation procedures. Development of any complication was observed in 43 patients (31.6%), out of whom 29 (21.3%) experienced one, 10 (7.4%) two and 4 (2.9%) three complications. Most of them were minor complications. Serious complications which included pneumothorax, mediastinal hematoma and cardiac tamponade were observed in 6 (4.4%) cases, there were no perioperative deaths. The occurrence of complications was significantly more frequent in females (OR , 3.45, 95% CI 1.37–8.71, p 0.008), was associated with prolonged procedure time (OR 1.11, 95% CI 1.04–1.20, p 0.003) and prolonged hospitalization time (OR 1.16, 95% CI 1.06–1.27, p 0.001). Conclusion: Overall, implantations of CRT devices are burdened with a substantial risk of complications, although the majority of them are minor and do not require subsequent surgical intervention. The risk of developing serious complications is low, accounting for 4.4%.

Effect of Optimization of Medical Treatment on Long-Term Survival of Patients With Heart Failure After Implantable Cardioverter Defibrillator and Cardiac Resynchronization Device Implantation (from the French National EGB Database)

Prognosis of heart failure with reduced ejection fraction (HFrEF) is improved by drug optimization according to guidelines; however, little is known regarding such optimization in HFrEF patients with an implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT). This study aimed to describe implementation of this optimized strategy and its impact in patients implanted with an ICD/CRT. Using a 1/97th representative sample of the French national health-care insurance system claims database, a retrospective cohort study was conducted including HFrEF patients implanted with ICD or CRT between January 2009 and December 2014. HFrEF treatments were analyzed before and after ICD/CRT implantation. Heart failure (HF) hospitalization and survival were examined at 1, 3, and 5 years: 378 patients (135 CRT, 243 ICD) with a mean age of 68 ± 13 years were included. Mean follow-up was 23 months [11-42]. At baseline, 36% of patients had no or only 1 HFrEF drug among β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and mineralocorticoid receptor antagonists, whereas 26% of patients received an optimal treatment (all 3 classes). At 3 months after ICD/CRT implantation, the prescription rate of HFrEF drugs was higher than baseline but returned to preimplantation levels at the end of follow-up. HF hospitalization rate was higher in the nonoptimized patient group (28% vs 14%, p = 0.001). Optimal HFrEF treatment was associated with better survival (hazard ratio = 0.59 [0.4-0.86], p = 0.006). In conclusion, HFrEF drugs are underprescribed before and after ICD/CRT implantation despite the demonstration that HFrEF drug optimization also reduces death and HF hospitalization in this population.

Inverse Correlation of Venous Brain Natriuretic Peptide Levels with Body Mass Index Is due to Decreased Production

Objective: The aim of this paper was to study the association between body mass index (BMI) and coronary sinus (CS) brain natriuretic peptide (BNP) levels in patients with heart failure and reduced systolic function (HFrEF). Background: There is an inverse relationship between systemic venous BNP (V-BNP) levels and BMI in patients with HFrEF. It is unclear whether this finding is due to decreased production or due to an increased metabolism of BNP. Since CS-BNP levels reflect BNP production, we hypothesized that assessing the correlation of CS-BNP levels with BMI would provide insight into the mechanism of this inverse relationship of V-BNP and BMI. Methods: We prospectively enrolled 54 subjects with HFrEF who were to undergo cardiac resynchronization device implantation. CS-BNP, V-BNP, and arterial BNP (A-BNP) levels were measured during the implant procedure. Subjects were divided into 2 groups based on their BMI (group 1: BMI <30 and group 2: BMI ≥30). Results: The mean age of the overall study group was 64 ± 10 years. Average BMI for group 1 was 25.8 ± 2.8 and 36.8 ± 4.6 for group 2 (p < 0.03). A history of hypertension was present in 55% (n = 26) of the subjects, while diabetes was reported in 31% (n = 15). Serum creatinine was 1.0 ± 0.2 mg/dL and TSH 2.1 ± 1.4 mIU/L. 79% of the subjects were receiving β-blockers, while 94% were receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. The mean CS-BNP, V-BNP, and A-BNP levels in group 2 were significantly lower than in group 1 (286.2 ± 170.5 vs. 417.5 ± 247.5 pg/mL, p = 0.04; 126.6 ± 32.5 vs. 228 ± 96.4 pg/mL, p = 0.01; and 151.9 ± 28.6 vs. 242 ± 88.8 pg/mL, p = 0.04, respectively). Univariate analysis and multivariate regression adjusted for age, diabetes mellitus, sex, glomerular filtration rate, and left atrial size confirmed BMI as an independent predictor of CS-BNP levels (β = -0.372, p = 0. 03) in our study. Conclusions: In this study, we demonstrate an inverse relationship between CS-BNP levels and BMI in patients with HFrEF. These findings suggest that the previously established inverse relationship between V-BNP and BMI is due to a decreased cardiac production of BNP in obese patients rather than from increased peripheral metabolism.

