Structural Heart Disease In Patients Research Articles

Presence of Dysautonomia as a Predictor of Structural Heart Disease in Patients with Chagas Disease

Presence of Dysautonomia as a Predictor of Structural Heart Disease in Patients with Chagas Disease

Catheter ablation as first-line treatment for ventricular tachycardia in patients with structural heart disease and preserved left ventricular ejection fraction: a systematic review and meta-analysis

In this systematic review and meta-analysis, we aim to evaluate the efficacy and safety of catheter ablation as the first-line treatment of ventricular tachycardia (VT) in patients with structural heart disease (SHD) and preserved left ventricular ejection fraction (LVEF). Patients with SHD are particularly susceptible to VT, a condition that increases the risk of sudden cardiac death (SCD). Implantable cardioverter-defibrillators (ICDs) can terminate VT and prevent SCD but do not prevent VT recurrence. The efficacy and safety of CA as a first-line treatment in SHD patients with preserved LVEF remain unclear. We searched PubMed/Medline, EMBASE, Web of Science, and Cochrane CENTRAL for studies reporting the outcomes of CA therapy in patients with VT and preserved LVEF, published up to January 19, 2023. The primary outcome was the incidence of SCD following catheter ablation as the first-line treatment of VT in patients with SHD and preserved LVEF. Secondary outcomes included all-cause mortality, VT recurrence, procedural complications, CA success rate, and ICD implantation after catheter ablation. We included seven studies in the meta-analysis, encompassing a total of 920 patients. The pooled success rate of catheter ablation was 84.6% (95% CI 67.2–93.6). Complications occurred in 6.4% (95% CI 4.0–9.9) of patients, and 13.9% (95% CI 10.1–18.8) required ICD implantation after ablation. VT recurrence was observed in 23.2% (95% CI 14.8–34.6) of patients, while the rate of sudden cardiac death (SCD) was 3.1% (95% CI 1.7–5.6). The overall prevalence of all-cause mortality in this population was 5% (95% CI 1.8–13). CA appears promising as a first-line VT treatment in patients with SHD and preserved LVEF, especially for monomorphic hemodynamically tolerated VT. However, due to the lack of direct comparisons with ICDs and anti-arrhythmic drugs, further research is needed to confirm these findings.

Cardiac magnetic resonance reveals concealed structural heart disease in patients with frequent premature ventricular contractions and normal echocardiography: A systematic review

Premature ventricular contractions (PVCs) are a common form of arrhythmic events, often representing an idiopathic and benign condition without further therapeutic interventions. However, in certain circumstances PVCs may represent the epiphenomenon of a concealed structural heart disease (SHD). Surface 12‑leads EKG and 24-h dynamic EKG are necessary to assess their main characteristics such as site of origin, frequency and complexity. Echocardiography represents the first-line imaging tool recommended to evaluate cardiac structures and function. Cardiac Magnetic Resonance (CMR) is recognized as a superior modality for detecting structural cardiac alterations, that might evade detection by conventional echocardiography. Moreover, in specific populations such as athletes, CMR may have a crucial role to exclude a concealed SHD and the risk of serious arrhythmic events during sport activity. Some clinical characteristics such as male sex, older age or family history of sudden cardiac death (SCD) or cardiomyopathy, and some electrocardiographic features of PVCs, in particular a right branch bundle block (RBBB) with superior/intermediate axis morphology, the reproducibility of VAs during exercise test (ET) or the evidence of complex ventricular arrhythmias, may warrant a CMR evaluation, due to the high probability of SHD. In this systematic review our objective was to provide an exhaustive overview on the role of CMR in detecting a concealed SHD in patients with high daily burden of PVCs and a normal echocardiographic evaluation, paving the way for a more extensive utilization of CMR in presence of certain high-risk clinical and/or EKG features identified during the diagnostic workup.

Use of class IC antiarrhythmic drugs in patients with structural heart disease and implantable cardioverter defibrillator.

