Bioethics

Introduction: "Takotsubo cardiomyopathy" is characterized by transient LV dysfunction and mimicking acute myocardial infarction. Case presentation: We reported a case with atypical presentation of "takotsubo cardiomyopathy" without ST segment elevation, but with severe transient left ventricular dysfunction. Conclusion: Diagnosis of "takotsubo cardiomyopathy" should be based on typical left ventricular dysfunction without coronary artery disease.

Background: Myocardial blush grade (MBG) predicts mortality after reperfusion of ST-segment elevation myocardial infarction patients even among those achieving normal epicardial reperfusion. Whether MBG is useful in predicting outcomes in non-ST segment elevation (NSTEMI) patients after early invasive management is unknown.

Background: Cardiac re-synchronization therapy (CRT) is a proven therapy in patients (pts) with cardiomyopathy (CM). In these pts, the presence of myocardial scar (Sc), by cardiac magnetic resonance (CMR), is a poor prognostic factor. We sought to assess the effect of Sc on survival in pts undergoing CRT. Methods: We included 98 consecutive pts with CM (54% ischemic) who underwent CMR followed by CRT placement. Overall survival was the primary outcome with a median follow-up of 2.5 years (yrs) post CRT implantation. A Cox proportional hazards regression model was built to predict mortality as a function of % Sc on CMR, after adjustment for baseline risk factors, including LBBB and an interaction term between % Sc and time. Results: Mean age was 62 yrs (+/-12), 33% were females. Mean EF by CMR was 23% (+/-10) with a median time from CMR to CRT of 81 days. During follow-up, 28 patients died (22 with ICM). After adjusting for baseline factors and LBBB, % Sc × time was statistically significant. %Sc significantly predicted mortality in the 1st year post CRT; the estimated HR for pts with moderate (5-30%) and severe scar (>30%) were 36.2 and 61.7, relative to those with mild scar (p=0.001 and p=0.007); in contrast, the estimated HRs were 0.54 and 1.31, respectively for moderate and severe scar (p<0.001 and p=0.012) after 1 year, (Figure 1). Conclusions: In pts with CM undergoing CRT, higher %Sc is associated with significant risk of mortality in the 1st year, with a diminished effect as time passes.

Background: Obesity may be associated with an increased risk of developing heart failure but also with improved survival in patients with heart failure. However, the effect of body mass index (BMI) in patients with heart failure undergoing CRT implantation is unknown. Methods: We retrospectively reviewed patients receiving CRT at our hospital (n=805) with a diagnosis of heart failure, echo both pre-CRT (EF < 35 %) and post-implant echo close to 6 months to measure response to CRT, defined as an improvement of EF of > 5 %. BMIs for each of these patients were calculated and patients were separated into 3 categories: (normal BMI < 25, overweight BMI 25 to < 30, and obese BMI > 30). Survival was calculated as time from implant to death, LVAD implantation, or heart transplant. Results: CRT response was similar among all 3 groups (normal weight: 60.4%, overweight 61.6%, obese 68.6%, p=0.10 among all 3). However, survival differed significantly. Obesity conferred a significant benefit in this population (p<0.001). In a multivariable cox regression with univariate predictors, significant predictors of improved survival (p <0.05) were higher BMI level, female sex, NICM, lower creatinine level, and lower NYHA class. Conclusion: Obesity has a significant survival advantage in patients implanted with CRT independent of its effect on left ventricular remodeling and improvement in ejection fraction.

