Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)
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Cardiology News / Recent Literature Review / Third Quarter 2015
Get PDFTCT Meeting 2015: San Francisco, 11-15/10/2015HCS Congress: Thessaloniki, 29-31/10/2015AHA Scientific Sessions: Orlando, 7-11/11/2015Boston AF Symposium: Orlando, 14-16/1/2016ACC 65th Annual Session: Chicago, 2-4/4/2016HRS 37th Annual Meeting: San Francisco, 4-7/5/16CardioStim/Europace: Nice, 8-11/6/2016Euro PCR: Paris, 17-20/5/2016ESC Meeting: Rome, 27-31/8/2016Sustained Chronic Obesity Results in Chronic Stretch, Diffuse Interstitial Fibrosis, Conduction Abnormalities, and Increased Vulnerability to AFIn an animal study, 10 chronically obese sheep, compared with 10 age-matched controls, demonstrated greater total body fat, left atrial (LA) volume, LA pressure, and pulmonary artery pressures, reduced atrial conduction velocity with increased conduction heterogeneity, increased fractionated electrograms, decreased posterior LA voltage, and increased voltage heterogeneity (all p<0.001), with no change in the effective refractory period (ERP) or ERP heterogeneity. Obesity was associated with more episodes (p=0.02), prolongation (p=0.01), and greater cumulative duration (p=0.02) of atrial fibrillation (AF). Epicardial fat infiltrated the posterior LA in the obese group (p<0.001), consistent with reduced endocardial voltage in this region. Atrial fibrosis (p=0.03) and atrial transforming growth factor (TGF)-β1 protein (p= 0.002) were increased in the obese group. The authors concluded that obesity results in global biatrial endocardial remodeling, and increased propensity for AF (Mahajan R et al, J Am Coll Cardiol 2015;66:1-11).An Increased Percentage of PVCs on 24-h Holter Monitor Confers a Decrease in LVEF, Increased Incident CHF, and Increased Mortality: PVCs might be an Important Cause of Occult or “Idiopathic” Cardiomyopathy and an Important Determinant of Incident CHF Among Those with Other Established CHF Risk FactorsAmong 1,139 Cardiovascular Health Study (CHS) participants, with a normal LVEF and no history of CHF, randomly assigned to 24-h Holter monitoring, those in the upper quartile vs the lowest quartile of PVC frequency had a 3-fold greater odds of a 5-year decrease in LVEF (odds ratio - OR: 3.10; p= 0.005), a 48% increased risk of incident CHF (HR: 1.48; p= 0.02), and a 31% increased risk of death (HR: 1.31; p = 0.01) during a median follow-up of >13 years. The specificity for the 15-year risk of CHF exceeded 90% when PVCs included at least 0.7% of ventricular beats. The population-level risk for incident CHF attributed to PVCs was 8.1%. The authors concluded that in a population-based sample, a higher frequency of PVCs was associated with a decrease in LVEF, an increase in incident CHF, and increased mortality (Dukes JW et al, J Am Coll Cardiol 2015;66:101-109)... (excerpt
Hypertrophic Cardiomyopathy: Recent Evidence on Genotype-Phenotype Correlation
Get PDFHypertrophic cardiomyopathy (HCM), in contrast to common prejudications, has been recognized as the most common genetically determined cardiac disease. It is inherited with an autosomal dominant pattern and many different mutations in numerous genes responsible for the production of sarcomere proteins and other regulatory molecules contributing to the systolic function of cardiac myocyte have been identified. The natural course of the disease is benign in the majority of cases and most patients achieve near-normal life expectancy. Unfavorable prognosis is established mainly on the basis of clinical, morphological and family history data. The genotype contributes undoubtedly to the clinical picture. However, the existing data do not allow for a consistent genotype-phenotype correlation and hence genetic information is not incorporated in modern risk assessment clinical tools. In this brief review we summarize the recent data on the genetic characterization of HCM
An Underexpanded Stent Does not Forgive
Get PDFResistant coronary lesions regularly challenge physicians performing percutaneous coronary interventions (PCI) and specific techniques may be required to achieve procedural success. Underestimation of a resistant lesion may result in implanting an underexpanded stent due to insufficient plaque modification. Stent underexpansion is a risk factor for stent thrombosis and particularly difficult to treat. We present herein a case of a resistant right coronary artery lesion, insufficiently modified before stenting and finally treated with an underexpanded stent which could not be expanded by balloon post-dilatation at the initial intervention. Two inferior wall myocardial infarctions ensued one and three years later, both due to stent thrombosis despite intensive dual antiplatelet therapy and both treated by primary PCI. The stent could only be expanded by aggressive non-compliant balloon dilatation at the last procedure. The case presentation is followed by a brief discussion concerning techniques to successfully treat resistant coronary lesions and underexpanded stent
Ablation Techniques in a Patient with a Right Accessory Pulmonary Vein. Is it Always Feasible?