Due to suspected pro-arrhythmic effects and increased mortality associated with class-IC antiarrhythmic drugs (AADs) in previous trials, AAD therapy in structural heart disease (SHD) is mainly restricted to amiodarone. In the presence of diagnostic and therapeutic advancements in cardiovascular medicine, it remains unclear if previous studies adequately reflect contemporary patients. In clinical practice, class-IC-AADs are occasionally used in individual cases, particularly in patients with an implantable cardioverter defibrillator (ICD). This study retrospectively investigated outcome in ICD-carriers with SHD in whom class-IC-AADs were used as an individualized therapy due to failure, side effects, or unacceptable risk of alternative therapeutic options. Fifty patients from four tertiary centers were included (median age 48.5years; 52% female). The most common underlying SHD were dilated (42%) or ischemic cardiomyopathy (26%) (median LVEF = 45%). Indications for AAD were sustained ventricular arrhythmias (VA) (58%), symptomatic premature ventricular contractions (26%), or atrial arrhythmias (16%). Median follow-up was 27.8months. Freedom from sustained VA was 72%, and freedom from ICD therapy was 80%. In 19 patients (38%), AAD therapy was terminated. The most common reason was insufficient efficacy (n = 8). Pro-arrhythmia was suspected in three patients. Five patients died during follow-up (10.0%), two of cardiovascular cause (4.0%). In a multicenter cohort of ICD-carriers with SHD, class-IC-AADs were associated with a low rate of pro-arrhythmic effects or cardiovascular mortality. The majority of patients remained free from sustained VA during a follow-up of > 2years. Further efforts should be made to evaluate the safety of class-IC-AADs in SHD patients receiving contemporary cardiovascular therapy.

The cardiomyopathy of cystic fibrosis: a modern form of Keshan disease.

We conducted a study to determine the prevalence of structural heart disease in patients with CF, the characteristics of a cardiomyopathy not previously described in this population, and its possible relationship with nutritional deficiencies in CF. We studied 3 CMP CF patients referred for heart-lung transplantation and a prospective series of 120 adult CF patients. All patients underwent a clinical examination, blood tests including levels of vitamins and trace elements, and echocardiography with evaluation of myocardial strain. Cardiac magnetic resonance imaging (CMR) was performed in patients with CMP and in a control group. Histopathological study was performed on hearts obtained in transplant or necropsy. We found a prevalence of 10% (CI 4.6%-15.4%) of left ventricular (LV) dysfunction in the prospective cohort. Myocardial strain parameters were already altered in CF patients with otherwise normal hearts. Histopathological examination of 4 hearts from CF CMP patients showed a unique histological pattern of multifocal myocardial fibrosis similar to Keshan disease. Four of the five CF CMP patients undergoing CMR showed late gadolinium uptake, with a characteristic patchy pattern in 3 cases (p < 0.001 vs. CF controls). Selenium deficiency (Se < 60 µg/L) was associated with more severe LV dysfunction, higher prevalence of CF CMP, higher NTproBNP levels, and more severe pulmonary and digestive involvement. 10% of adults with CF showed significant cardiac involvement, with histological and imaging features resembling Keshan disease. Selenium deficiency was associated with the presence and severity of LV dysfunction in these patients.

Preinterventional quantification of dense scar or borderline zone in patients undergoing ventricular tachycardia ablation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction This study sought to examine the prognostic role of quantifying areas of interest in preinterventional cardiac magnetic resonance (CMR) in patients with structural heart disease (SHD) referred for ablation of ventricular tachycardia (VT). Background The role of preinterventional CMR for the identification of scar areas, borderline zones and reentry channels in the ventricles has been well established. Whether the burden of dense scar or borderline tissue has a prognostic impact on the acute and the long-term ablation outcome in SHD patients is disputed. Methods and results We investigated 185 patients with SHD undergoing preinterventional CMR prior to VT-ablation. 38 patients were excluded because of poor imaging quality, leaving a cohort of 147 patients with positive late enhancement (LGE) imaging (mean age 62 years, 47% non-ischemic cardiomyopathy, mean left ventricle ejection fraction 38%, 96% with implanted ICD). The cohort was divided in ischemic (ICM) and non-ischemic (NICM) cardiomyopathy group and the results regarding burden of overall scar tissue, dense scar, borderline zone, as well as clinical and procedural characteristics, acute and long-term results of the two groups were compared. The ICM patients had more advanced NYHA stadium (p = 0.046), reduced left ventricular ejection fraction (LV-EF, p &amp;lt;0.001) and higher left ventricular enddiastolic volume (LVEDV, p &amp;lt;0.001). The NICM patients were more often under antiarrhythmic therapy (p = 0.005) and underwent more frequently epicardial ablation (p &amp;lt;0.001). Although the overall scar burden war higher in ICM patients (p &amp;lt;0.001), the groups showed no significant difference in borderline zone burden (p = 0.580). Furthermore, the two groups had similar results in number of inducible VTs (p = 0.054) and VT inducibility at the end of the procedure (p = 0.121). Nevertheless, the NICM group underwent overall more ablation procedures during the 19-month follow up (p = 0.023). Both groups showed similar results regarding assist device implantation, heart transplantation or death until the end of the follow up (p = 0.192). Conclusion While quantification of the scar tissue and the borderline zone is feasible in ICD patients with SHD, the scar or the borderline zone burden were not predictive of the VT ablation outcome.