Comparison of Conventional versus Steerable-Catheter Guided Coronary Sinus Lead Positioning in Patients Undergoing Cardiac Resynchronization Device Implantation

ObjectivesThe aim of this study was to compare conventional versus steerable catheter guided coronary sinus (CS) cannulation in patients with advanced heart failure undergoing cardiac resynchronization therapy (CRT).BackgroundSteerable catheter guided coronary sinus cannulation could reduce fluoroscopy time and contrast medium use during CRT implantation.Methods176 consecutive patients with ischemic and non-ischemic heart failure undergoing CRT implantation from January 2008 to December 2012 at the University Hospital of Cologne were identified. During the study period two concurrent CS cannulation techniques were used: standard CS cannulation technique (standard-group, n = 113) and CS cannulation using a steerable electrophysiology (EP) catheter (EPCath-group, n = 63). Propensity-score matched pairs of conventional and EP-catheter guided CS cannulation made up the study population (n = 59 pairs). Primary endpoints were total fluoroscopy time and contrast medium amount used during procedure.ResultsThe total fluoroscopy time was 30.9 min (interquartile range (IQR), 19.9–44.0 min) in the standard-group and 23.4 min (IQR, 14.2-34-2 min) in the EPCath-group (p = 0.011). More contrast medium was used in the standard-group (60.0 ml, IQR, 30.0–100 ml) compared to 25.0 ml (IQR, 20.0–50.0 ml) in the EPCath-group (P<0.001).ConclusionsUse of steerable EP catheter was associated with significant reduction of fluoroscopy time and contrast medium use in patients undergoing CRT implantation.

IT IS POSSIBLE TO REDUCE EXPOSURE TO IONIZING RADIATION BY > 90% DURING CARDIAC RESYNCHRONIZATION THERAPY IMPLANT PROCEDURES IN THE EP LAB: THE MONTRÉAL HEART INSTITUTE EXPERIENCE WITH LOW-DOSE FLUOROSCOPY SETTINGS AND MEDIGUIDE

All cardiologists working with ionizing radiations (IR) should apply the ALARA (As Low As Reasonably Achievable) principles. Among all procedures, implantation of cardiac resynchronization devices (CRT) result in the highest IR exposure, to the patients, staff and implanter with average IR doses (Dose-Area-Product: DAP) in the range of 2,500 μGray.cm2. These doses can easily double in difficult procedures (longer fluoroscopic times and higher DAP/min generated by fluoroscopic tube angulations, LAO projection being the worst). Our objective is to report on our recent experience to reduce IR exposure with the new 3-D navigation system (MediGuide, MDG, St Jude Inc.) and low-dose fluoroscopy settings during CRT implant procedures. Since January 2013, we’ve collected for all CRT implantations the procedure duration and fluoroscopy exposure (time in minutes, DAP in μGy.cm2 and DAP/min). In June 2013, MDG was installed in one (of 3) EP lab where CRT are implanted and in December 2014, we changed the fluoroscopy settings in all labs to lower-dose parameters (power and frame rate), sacrificing image quality in favor of lower IR exposure. 283 procedures are included in the data base (table). With lower fluoroscopy settings, DAP non-significantly decreased by 33% (P=0.386) compared to normal settings (non-MDG cases). The benefits of lower DAP/min were offset by longer fluoroscopy times. Usage of MDG (normal settings) resulted in 75% reduction of DAP (P<0.001), mainly due to a 72% reduction in fluoro duration (P<0.001). The most striking effects were noted when low-dose fluoroscopy settings were used in combination with MDG: 94% reduction in DAP (vs. NON-MDG), due both to shorter fluoroscopy duration and reduction of DAP/min (all P<0.001). Of note, these beneficial effects were not obtained at the cost of longer procedure duration (expected with lower image quality). It is possible (and desirable) to reduce by >90% ionization radiation exposure during CRT implantation procedures. Adopting low-dose fluoroscopy settings, failed to reduce IR exposure, the benefits from lower DAP/min being offset by longer fluoroscopy usage times. However, using low-fluoroscopy settings with a 3-D navigating system (MediGuide) during the difficult steps (CS cannulation and LV lead placement) significantly reduced exposure to ionizing radiation by 94% (with benefits coming from both lower fluoroscopy time and IR dose/minute).

