Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)
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Impasse During Cardiac Implantable Electronic Device Lead Extraction: Only Patience, Endurance and the Right Tools Can Bail You Out
Get PDFA case of complex and arduous percutaneous cardiac implantable electronic device (CIED) lead extraction is presented that illustrates several aspects of technical challenges that may emerge during the procedure requiring a change of strategy, appropriate tool selection, and operator and patient endurance. Rhythmos 2018;13(4):78-80
The Diminished Role of an Electrophysiology Study in the Current Guidelines for Sudden Cardiac Death
Get PDFAccording with the new European and American guidelines, the role of an electrophysiology study (EPS) remains small for risk stratification for sudden cardiac death (SCD), limited to patients with an LVEF >35%, mostly indicated when evaluating symptoms suggestive of ventricular tachyarrhythmias, including palpitations, presyncope and syncope, mainly in those with underlying structural heart disease, particularly coronary artery disease in the setting of a remote myocardial infarction rather than non-ischemic cardiomyopathy. Importantly, there is no indication or need of EPS as a prerequisite for any of the standard indications of implantable cardioverter defibrillator (ICD) for secondary or primary prevention of SCD. Rhythmos 2018;13(1): 1-4
Catheter Ablation in Patients With Heart Failure: Current Data from Recently Published Randomized Trials
Get PDFAtrial fibrillation in patients with heart failure with reduced left ventricular ejection fraction is common and is associated with an increased risk of mortality, hospitalization and all-cause death. Rhythm control via medical treatment in these patients is restricted to use of amiodarone as the only suitable antiarrhythmic drug with the least proarrhythmic effect compared to other antiarrhythmic drugs for this population of patients. Over the last years there is a growing evidence that catheter ablation is beneficial in patients with heart failure since randomized clinical trials with hard endpoints have already been published. However, there are still unanswered questions about the patient categories that could benefit from the ablation procedures and the optimal ablation strategies in these patients. These issues are herein reviewed. Rhythmos 2018;13(4):75-77
Cardiology News / Recent Literature Review / Last Quarter 2017
Get PDFAF Symposium 2018: Orlando, FL, 11-13/1/208ACC.18 Congress: Orlando, FL, 10-12/3/2018EHRA Meeting: Barcelona, 18-20/3/2018HRS Meeting: Boston, 9-12/5/2018EuroPCR Meeting: Paris, 22-25/5/2018ESC Meeting: Munich, 25-29/8/2018SPAIN Study: Dual-Chamber Pacing With Closed Loop Stimulation (DDD-CLS) Reduced Syncope Burden and Time to First Recurrence by 7-Fold, and Prolonged Time to First Syncope Recurrence in Patients Age≥40 Years With Tilt-Induced Cardio-inhibitory Vasovagal SyncopeDDD-CLS pacing is a rate-responsive mode that uses intracardiac impedance as a surrogate of cardiac contractility to adapt heart rate to patient needs. Among 46 patients, aged 56.30 ± 10.63 years, with tilt-induced cardioinhiboitory vasovagal syncope, the proportion of patients with ≥50% reduction in the number of syncopal episodes was 72% with DDD-CLS compared with 28% with sham DDI mode (p=0.017). A total of 4 patients (8.7%) had events during DDD-CLS and 21 (45.7%) during sham DDI (hazard ratio: 6.7). Kaplan-Meier curve was significantly different between groups in time to first syncope: 29.2 months vs 9.3 months (p< 0.016); odds ratio: 0.11 (p< 0.0001) (Baron-Esquivias G et al, J Am Coll Cardiol 2017;70: 1720–28).PESA Study: Skipping Breakfast is Associated With an Increased Odds of Prevalent Noncoronary and Generalized Atherosclerosis Independently of the Presence of Conventional CV Risk Factors Three patterns of breakfast consumption were studied: high-energy breakfast, when contributing to >20% of total daily energy intake (27% of the population); low-energy breakfast, when contributing between 5% and 20% of total daily energy intake (70% of the population); and skipping breakfast, when consuming <5% of total daily energy (3% of the population). Independent of the presence of traditional and dietary CV risk factors, and compared with high-energy breakfast, habitual skipping breakfast was associated with a higher prevalence of noncoronary (odds ratio-OR: 1.55) and generalized (OR: 2.57) atherosclerosis (Uzhova I et al, J Am Coll Cardiol 2017;70: 1833-42)."Real life" Longevity of Implantable Cardioverter-Defibrillator Devices (ICDs) Much