Machine learning based prediction of 1-year arrhythmia recurrence after ventricular tachycardia ablation in patients with structural heart disease

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1–2016-0017 (’National Heart Program’) - National Research, Development and Innovation Fund of Hungary Thematic Excellence Programme (2020-4.1.1.-TKP2020) of the Ministry for Innovation and Technology in Hungary Background Ventricular tachycardia (VT) is a life-threatening condition. Catheter ablation treatment is often successful, however post procedural VT recurrence still remains an issue. Therefore, there is a demand for an accurate risk stratification system to assess the probability of arrhythmia recurrence after the procedure. Objective We aimed to implement a machine learning (ML) pipeline to predict 1-year VT recurrence in patients with structural heart disease (SHD) undergoing VT ablation. Methods For 297 patients who underwent VT ablation, we collected medical history, laboratory, echocardiography, and procedural data. Following manual and ML-based feature selection, we trained several supervised machine learning models to predict 1-month and 1-year recurrence. The area under the receiver operating characteristic curve (AUC) was calculated to quantify the models’ performance. Results 1-year VT recurrence was observed in 107 (36%) cases. The best predictions of VT recurrence were demonstrated by random forest models utilizing 7 input features [1-month AUC: 0.74; 1-year AUC: 0.76]. These models significantly outperformed a previously published risk score, the I-VT score [AUC: 0.63, p=0.024] on our data. The most important predictors of recurrence were the number of VT morphologies during the procedure, electrical storm, left ventricular ejection fraction, left ventricular end systolic diameter, and the severity of mitral regurgitation. Conclusion Our machine learning model can efficiently predict VT recurrence in SHD patients undergoing VT ablation. Thus, it could facilitate the prompt identification of high-risk patients and the personalization of treatment and follow-up strategies, ultimately leading to improved outcomes.

Mortality after catheter ablation of structural heart disease related ventricular tachycardia

BackgroundThere is a paucity of data describing mortality after catheter ablation of ventricular tachycardia (VT). ObjectivesWe describe the causes and predictors of cardiac transplant and/or mortality following catheter ablation of structural heart disease (SHD) related VT. MethodsOver 10-years, 175 SHD patients underwent VT ablation. Clinical characteristics, and outcomes, were compared between patients undergoing transplant and/or dying and those surviving. ResultsDuring 2.8 (IQR 1.9–5.0) years follow-up, 37/175 (21%) patients underwent transplant and/or died following VT ablation. Prior to ablation, these patients were older (70.3 ± 11.1 vs. 62.1 ± 13.9 years, P = 0.001), had lower left ventricular ejection fraction ([LVEF] 30 ± 12% vs. 44 ± 14%, P < 0.001), and were more likely to have failed amiodarone (57% vs. 39%, P = 0.050), compared to those that survived. Predictors of transplant and/or mortality included LVEF≤35% (HR 4.71 [95% CI 2.18–10.18], P < 0.001), age ≥ 65 years (HR 2.18 [95% CI 1.01–4.73], P = 0.047), renal impairment (HR 3.73 [95% CI 1.80–7.74], P < 0.001), amiodarone failure (HR 2.67 [95% CI 1.27–5.63], P = 0.010) and malignancy (HR 3.09 [95% CI 1.03–9.26], P = 0.043). Ventricular arrhythmia free survival at 6-months was lower in the transplant and/or deceased, compared to non-deceased group (62% vs. 78%, P = 0.010), but was not independently associated with transplant and/or mortality. The risk score, MORTALITIES-VA, accurately predicted transplant and/or mortality (AUC: 0.872 [95% CI 0.810–0.934]). ConclusionsCardiac transplant and/or mortality after VT ablation occurred in 21% of patients. Independent predictors included LVEF≤35%, age ≥ 65 years, renal impairment, malignancy, and amiodarone failure. The MORTALITIES-VA score may identify patients at high-risk of transplant and/or dying after VT ablation.