Get PDFA 32-year-old woman with lone paroxysmal atrial fibrillation had two pulmomary vein isolation procedures over 1 year, by means of the circular multipolar duty-cycled radiofrequency PVAC catheter in the first and the Thermocool® SmartTouchTM catheter in the second procedure. Following both procedures, the patient remained highly symptomatic on a weekly to monthly basis and a third procedure was performed by using the second generation of cryoballoon Arctic Front AdvanceTM. Right inferior pulmonary vein was completely reconnected and an extreme hockey stick configuration was necessary in order to achieve complete occlusion and isolation. Thirty months later the patient remains symptom free in the absence of any therapy. Rhythmos 2016;11(4):96-97
Cardiology News / Recent Literature Review / Last Quarter 2015
Get PDFBoston AF Symposium: Orlando, 14-16/1/2016ACC 65th Annual Session: Chicago, 2-4/4/2016HRS 37th Annual Meeting: San Francisco, 4-7/5/16CardioStim/Europace: Nice, 8-11/6/2016Euro PCR: Paris, 17-20/5/2016ESC Meeting: Rome, 27-31/8/2016Targeting Ablation to the Distal Segment of the Main Renal Artery and Post-Bifurcation Branches May Optimize Renal Denervation (RDN)Insufficient procedural efficacy has been proposed to explain nonresponse to renal denervation (RDN). The impact of different patterns of lesion placements on the efficacy and consistency of catheter-based radiofrequency (RF) RDN was examined in pigs. Increasing the number of RF lesions (4, 8, and 12) in the main renal artery was not sufficient, but targeted treatment of the renal artery branches or distal segment of the main renal artery resulted in markedly less variability of response and significantly greater reduction of both norepinephrine (NE) and axon density than conventional treatment of only the main renal artery. Combination treatment (main artery plus branches) produced the greatest change in renal NE and axon density with the least heterogeneity. The changes lasted through 28 days post-treatment (Mahfoud F et al, J Am Coll Cardiol 2015;66:1766-1775).High Levels of Cardiorespiratory Fitness in Midlife Confer Lower Mortality, Use of Health Care Resources, and Health Care Costs Later in LifeAmong 19,571 healthy individuals who underwent cardiorespiratory fitness assessment at a mean age of 49 years, over 126,388 person-years of follow-up, average annual health care costs were significantly lower for participants aged >65 years with high than low midlife fitness in both men and women. Average annual health care costs in later life were incrementally lower per MET achieved in midlife in men and women. The authors concluded that higher cardiorespiratory fitness in middle age is strongly associated with lower health care costs at an average of 22 years later in life, independent of cardiovascular risk factors (Bachmann JM et al, J Am Coll Cardiol 2015;66:1876-1885).Moderate Physical Activity is Associated with a Reduced Risk of Atrial Fibrillation (AF) in Middle-Aged and Elderly Women According to a Swedish study comprising 36,513 AF-free women (aged 49–83, median 60 years) during a median of 12 years, 2915 cases of AF were diagnosed. The risk of AF decreased with increasing levels of leisure-time exercise at study entry (relative risk - RR 0.85, for ≥4 h/week vs <1 h/week) and walking/bicycling (RR 0.81, for ≥40 min/day vs almost never) (Drca N et al, Heart 2015;101:1627-1630)... (excerpt
Atrial Fibrillation and Cognitive Impairment
Get PDFGrowing evidence suggests that atrial fibrillation (AF), in addition to its known thromboembolic risk, is a risk factor for significant cognitive impairment via several pathways, further contributing to morbidity and mortality. Whether anticoagulation, rhythm control strategies and other interventions aiming at preventing thromboembolic events and ameliorating the clinical outcome of AF patients, may also have a beneficial effect on long-term cognitive function remains to be seen in future studies
Minimally Invasive Hemodynamic Monitoring in Intensive Care Unit. A Brief Review
Get PDFTo avoid use of a Swan-Ganz catheter and its attendant complications, new technologies have now become available to help the clinician perform a less invasive hemodynamic monitoring in patients in the intensive care unit (ICU). Among these, conventional echocardiography, the esophageal Doppler, pulse pressure analysis, the transpulmonary thermodilution, the indicator dilution and the thoracic electrical bioimpedance and bioreactance, all aim at measuring stroke volume and cardiac output by less invasive means and they are herein briefly reviewed
The End of the Digoxin Era?
Get PDFDigoxin is one of the oldest of cardiovascular drugs which is still frequently used, both in patients with atrial fibrillation (AF) and patients with heart failure with or without AF. The use of digoxin preceded the era of evidence based medicine. However, over the recent past, there has been growing evidence disputing and challenging the safety and efficacy of digoxin, while evidence has accumulated that a plethora of other therapies for both heart failure and atrial tachyarrhythmias has proven more effective and safe. Nevertheless, digoxin still retains its role, albeit limited, in the current era, but most recent evidence has cast significant doubts about its safety. Thus, its role remains controversial and the drug should be reserved for specific patients and clinical scenarios, with careful monitoring of its serum concentration due to its narrow therapeutic and toxic ranges, maintaining it <0.8 ng/mL, with additional monitoring of serum electrolytes and renal function to avoid potential confounders that may enhance the proarrhythmic risk and susceptibility to digoxin toxicity.