3D Echocardiographic Location of Implantable Device Leads and Mechanism of Associated Tricuspid Regurgitation

This study sought to: 1) determine the feasibility of using 3-dimensional transthoracic echocardiography (3D TTE) in patients with implantable cardiac resynchronization devices, pacemakers, and defibrillators to visualize the device leads in the right heart and their position relative to the tricuspid valve leaflets; 2) determine the prevalence of different lead positions; and 3) study the relationship between lead location and tricuspid regurgitation (TR) severity. Pacemaker, defibrillator, and cardiac resynchronization device implantation is currently guided by fluoroscopy, not allowing targeted lead positioning relative to the tricuspid valve leaflets. These leads have been reported to cause TR of variable degrees, but echocardiography is not routinely used to elucidate the mechanisms of lead interference with tricuspid valve leaflets in individual patients. 3D TTE full-volume images of the right ventricle and/or zoomed images of the tricuspid valve were obtained in 121 patients with implanted devices. Images were viewed offline to determine the position of the device-lead relative to the tricuspid valve leaflets. Severity of TR was estimated on the basis of vena contracta measurements. 3D TTE clearly depicted lead position in 90% of patients. The right ventricular lead was impinging on either the posterior (20%) or septal (23%) leaflet or was not interfering with leaflet motion (53%) when positioned near the posteroseptal commissure or in the central portion of the tricuspid valve orifice. In the remaining patients, leads were impinging on the anterior leaflet (4%) or positioned in either the anteroposterior or anteroseptal commissure (3%). Leads interfering with normal leaflet mobility were associated with more TR than nonimpinging leads (vena contracta: median 0.62 cm [1st and 3rd quartiles: 0.51, 0.84 cm] vs. 0.27 cm [1st and 3rd quartiles: 0.00, 0.48 cm]; p < 0.001). 3D TTE showed a clear association between device lead position and TR. To minimize TR induced by device-leads, 3D TTE guidance should be considered for placement in a commissural position.

Impact of intracoronary reinfusion of bone marrow-derived mononuclear progenitor cells on cardiopulmonary exercise capacity in patients with chronic postinfarction heart failure

Intracoronary infusion of bone marrow-derived progenitor cells (BMC) in patients with chronic ischaemic heart failure (CHF) is associated with improvement in left ventricular ejection fraction (LVEF), reduction of NT-proBNP levels and improved prognosis. However, effects of this therapy on cardiopulmonary exercise capacity have not been investigated separately so far. One hundred and fifty-four patients with ischaemic heart failure (mean LVEF 40.3 ± 10.9 %, NT-proBNP 1,103 ± 1,436 pg/ml) underwent cardiopulmonary exercise capacity testing (CPX) before and 3 months after intracoronary infusion of autologous BMC. Thirty patients with a potential bias on the CPX course as concomitant coronary intervention, bypass surgery, new onset of arrhythmias or implantation of cardiac resynchronization devices were excluded from further analysis. The remaining 124 patients showed an increase in exercise time and peak workload by 16.8 and 6 %. Peak oxygen uptake and oxygen uptake efficiency slope also improved by 2.9 and 12.9 %, whereas other parameters like peak oxygen pulse and the slope of minute ventilation versus CO2 elimination remained unchanged. Analysis of patients with poor, moderate and conserved CPX results prior to cell therapy documented that patients in tertiles with lowest initial exercise capacity showed the largest improvements in CPX after therapy. The differences in response to cell therapy were detectable in all investigated CPX parameters and became significant for exercise time, peak oxygen uptake and peak oxygen pulse. These findings indicate that intracoronary BMC therapy improves exercise capacity in CHF patients with more advanced heart failure.