Catheter Ablation for Atrial Fibrillation in Structural Heart Disease: A Review

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. Patients with structural heart disease (SHD) are at an increased risk of developing this arrhythmia and are particularly susceptible to the deleterious hemodynamic effects it carries. In the last two decades, catheter ablation (CA) has emerged as a valuable strategy for rhythm control and is currently part of the standard care for symptomatic relief in patients with AF. Growing evidence suggests that CA of AF may have potential benefits that extend beyond symptoms. In this review, we summarize the current knowledge of this intervention on SHD patients.

Correlation of spatial patterns of endocardial pace mapping to underlying scar topography in patients with scar-related ventricular tachycardia.

Endocardial pace mapping (PM) can identify conducting channels for ventricular tachycardia (VT) circuits in patients with structural heart disease (SHD). Recent findings show the temporal and spatial pattern of PM may aid identification of the surface harboring VT isthmii. The specific correlation of PM patterns to scar topography has not been examined. To correlate the pattern of endocardial PMs to underlying scar topography in SHD patients with VT. Data from patients undergoing VT ablation from August 2018 to February 2022 were reviewed. Sixty-three patients with SHD-related VT (mean age 65 ± 14 years) with 83 endocardial PM correlation maps were analysed. Two main correlation patterns were identified, an "abrupt-change correlation pattern (AC-pattern)" and "centrifugal-attenuation correlation pattern (CA-pattern)." AC-pattern had lower scar ratio (unipolar/bipolar % scar area; 1.1 vs. 1.5, p < .001), had longer maximal stimulus-QRS intervals (97.5 vs. 68 ms, p = .002), and higher likelihood of endocardial dominant scar (11/21 [52%] vs. 3/38 [8%], p < .001) than CA-pattern seen on intracardiac echocardiography (ICE). In contrast, CA-pattern was more likely to have epicardial dominant scar or mid-intramural scar on ICE (epicardial dominant scar; CA-pattern: 12/38 [32%] vs. AC-pattern: 1/21 [5%], p = .02, mid-intramural scar; CA-pattern: 15/38 [39%] vs. AC-pattern: 1/21 [5%], p = .005). The spatial pattern of endocardial PM in SHD-related VT directly correlates with scar topography. AC-pattern is associated with endocardial dominant scar on ICE with lower scar ratio and longer stimulus-QRS intervals, whereas CA-pattern is strongly associated with epicardial dominant or mid-intramural scar with higher scar ratio and shorter stimulus-QRS intervals.

Programmed ventricular stimulation in structural heart disease: Implications of patterns of ventricular arrhythmias induced to long-term outcomes

IntroductionCurrently available data gives some credence to utility of VT induction studies in patients with stable ischemic cardiomyopathy, there are some unresolved questions as to define sensitive threshold for low-risk and the prognostic relevance of ill sustained or non-specific tachycardia on induction study. We evaluated potential ability of VT inducibility to predict likelihood of SHD (Structural heart disease) patients for subsequent arrhythmic or adverse cardiac events. Material and MethodsAll consecutive patients with syncope/documented arrhythmia who had VT induction done were included and patients with VT storm, ACS,uncontrolled HF were excluded. We studied in 4 groups-monomorphic VT, sustained polymorphicVT, ill sustainedVT/VF and no VT/VF induced. The primary-endpoints were – Sudden death, all-cause mortality and secondary-endpoints were – MACE (AICD shock, death,HF, recurrence of VT). We screened 411 patients and included 169 within inducible (n = 79) and non-inducible group (n = 90). ResultsThere were a higher number of patients with coronary artery disease, LV dysfunction, patients on amiodarone in inducible group and no difference in usage of beta-blockers. Recurrence of VT, composite of MACE was significantly higher in inducible group (p < 0.05). Mortality was not different in 3 groups compared with no VT/VF group. We found that monomorphic VT group had significantly higher MACE as compared to others and also predicted recurrence of VT and AICD shock and showed a trend towards significance for prediction of mortality. Inducible patients on AICD had mortality similar to non-inducible group. ConclusionInduction of monomorphicVT/polymorphicVT with ≤3extrastimuli is associated with a higher number of MACE events on follow up. Induction of monomorphicVT predicts recurrence of VT/ICD shock.