Background: Patients with severe left ventricular dysfunction were under-represented in clinical trials of cardiac resynchronization therapy (CRT). Whether patients with the most extreme forms of systolic dysfunction improve with CRT, and if so, what predicts such improvement remain unclear. Methods: We analyzed 231 patients with a baseline left ventricular ejection fraction (LVEF) ≤15% and a QRS ≥120 ms undergoing CRT from the Cleveland Clinic and Johns Hopkins Hospital. Patients were deemed responders if their LVEF improved >5% and superresponders if their LVEF improved ≥20%. Incidence and predictors of response were analyzed. Results: Of 231 patients, 110(47.6%) met criteria for response and 36(15.6%) for super-response. The mean baseline LVEF was 13.0±2.4%. In multivariate analysis controlling for multiple confounders, left ventricular end-diastolic diameter (LVEDD) was the sole variable associated with response (β= 0.61; CI 0.44-0.85; P=0.004). LVEDD (β=3.8; CI 1.5-9.4; P=0.004) and left bundle branch block (β=0.43; CI 0.27-0.70; P=0.001) were the only two variables significantly associated with super-response. Conclusion: In patients with severe left ventricular dysfunction (LVEF ≤15%), left ventricular size is an important determinant of improvement in ejection fraction with CRT. In a minority of patients with smaller LV dimensions and a LBBB, dramatic improvement in LVEF in these patients is possible.

IntroductionIn patients with chronic systolic heart failure and frequent right ventricular pacing (RVP), upgrade to cardiac resynchronization therapy (CRT) has become common practice despite a lack of randomized clinical trials. We aimed to evaluate long term outcomes in patients upgraded to CRT from chronic RVP compared with de novo CRT implants.Methods and resultsWe reviewed medical charts on consecutive patients with a left ventricular ejection fraction (LVEF) ≤ 35% and a QRSd ≥ 120 ms undergoing CRT. Survival free of left ventricular assist device (LVAD) and a heart transplant was compared amongst patients on the basis of pre‐CRT QRS morphology. Improvement in LVEF was also compared across groups. A total of 1260 patients met inclusion criteria of whom 233 were upgraded from chronic RVP. Over a mean follow up 6.5 ± 4.0 years there were 821 endpoints (27 LVAD, 30 heart transplants, and 764 deaths). In a multivariate Cox regression model, upgraded patients had worse outcomes (HR 1...

ObjectiveDetermine the prognostic impact of scar quantification (scar %) by cardiac magnetic resonance (CMR) in predicting heart failure admission, death and left ventricular (LV) function improvement following cardiac resynchronisation therapy (CRT), after controlling for the presence of left bundle branch block (LBBB), QRS duration (QRSd) and LV lead tip location and polarity.MethodsConsecutive patients who underwent CMR between 2002 and 2014 followed by CRT were included. The primary endpoint was death or heart failure admission. The secondary endpoint was change in ejection fraction (EF) ≥3 months after CRT. Cox proportional hazards, linear regression models and change in the area under the receiver operating characteristic curve (AUC) were used.ResultsA total of 84 patients were included (63% male, 51% with ischaemic cardiomyopathy). After adjusting for clinical factors, presence of LBBB and QRSd and LV lead tip location and polarity, greater scar % remained associated with a h...

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Background: Cardiac re-synchronization therapy (CRT) is a proven therapy in patients (pts) with cardiomyopathy (CM). In these pts, the presence of myocardial scar (Sc), by cardiac magnetic resonance (CMR), is a poor prognostic factor. We sought to assess the effect of Sc on survival in pts undergoing CRT. Methods: We included 98 consecutive pts with CM (54% ischemic) who underwent CMR followed by CRT placement. Overall survival was the primary outcome with a median follow-up of 2.5 years (yrs) post CRT implantation. A Cox proportional hazards regression model was built to predict mortality as a function of % Sc on CMR, after adjustment for baseline risk factors, including LBBB and an interaction term between % Sc and time. Results: Mean age was 62 yrs (+/-12), 33% were females. Mean EF by CMR was 23% (+/-10) with a median time from CMR to CRT of 81 days. During follow-up, 28 patients died (22 with ICM). After adjusting for baseline factors and LBBB, % Sc × time was statistically significant. %Sc significantly predicted mortality in the 1st year post CRT; the estimated HR for pts with moderate (5-30%) and severe scar (>30%) were 36.2 and 61.7, relative to those with mild scar (p=0.001 and p=0.007); in contrast, the estimated HRs were 0.54 and 1.31, respectively for moderate and severe scar (p<0.001 and p=0.012) after 1 year, (Figure 1). Conclusions: In pts with CM undergoing CRT, higher %Sc is associated with significant risk of mortality in the 1st year, with a diminished effect as time passes.

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.