181: Cardiac resynchronization device implantation procedure in real life. The French Electra survey

Cardiac resynchronization therapy (CRT) has been a major breakthrough in cardiac failure management. However, implantation procedure is not standardized. To evaluate routine implantation procedure habits in french practice. A survey was e-mailed to 100 French CRT implanters in November 2011. Physicians were interviewed on their own strategy in the center. Answers had to concern the most frequent routine attitude. If appropriate, physicians could answer “no standardized attitude or “other”. Among the 62 physicians who answered, 45% practise in a university hospital, 24% in a non-university hospital and 23% in a private institution. The rate of physician implantations is <30/year, 30-50/year and >50/year in 42%, 25% and 33%, respectively. Implantations are performed by a single operator in 49%, and in 43% by two physicians, 16% of implants being done under general anaesthesia. CRT-Pacemaker (CRT-P) implantations are right-sided in 18%, left-sided in 51%, unsettled in 20%, and for CRT-Defibrillator (CRT-D) 8%, 82 and 10% respectively. The venous approach is “all cephalic” in 21%, all subclavian in 18% and combined in 62%. First implanted lead is the right ventricular lead (RV) in 74%, and the coronary sinus (CS) lead in 23%. RV lead is placed in apical position in 26% and in septal position in 67%. To catheterize the CS, a sheath isused in first intention in 81%. CS angiography is performed in 90%, with an inflated balloon in 59%. In case of atrial fibrillation with CHA2DS2-vasc<2, 38% implant without VKA interruption, 57% stop VKA without substitution, and unfractionned heparin (UH) or low weight heparin (LWH) substitution is chosen in 5%, vs respectively 69% and 11% and 19% if CHA2DS2-vasc >4. Most of implantations are performed under local anesthesia. Left sided is prefered, especially in case of CRT-D implantation. Most physicians combine the venous accesses, start with the RV septal lead, and perform a CS angiogram via an inflated balloon. In AF patient, VKA interruption is preferred in low risk patients but not in high risk ones. Few implanters choose VKA substitution.

How reliable are left ventricular ejection fraction cut offs assessed by echocardiography for clinical decision making in patients with heart failure?

We aimed to study the potential influence of the variability in the assessment of echocardiographically measured left ventricular ejection fraction (LVEF) on indications for the implantation of internal cardioverter defibrillator and/or cardiac resynchronization devices in heart failure patients. TIME-CHF was a multicenter trial comparing NT-BNP versus symptom-guided therapy in patients aged ≥60 years. Patients had their LVEF assessed at the recruiting centre using visual assessment, the area-length or biplane Simpson's method. Echocardiographic data were transferred to the study core-lab for re-assessment. Re-assessment in the core-lab was done with biplane Simpson's method, and included an appraisal of image quality. 413 patients had the LVEF analyzed at the recruiting centre and at the core lab. Image quality was optimal in 191 and suboptimal in 222. Overall, the correlation between LVEF at the recruiting centres and at the core-lab was good, independent of image quality (R² = 0.62). However, when a LVEF ≤30 % or ≥30 % was used as a cut-off, about 20 % of all patients would have been re-assigned to having either a LVEF above or below the cut-off, this proportion was not significantly influenced by image quality. We conclude that correlation between LVEF assessed by different centres based on the same ultrasound data is good, regardless of image quality. However, one fifth of patients would have been re-assigned to a different category when using the clinically important cut-off of 30 %.

Implantation of cardioverter-defibrillator and cardiac resynchronization device in a patient with preserved right ventricular lead after tricuspid valve surgery

Implantation of cardioverter-defibrillator and cardiac resynchronization device in a patient with preserved right ventricular lead after tricuspid valve surgery

Disparities in Cardiac Care for Patients With Complex Cardiovascular Care Needs

The United States continues to have a prevailing public health problem related to disparities in healthcare. Factors contributing to disparities include ethnicity, gender, socioeconomic status, educational level, geographic location, and hospital characteristics. In cardiovascular care, gaps in care have been associated with lack of conformity to evidence-based therapies known to improve clinical outcomes, including survival, quality of life, and freedom from rehospitalization. Specifically, there are disparities in use of a number of cardiovascular life-saving procedures including cardiac catheterization, percutaneous coronary intervention, coronary artery bypass surgery, and implantation of defibrillators and cardiac resynchronization devices. The purpose of this article was to illustrate the range of disparities that exist in relation to management of patients with acute coronary syndromes, interventional cardiology procedures, cardiac surgery, heart failure, and device implantation. Because the impact on patient outcomes is high, potential interventions to address disparities will be provided.

The Emerging Role of Cardiac Resynchronization Therapy in Milder Heart Failure: Are We Implanting Too Late for Response?

The role of cardiac resynchronization therapy in mild heart failure has become a focus of attention with the publication of recent clinical trials. We present a review of the data supporting implantation of cardiac resynchronization devices in early stage heart failure. In addition, we present evidence that may suggest patients are often implanted too late for clinical benefit, potentially contributing to the relatively high nonresponder rate seen in randomized trials and clinical practice.

ORAL PRESENTATION

ORAL PRESENTATION