“Innocent” ventricular arrhythmia – can cardiovascular magnetic resonance augment diagnosis of structural heart disease?

Abstract Background Ventricular arrhythmias (VA) include a spectrum that ranges from premature ventricular beats (VPBs) to ventricular fibrillation (VF) and account for approximately 50% of all cardiovascular deaths. Echocardiography is commonly used to identify structural heart disease (SHD), the most frequent substrate of VA. Cardiovascular magnetic resonance (CMR) is recommended to complement echocardiography when image quality is suboptimal. Purpose This study sought to determine whether CMR may identify SHD in patients (pts) with VA, who had normal baseline ECGs and whose echocardiogram with fair technical conditions, ruled out pathological findings. Methods We included consecutive pts followed in arrythmia outpatient clinic of one clinical center from June 2014 to June 2021 for significant VA; this was categorized as &amp;gt;1,000 but &amp;lt;10,000 VPBs/24 h; ≥10,000 VPBs/24 h; nonsustained ventricular tachycardia (NSVT), sustained VT, or a history of resuscitated cardiac arrest, and no pathological findings at echocardiography, requiring a clinically indicated CMR. Primary endpoint was CMR detection of SHD. Data were collected at the end of the study. Results A total of 75 pts were included (no SHD: N=59; 45±15 years old; SHD: N=16, 53±15 years). All pts performed CMR, and Table 1 shows pts' baseline characteristics, VA diagnosis and CMR measurements. Definite SHD was diagnosed in 8 patients (11%): ischemic cardiopathy (three pts), myocarditis (1 pt), hypertrophic cardiomyopathy (1 pt), right ventricle arrhythmogenic disease (1 pt), non-compaction cardiomyopathy (1 pt); 1 patient presented higher myocardial T2 signal and was later diagnosed with sarcoidosis. Furthermore, abnormal findings not specific for a definite SHD diagnosis were found in other 8 pts (10%) who showed unspecific intra-myocardium enhancement. Discussion and conclusion CMR imaging identified SHD in around 20% of patients with normal ECG and echocardiogram. Among patients with identified SHD, ischemic cardiopathy was the most common finding, differently from the largest study that showed myocarditis as the main diagnosis. This may be associated to higher age in the SHD group. In conclusion, CMR allowed diagnosis of clinically relevant SHD even when echocardiography excluded it. Funding Acknowledgement Type of funding sources: None.

The cardiovascular risk factors profile and structural heart disease in patients with long-term episodes of persistent atrial fibrillation

Background and Aims : To evaluate the cardiovascular risk factors (CVRF) profile and structural heart disease in patients with persistent atrial fibrillation (AF) and the duration of its episode <90 and ≥90 days.

Catheter ablation of well tolerated ventricular tachycardia in patients with structural heart disease: long term follow-up of 62 cases without automatic defibrillator implantation

Abstract Funding Acknowledgements Type of funding sources: None. Background The occurrence of a sustained monomorphic ventricular tachycardias (SMVT) in patients with underlying structural heart disease (SHD) is considered correlated to a poor prognosis, based on historical data in patients with heterogeneous heart disease and clinical presentation; therefore the recommendation for implantation of automatic implantable cardioverter defibrillator (AICD) is strong. Information about prognosis of patients with SMVT is still limited, but recent studies have established that these patients represent a low-risk subgroup for sudden death that could benefit from radiofrequency (RF) ablation of the arrhythmic substrate and the AICD implantation could be deferred during the follow up. Purpose Patients with well-tolerated SMVT, SHD and left ventricular ejection fraction (LVEF) over 30% can benefit from a primary VT ablation strategy without the immediate need for AICD implantation. Methods We reviewed consecutive SHD patients with LVEF over 30% admitted for the occurrence of SMVT and who were treated by RF ablation as a first-choice therapy in a single Italian center, between 2009 and 2020 and who were discharged without AICD implantation. The primary outcome of the study was a composite of all-cause death and recurrence of VT. The secondary outcome was death from all causes. Patients with similar characteristics but who underwent AICD implantation during the same period served as control group. Results Clinical and electrophysiological features of 62 patients were analyzed (Table 1). In the study group, 88% were male; the median age was 72 years (IQR 55-81) and the median LVEF was 50.0% (IQR 40.0-55.0). The estimated success rate of ablative procedures (defined as VT no longer inducible) was around 82%. After a median follow-up of 38.8 months (IQR 15.6-76.1), the primary outcome occurred in 24 patients and the secondary outcome in 11 patients. All-cause mortality was 17%, corresponding to an annual mortality rate of 4.3%. Ten patients died for non-cardiovascular causes and one for advanced heart failure. No patient in the study died from sudden death. During the follow-up, 10 patients (16.1%) underwent AICD implantation due to VT relapse. At 36 months, between study and control groups, there was no difference in either the primary composite outcome (HR 1.03, 95% CI 0.45-2.21, p = 0.98) or in the secondary outcome (HR 1.4, 95% CI 0.48-4.54, p = 0.49). Conclusions Patients with well-tolerated SMVT, SHD and LVEF over 30% represent a subgroup of patients at lower risk that can benefit of RF ablation as a first-choice therapy. Delay in AICD implantation, after a possible VT relapse or clinical worsening, appears to represent a safe therapeutic strategy. Therefore, it is ethical and desirable to start a prospective randomized clinical trial to evaluate the benefit and cost-effectiveness of this strategy, as an alternative to AICD implantation.