Typical Atrial Flutter Ablation: Demonstration of Cavo-Tricuspid Isthmus Block Aided by a Halo Catheter
Get PDFA 61-year-old gentleman with one-year history of atrial flutter (see typical saw-tooth appearance of flutter –F waves in the inferior ECG leads in Panel A) refractory to antiarrhythmic agents was submitted to cavotricuspid isthmus ablation. During the procedure, use of an eicosapolar halo catheter (Panel B, arrow) helped to demonstrate the counterclockwise direction of activation (from proximal pole pairs Halo 10 toward Halo 1, Panel D). Upon completion of the ablation line along the isthmus, conversion of atrial flutter into sinus rhythm was noted (Panel C, arrow). With the aid of the halo catheter, bidirectional block could be easily determined by pacing near the coronary sinus os (Panel E, arrow) and recording the late activation of Halo 1, which was withdrawn to the lateral wall of the low right atrium, and finally pacing at the low lateral wall (Panel F, arrow) and recording late activation by the catheter near the coronary sinus os... (excerpt
Cardiology News /Recent Literature Review / Last Quarter 2014
Get PDF20th Annual Boston AF Symposium: Orlando, 8-10/1/15HCS Working Groups Seminar: Ioannina, 2/2015ACC: San Diego, 14-16/3/15HRS: Boston, 13-16/5/15EuroPCR: Paris, 19-22/5/15Europace: Milan, 21-24/6/15ESC: London, 29/8-2/9/15AFFORD study: n-3 Polyunsaturated Fatty Acids (Fish Oil) do not Reduce Atrial Fibrillation RecurrencesIn a double-blind, randomized, placebo-controlled trial of fish oil (4 g/day, docosahexaenoic acid - DHA: eicosapentaenoic acid - EPA 1:2) vs safflower oil placebo in 337 patients with symptomatic paroxysmal or persistent AF followed for 9 ± 4 months, the primary endpoint (time to first symptomatic or asymptomatic AF recurrence lasting >30 s) occurred in 64% of patients in the fish oil arm and 63% of patients in the placebo arm (hazard ratio: 1.10; p= NS). hs-CRP and myeloperoxidase - MPO were normal at baseline and decreased to a similar degree at 6 months. The authors concluded that high-dose fish oil does not reduce AF recurrence in patients with a history of AF not receiving AA therapy, and does not reduce inflammation or oxidative stress markers in this population (Nigam A et al, J Am Coll Cardiol 2014;64:1441-1448). N.B.: Another randomized study (VITAL - VITamin D and OmegA-3 TriaL) is currently examining the effect of 1 g/d of n-3 PUFAs on AF in a much larger population (N=25,875) without cardiac disease over 5 years.RELAX-AHF: Serelaxin Reduces Mainly Cardiova-scular & Sudden Deaths, Rather than HF DeathsThe RELAX-AHF study showed that IV serelaxin (recombinant human relaxin-2) compared with placebo reduced mortality at 6 months among 1,161 patients with acute heart failure (HF). In this group there were 107 deaths (9.3%): 37 (35%) from HF, 25 (23%) from sudden death, 15 (14%) from other cardiovascular (CV) causes, 19 (18%) from non-CV causes, and 11 (10%) classified as unknown. The treatment effect of serelaxin was most pronounced on other CV deaths (hazard ratio - HR: 0.29; p= 0.005) and sudden death (HR: 0.46; p= 0.065), with no effect of serelaxin treatment on HF or non-CV deaths. The authors concluded that the effects of serelaxin on mortality were mainly due to reduced CV causes and sudden death, without apparent effect on HF deaths (Feleker GM et al, J Am Coll Cardiol 2014;64:1591-1598). N.B.: an ongoing large phase III outcome trial (NCT01870778) will further examine serelaxin’s effect on mortality.ARISTOTLE: Anticoagulation Quality was Lower in Warfarin-Treated Patients who Received Amiodarone, and Amiodarone was Associated with Significantly Higher Risk of Thrombo-embolism, while Apixaban had a Benefit over Warfarin in Both GroupsIn the ARISTOTLE trial, 2,051 (11.4%) patients received amiodarone. Time in the therapeutic range (TTR) in patients on warfarin and amiodarone was lower than patients not on amiodarone (56.5% vs 63%; p<0.0001). More patients on amiodarone had thromboembolism (stroke or systemic embolism) (1.58%/year vs 1.19%/year; hazard ratio -HR: 1.47; p= 0.0322). Mortality and major bleeding rates were higher, albeit not significantly different, in the amiodarone vs the non-amiodarone group. Apixaban, compared with warfarin, decreased systemic embolism, death, and major bleeding in both groups. The authors concluded that amiodarone was associated with significantly increased stroke and systemic embolism risk and a lower TTR when used with warfarin. Apixaban consistently reduced the rate of stroke and systemic embolism, death, and major bleeding compared with warfarin in both (amiodarone and non-amiodarone) groups (Flaker G et al, J Am Coll Cardiol 2014;64:1541-1550)... (excerpt