Shorter than Manufacturers’ Projected LongevityManufacturers of implantable cardioverter-defibrillators (ICDs) promise a 5- to 9-year projected longevity; however, real-life data indicate otherwise. Over 20 years, among 685 ICD patients (601 men; age, 63.1 ± 13.3 years) with coronary (n = 396) or valvular (n = 15) disease, cardiomyopathy (n = 220), or electrical disease (n = 54) (mean ejection fraction 35%) and devices implanted for secondary (n = 562) or primary (n = 123) prevention (292 single-, 269 dual-chamber and 124 CRT devices implanted in the abdomen in 17 or chest in 668), ICD pulse generator replacements were performed in 238 patients. These were 209 men and 29 women, aged 63.7 ± 13.9 years, with ejection fraction of 37.7% ± 14.0%, who had an ICD for secondary (n = 210) or primary (n = 28) prevention. The mean ICD longevity was 58.3 ± 18.7 months. In 20 (8.4%) patients, devices exhibited premature battery depletion within 36 months. Most (94%) patients had none, minor, or modest use of ICD therapy. Longevity was longest for single-chamber devices and shortest for CRT devices. Latest-generation devices replaced over the second decade lasted longer compared with devices replaced during the first decade. When analyzed by manufacturer, Medtronic devices appeared to have longer longevity by 13 to 18 months. The authors concluded that ICDs continue to have limited longevity of 4.9 ± 1.6 years, and 8% demonstrate premature battery depletion by 3 years. CRT devices have the shortest longevity (mean, 3.8 years) by 13 to 17 months, compared with other ICD devices (Manolis AS et al, Clin Cardiol 2017;40:759-764)... (excerpt
Cardiac Allograft Vasculopathy in Redo-transplants: Is it More or Less the Same the Second Time Around?
Get PDFPurpose: Cardiac allograft vasculopathy (CAV) continues to hinder the long-term success of heart transplant recipients. Redo-transplantation is currently the only definitive treatment for advanced CAV. We examined whether these patients are at similar CAV-risk with the second transplantMethods: Heart recipients from 1985 to 2011 at the UTAH program were included in the study and those with CAV as an indication for redo-transplantation were identified. CAV diagnosis was made by coronary angiography and based on the 2010 ISHLT standardized nomenclature for CAV. Patient demographics, rejection history, and CAV incidence were analyzed. Results: Of the 1,169 eligible patients, 135 (11.5%) developed CAV post their first transplant; 78 cases within 10 years and 54 beyond 10 years. The mean time to CAV was 6.58 years. Of the 135 patients who developed CAV, only 21 (15.5%) ended up requiring a redo-transplant. Of the 21 retransplanted patients, 4 (19.0%) developed CAV again; 2 patients within 10 years and 2 patients beyond 10 years indicating a similar risk for CAV occurrence for first and redo-transplant. Conclusions: Our results indicate that CAV is as likely to develop in redo-transplants despite recent advances in immunosuppression and the standardized use of lipid-lowering agents. Although outcomes in redo-transplantation for the indication of CAV are favorable, efforts to better understand and minimize CAV are needed, especially in the face of scarce donor organs
2:1 and Mobitz Type II Atrioventricular Block: A Common Fallible Diagnosis
Get PDFA patient with Wenckebach phenomenon followed by runs of 2:1 atrioventricular (AV) block, labeled as Mobitz type II AV block by the referring physician, was referred for permanent pacemaker implantation. Apropos with this case and similar publications with this fallible diagnosis, the correct diagnosis of second degree AV block is revisited. It is pointed out that an ECG diagnosis of 2:1 AV block is by no means synonymous to Mobitz type II AV block, as two successive PR intervals are required to make a distinction between Mobitz type I and type II, which is never the case with a constant 2:1 AV block recording. On the other hand, the correct diagnosis can only be made by association. When longer ECG recordings are available and at least two consecutive PR intervals are seen, as in the present case, and one can discern a definite pattern of Mobitz type I (with progressive PR prolongation) or type II block (with stable PR intervals), then one can conclude that the 2:1 AV block is a consequence of one of the two types. Rhythmos 2018;13(2): 35-37
Aspirin Hypersensitivity and Coronary Artery Disease: A Difficult Clinical Issue