A real-world analysis of the effectiveness, resource use, and costs associated with ventricular tachycardia catheter ablation in Japanese patients aged ≤75 years.

Catheter ablation is important to reduce ventricular tachycardia (VT) or to prevent its recurrence, especially in the setting of structural heart disease (SHD). In idiopathic VT current recommendations place ablation as first-line therapy. In SHD patients it is typically reserved for when antiarrhythmic drugs (AADs) have failed, although multicenter randomized controlled trials have demonstrated ablation to decrease VT burden, painful implantable cardioverter-defibrillator / cardiac resynchronization therapy device (ICD/CRT-D) shocks, and recurrence at 6 months.

29 Comparison between pure tachycardiomyopathy and acute heart failure and structural heart disease

Abstract Aims Tachycardiomyopathy (TCM) is a reversible cause of left ventricular dysfunction, secondary to rapid and/or asynchronous, irregular myocardial contraction. The disease can be divided in two main subgroups: arrhythmia-induced TCM also known as pure TCM, where the arrhythmia is the sole reason for the dysfunction, and impure TCM also known as arrhythmia mediated TCM, where the arrhythmia can exacerbate or worsen heart failure (HF) or an underlying heart disease. Pure TCM has already been described as affecting almost 1 out of 10 patients admitted for de novo acute HF. The aim of our study was to compare pure TCM and de novo acute HF and structural heart disease patients in terms of mortality and cardiovascular (CV)-related hospitalizations. Methods and results Prospective, observational study enrolling all consecutive patients with a confirmed diagnosis of TCM and all patients admitted for de novo acute HF. The TCM diagnosis was suspected in all patients admitted for HF-related symptoms, an ejection fraction &amp;lt;50% with concomitant persistent atrial or ventricular arrhythmia, and confirmed after clinical and echocardiographic recovery. Acute HF diagnosis was made in all patients with an ejection fraction &amp;lt;50%, new HF-like symptoms, diagnosis of structural heart disease and no evidence of clinical or echocardiographic recovery. For each patient, all-cause death and CV-related hospitalizations were recorded. One-hundred-and-ten patients with TCM (61.8% males, 68 ± 13 years old) were propensity matched with a control population of patients with HF and structural heart disease (76.6% males, 71 ± 15 years old, 75% ischaemic heart disease). After a median follow-up of 5.1 years (1st–3rd quartile 2.6–7.0 years) TCM patients showed an overall higher estimate of survival when compared to HF patients (78% vs. 58%; P = 0.031; Figure 1A) but a lower estimate of time free from CV-related hospitalization (31% vs. 57%, P = 0.014; Figure 1B). TCM patients got most often readmitted for AF-related elective procedures (60.8% of all hospitalizations) such ablation procedures or elective cardioversion, TCM recurrence (13.7%), and elective coronary angiography (5.9%). On the other hand, HF patients got readmitted for HF worsening (40.9%), cardiac or vascular surgery (22.7%), and elective coronary angiography (9.1%). Propensity-score matched analysis confirmed the results for all-cause death (81% vs. 49%; P = 0.006) and CV-related hospitalizations (29% vs. 54%; P = 0.007). Conclusions TCM is associated with higher rate of survival when compared to de novo acute HF, even after propensity score adjustment. On the other hand, patients with TCM got readmitted more frequently, requiring more often elective procedures in order to control the triggering arrhythmia.

Lessons for Treating Structural Heart Patients during the COVID-19 Pandemic and Beyond

ABSTRACT Background We sought to compare characteristics and outcomes of structural heart disease (SHD) patients treated during the regional peak of the Coronavirus Disease 2019 (COVID-19) pandemic (“COVID era”) compared with historical controls. During the COVID era, elective SHD procedures at Beth Israel Deaconess Medical Center were canceled but urgent cases were still performed. We enacted several practice changes in an effort to minimize complications, prevent COVID transmission, and decrease hospital stay during the pandemic. Methods Baseline characteristics and outcomes were collected on all patients who underwent SHD procedures during the COVID era and compared with patients treated during the same time period in 2019. Results Compared with SHD patients treated during 2019 (N = 259), those treated during the COVID era (N = 26) had higher left ventricular end diastolic pressure (LVEDP; 28 vs. 21 mmHg, p = 0.001), and were more likely New York Heart Association class IV (26.9% vs. 10.0%, p = 0.019), but had a lower rate of bleeding/vascular complications (0% vs. 16.2%, p = 0.013), a lower rate of permanent pacemaker implantation (0% vs. 17.4%, p = 0.019), and a greater proportion of patients were discharged on post-operative day 1 (POD#1; 68.2% vs. 22.2%, p < 0.001). Conclusion Practice changes employed for patients treated during the COVID era were associated with fewer vascular complications, a greater proportion of patients discharged on POD#1, and a lower rate of pacemaker implantation despite more severe illness. As a result, we plan to continue these practices in the post-COVID era.

Higth-sensitivity T troponin and NT pro B-type natriuretic peptide as predictors of early development of structural heart disease in patients with stage 0 of Chagas disease

Abstract Background Approximately 30% of patients with Chagas disease (ChD) develop structural heart disease at some point in their evolution. There is an asymptomatic period where there is no evidence of cardiac involvement, called stage 0. Prognostic evaluation in this group of patients remains a challenge. On the other hand, the presence of elevated hight-sensitivity T troponin (HS-TnT) and N-terminal pro B-type natriuretic peptide (NT-proBNP) has been documented in the early stages of the ChD. The role of these biomarkers as predictors of early development of structural heart disease in the follow-up of stage 0 ChD has been poorly studied. Purpose The aim of this study is to evaluate if HS-TnT and NT-proBNP are a predictor of early development of cardiac structural alterations in the follow up of patients with stage 0 ChD. Materials and methods Outpatients with stage 0 of ChD (positive serology, with normal electrocardiogram, 24-hours holter and echocardiogram) were included prospectively. Baseline measurement of HS-TnT and NT-proBNP was performed. The follow-up was carried out with serial echocardiography and 24-hour Holter. The end point of development of structural heart disease was considered, defined as one of the following: left ventricular dilation (diastolic diameter of left ventricle &amp;gt;60 mm in men or &amp;gt;55 mm in women), deterioration of ventricular function (Drop &amp;gt;10 points of Left Ventricular Ejection Fraction (LVEF) or LVEF &amp;lt;50%), Complex ventricular arrhythmia or Atrio-ventricular block ≥ second degree Mobitz II. Univariate and multivariate analysis was performed by cox regression. Results Three hundred two patients were included, with 47±9 years old, 46% woman. With a median of follow-up of 34 (interquartile range 19 – 43) months, the end point of development of structural heart disease was presented in 4.6% (n=14 patients). In multivariate analysis both HS-TnT and NT-ProBNP were independent predictors of development of structural heart disease [HR 1.18 (IC95% 1.05–1.33), p=0.003 and HR 1.01 (CI95% 1.00–1.01), p=0.001; respectively]. The area under the Receiver operating characteristic (ROC) curve was calculated, for HS-TnT it was 0.80 (95% CI 0.65–0.93), with a cut-off point for HS-TnT &amp;gt;14 ng/ml and for NT-proBNP it was 0.88 (95% CI 0.83–0.95) with a cut-off point for NT-proBNP &amp;gt;200 pg/ml. The figure shows the Kaplan-Meier curve for HS-TnT and NT-proBNP. In adjusted analysis, HS-TnT &amp;gt;14 ng/ml had a HR 5.27 (CI95% 1.4–18.9), p=0.01 and NT-proBNP HR 3.07 (CI95% 1.01–10.9), P=0.04. Conclusions In our population of patients with stage 0 chagas disease, HS-TnT and NT-proBNP were independent predictors of early development of structural heart disease, with good predictive capacity. The baseline measurement of these biomarkers can be useful in the evaluation and follow-up of patients with ChD without initial evidence of cardiac involvement. Funding Acknowledgement Type of funding sources: None. Kaplan-Meier curve