Get PDFCardiovascular disease is highly prevalent in modern western societies and aspirin has been established as an irreplaceable drug in such patients. A small but non-negligible number of these patients, manifest hypersensitivity to aspirin and /or other non-steroidal anti-inflammatory drugs (NSAIDs), which can take different forms depending on the underlying pathophysiology and clinical variability. In this brief communication, we review the types of hypersensitivity to NSAIDs, the diagnostic steps and its management, focusing on desensitization protocols in patients who require coronary interventions and long-term salicylate administration. Rhythmos 2018;13(2);30-34
CABANA Trial: The Aftermath after the Negative / Neutral Results
Get PDFThe results of the CABANA trial were recently presented at the Heart Rhythm Society Meeting in May 2018, indicating that ablation in patients with atrial fibrillation (AF) did not confer a benefit over drug treatment in the intention-to treat analysis, but did so in an on-treatment analysis. The presentation stirred commotion in the medical community with fierce controversy appearing in the media, mostly related to an apparent willingness of electrophysiologists to dispel the first and accept the second type of analysis. Rhythmos 2018;13(3): 45-47
Percutaneous Revascularization Strategy for Acute Coronary Syndrome With Two Culprit Arteries and Distal Left Main Disease With Consecutive Bifurcation Lesions
Get PDFThe case of a patient with NSTEMI is presented who was shown to have two culprit thrombotic coronary lesions and underwent successful percutaneous coronary intervention for multivessel coronary artery disease at a staged approach. Rhythmos 2018;13(3):54-58
Cardiology News / Recent Literature Review / Third Quarter 2018
Get PDFRhythmos 2018;13(4):81-88. HCS 39th Meeting: Athens, 18-20/10/2018AHA Meeting: Chicago, IL, USA, 10-12/11/2018ACC.19 Meeting: New Orleans, LA, USA, 16-18/3/2019EHRA Congress: Lisbon, 17-19/3/2019HRS Meeting: San Francisco, CA, USA, 8-11/5/2019EuroPCR: Paris, 21-24/5/2019ESC Meeting: Paris, 31/8-4/9/2019NOACs are All Associated With a Significant Standardized Absolute Risk Reduction of MI Compared With VKAAmong 31,739 patients with atrial fibrillation (AF) (median age, 74 years; 47% females), the standardized 1-year risk of MI for VKA was 1.6%, 1.2% for apixaban, 1.2% for dabigatran, and 1.1% for rivaroxaban. No significant risk differences were observed in the standardized 1-year risks of MI among the NOACs: dabigatran vs apixaban (0.04%), rivaroxaban versus apixaban (0.1%), and rivaroxaban versus dabigatran (−0.1%). The risk differences for NOACs vs VKA were all significant: −0.4% for apixaban, −0.4% for dabigatran, and −0.5% for rivaroxaban (Lee CJ-Y et al, J Am Coll Cardiol 2018;72: 17–26). ATLAS ACS 2-TIMI 51 Trial: In Patients With ACS, Addition of Rivaroxaban, 2.5 mg bid, to Dual Antiplatelet Therapy With Aspirin and Clopidogrel Was Associated With a Net Reduction in Fatal or Irreversible Events Compared to Dual Antiplatelet Therapy AloneRivaroxaban, 2.5 mg bid, in ACS patients treated with aspirin and clopidogrel/ticlopidine was associated with 115 fewer fatal or irreversible ischemic events (663 for placebo vs 548 for therapy) and 10 additional fatal or irreversible seriously harmful events (33 vs 23 for placebo) per 10,000 patient-years of exposure. Thus, there would be 105 fatal or irreversible events prevented per 10,000 patient-years of exposure to rivaroxaban compared with placebo, with 11 (10 of 115) fatal or irreversible ischemic events prevented for each fatal or irreversible seriously harmful event caused. If only nonbleeding cardiovascular death is included as a fatal or irreversible event, then 95 events would be prevented per 10,000 patient-years of exposure in the group taking 2.5 mg bid (Gibson CM et al, J Am Coll Cardiol 2018;72: 129-36)XANTUS Program: In a Pooled Analysis of Several practice-Based Registries, AF Patients on Rivaroxaban Had Generally Low Rates of Stroke, Bleeding, and Treatment Discontinuation and Results Were Broadly Consistent Across Different Regions of the WorldAmong 11,121 AF patients receiving rivaroxaban (mean age 70.5±10.5 years; female 42.9%) with comorbidities including heart failure (21.2%), hypertension (76.2%), and diabetes (22.3%), event rates were: events/100 patient-years: major bleeding 1.7 (lowest: Latin America 0.7; highest: Western Europe, Canada, and Israel 2.3); all-cause death 1.9 (lowest: Eastern Europe 1.5; highest: Latin America, Middle East, and Africa 2.7); and stroke or systemic embolism 1.0 (lowest: Latin America 0; highest: East Asia 1.8). One-year treatment persistence was 77.4% (lowest: East Asia 66.4%; highest: Eastern Europe 84.4%) (Kirchhof P et al, J Am Coll Cardiol 2018;72:141-53)... (excerpt