Safety and efficacy of catheter ablation for ventricular tachycardia in elderly patients with structural heart disease: a systematic review and meta-analysis.

Data regarding the age-specific outcomes of VT ablation in patients with structural heart disease (SHD) are scarce. We performed a systematic review and meta-analysis to evaluate the outcomes of VT ablation in elderly vs. younger patients with SHD. MEDLINE/PubMed, Cochrane, and Google Scholar and references comparing VT ablation in elderly vs. younger patients were screened and studies included if matching inclusion and exclusion criteria. Five retrospective studies enrolling 2778 SHD patients (868 elderly vs. 1910 younger) were included. Compared to younger subjects, the elderly showed similar results in terms of acute ablation success (OR 0.78, 95% CI 0.54-1.13, p = 0.189) and minor complications (OR 1.74, 95% CI 0.74-4.09, p = 0.205), a trend toward a higher risk of major complications (OR 2.30, 95% CI 0.83-6.40, p = 0.110) and significantly higher rates of all complications (OR 2.67, 95% CI 1.51-4.71, p = 0.001) and periprocedural mortality (OR 1.93, 95% CI 1.24-3.01, p = 0.004). At a mean follow-up of 18months, elderly patients showed similar long-term VT recurrence rate (OR 1.02, 95% CI 0.85-1.22, p = 0.861) and higher all-cause mortality (OR 2.00, 95% CI 1.40-2.86, p < 0.001). In elderly patients, urgent VT ablation is associated with higher risk of major complications (beta = 0.06, p < 0.001) and periprocedural mortality (beta = 0.03, p = 0.029), while advanced age is associated with higher risk of major complications (beta = 0.29 with p = 0.009) and all complications + periprocedural mortality (beta = 0.17 with p = 0.037). Compared to younger patients, VT ablation in elderly showed similar results in terms of acute ablation success and long-term VT recurrence rate with a significantly higher risk of all complications, periprocedural mortality, and long-term mortality, especially when the procedure is performed urgently and in the most aged patients. Large prospective multicenter randomized trials are required to confirm these findings.

Magnetic Resonance Detects Structural Heart Disease in Patients with Frequent Ventricular Ectopy and Normal Echocardiographic Findings.

The prognosis of patients with ventricular ectopy and a normal heart, as evaluated by echocardiography, is virtually unknown. Cardiac magnetic resonance (CMR) can detect focal ventricular anomalies that could act as a possible site of origin for premature ventricular contractions (PVCs). The aim of this study was to investigate the presence of cardiac anomalies in patients with normal findings at echocardiogram. Methods: Fifty-one consecutive patients (23 women, 28 men, mean age 59 years) with very high PVC burden (>10,000 PVC/day) and normal findings at standard echocardiography and exercise test were examined with CMR. The outcome was pathologic findings, defined as impaired ejection fraction, regional wall motion abnormalities, abnormal ventricular volume, myocardial edema and fibrosis. Results: Sixteen out of 51 patients (32%) had structural ventricular abnormalities at CMR. In five patients CMR showed impairment of the left ventricular and/or right ventricular systolic function, and six patients had a dilated left and/or right ventricle. Regional wall motion abnormalities were seen in six patients and fibrosis in four. No patient had CMR signs of edema or met CMR criteria for arrhythmogenic right ventricular cardiomyopathy. Five patients had extra-ventricular findings (enlarged atria in three cases, enlarged thoracic aorta in one case and pericardial effusion in one case). Conclusions: In this study 16 out of 51 patients with a high PVC burden and normal findings at echocardiography showed signs of pathology in the ventricles with CMR. These findings indicate that CMR should be considered in evaluating patients with a high PVC burden and a normal standard investigation.