Cardiology

Alvarez Villela, M., C. Y. Guerrero-Miranda, T. Chinnadurai, S. R. Patel and U. P. Jorde (2019). “Rate Response Pacing Left Ventricular Assist Device Patients.” ASAIO J Feb 22. [Epub ahead of print].

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Chronotropic incompetence (CI) is common in advanced heart failure and is associated with worse functional capacity. This impaired heart rate (HR) response during exercise is ameliorated but persists after left ventricular assist device (LVAD) implantation. Patients with continuous flow LVAD (CF-LVAD) suffer from significant exercise limitation despite restoration of resting cardiac output. Whether CI contributes to exercise limitation in this setting is unknown. We examined the role of CI and the effect of rate response pacing (RRP) on functional capacity in a group of stable patients with LVAD . . . Our findings demonstrate the association between CI and poor functional capacity in patients with advanced heart failure and CF-LVAD, in line with one small prior study. Findings in this cohort point out the inadequacy of current RRP technologies for sensing signals other than atrial rate during different types of physical activity. When RRP increased the HR promptly and in a sustained manner, replicating the activity of the sinus node, the effect on aerobic capacity was substantial, but this occurred in only a minority of patients. In contrast to the heterogeneous effect of RRP during treadmill-based CPX, its effect on 6 MWD was more homogeneous. This could represent a difference in CIED sensing efficacy since all of the employed devices in this study have an accelerometer-based RRP system. Ambulation, producing linear displacement of the body during 6 MWT could be more easily sensed by accelerometer-based systems than the more static motion during treadmill exercise. (Excerpts from advanced text; not paginated; no abstract available.)

Yarlagadda, B., T. Deneke, M. Turagam, T. Dar, S. Paleti, V. Parikh, L. DiBiase, P. Halfbass, P. Santangeli, S. Mahapatra, J. Cheng, A. Russo, J. Edgerton, M. Mansour, J. Ruskin, S. Dukkipati, D. Wilber, V. Reddy, D. Packer, A. Natale and D. Lakkireddy (2019). “Temporal relationships between esophageal injury type and progression in patients undergoing atrial fibrillation catheter ablation.” Heart Rhythm 16(2): 204-212.

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BACKGROUND: Currently, little is known about the onset, natural progression, and management of esophageal injuries after atrial fibrillation (AF) ablation. OBJECTIVES: We sought to provide a systematic review on esophageal injury after AF ablation and identify temporal relationships between various types of esophageal lesions, their progression, and clinical outcomes. METHODS: A comprehensive search of PubMed and Web of Science was conducted until September 21, 2017. All AF ablation patients who underwent upper gastrointestinal endoscopy within 1 week of the procedure were included. Patients with esophageal lesions were classified into 3 types by using our novel Kansas City classification: type 1: erythema; type 2a: superficial ulcers; type 2b: deep ulcers; type 3a: perforation without communication with the atria; and type 3b: perforation with atrioesophageal fistula. RESULTS: Thirty studies met our inclusion criteria. Of the 4473 patients, 3921 underwent upper gastrointestinal evaluation. The overall incidence of esophageal injuries was 15% (570). There were 206 type 1 lesions (36%), 222 type 2a lesions (39%), and 142 type 2b lesions (25%). Six of 142 type 2b lesions (4.2%) progressed further to type 3, of which, 5 were type 3a and 1 was type 3b. All type 1 and type 2a and most type 2b lesions resolved with conservative management. One type 3a and 1 type 3b lesions were fatal. CONCLUSION: Based on our classification, all type 1 and most type 2 lesions resolved with conservative management. A small percentage (4.2% [6 of 142]) of type 2b lesions progressed to perforation and/or fistula formation, and these patients need to be followed closely.

Vasudevan, A., J. W. Choi, G. A. Feghali, S. R. Lander, L. Jialiang, J. M. Schussler, R. C. Stoler, R. C. Vallabhan, C. E. Velasco and P. A. McCullough (2019). “Event dependence in the analysis of cardiovascular readmissions postpercutaneous coronary intervention.” J Investig Med Jan 18. [Epub ahead of print].

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Recurrent hospitalizations are common in longitudinal studies; however, many forms of cumulative event analyses assume recurrent events are independent. We explore the presence of event dependence when readmissions are spaced apart by at least 30 and 60 days. We set up a comparative framework with the assumption that patients with emergency percutaneous coronary intervention (PCI) will be at higher risk for recurrent cardiovascular readmissions than those with elective procedures. A retrospective study of patients who underwent PCI (January 2008-December 2012) with their follow-up information obtained from a regional database for hospitalization was conducted. Conditional gap time (CG), frailty gamma (FG) and conditional frailty models (CFM) were constructed to evaluate the dependence of events. Relative bias (%RB) in point estimates using CFM as the reference was calculated for comparison of the models. Among 4380 patients, emergent cases were at higher risk as compared with elective cases for recurrent events in different statistical models and time-spaced data sets, but the magnitude of HRs varied across the models (adjusted HR [95% CI]: all readmissions [unstructured data]-CG 1.16 [1.09 to 1.22], FG 1.45 [1.33 to 1.57], CFM 1.24 [1.16 to 1.32]; 30-day spaced-CG1.14 [1.08 to 1.21], FG 1.28 [1.17 to 1.39], CFM 1.17 [1.10 to 1.26]; and 60-day spaced-CG 1.14 [1.07 to 1.22], FG 1.23 [1.13 to 1.34] CFM 1.18 [1.09 to 1.26]). For all of the time-spaced readmissions, we found that the values of %RB were closer to the conditional models, suggesting that event dependence dominated the data despite attempts to create independence by increasing the space in time between admissions. Our analysis showed that independent of the intercurrent event duration, prior events have an influence on future events. Hence, event dependence should be accounted for when analyzing recurrent events and challenges contemporary methods for such analysis.

Shahian, D. M., T. G. Gleason, R. J. Shemin, J. D. Carroll and M. J. Mack (2019). “TAVR 2.0: Professional Societies Collaborating to Measure, Assure, and Improve Quality.” Ann Thorac Surg 107(2): 329-330.

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The 2018 TAVR [transcatheter aortic valve replacement] Multisociety Expert Consensus Systems of Care Document is a remarkable paradigm of professional society cooperation to advance patient quality and safety. Written by representatives of the four relevant specialty organizations—the American Association for Thoracic Surgery, the American College of Cardiology (ACC), the Society for Cardiovascular Angiography and Interventions, and The Society of Thoracic Surgeons (STS)—this document provides important recommendations that will sustain the steadily improving quality trajectory that has characterized this evolving field since the first Multisociety document was published in 2012 . . . Compared with the 2012 recommendations, this new document has stronger and more comprehensive requirements for quality and experience. TAVR quality measures include risk-adjusted in-hospital and 30-day mortality, and unadjusted 30-day neurologic events, vascular complications, bleeding, and aortic regurgitation (risk models are under development). In addition, there are plans to measure 1-year survival and patient-reported health status (Kansas City Cardiomyopathy Questionnaire [KCCQ]) and to develop 30-day and 1-year composite measures of mortality and morbidity. A STS/ACC Transcatheter Valve Therapy (TVT) Registry public reporting initiative is also planned. For surgical AVR (SAVR), perioperative outcomes and long-term durability have been extensively studied for almost 60 years. STS has implemented sophisticated composite performance measures for a variety of procedures, including AVR, and these are voluntarily publicly reported by 65% of adult cardiac programs. STS is planning to add 1-year KCCQ and survival status so that outcomes are fully comparable with those of TAVR. (Excerpt from text of this editorial, p. 329. Refers to article: Joseph E. Bavaria, et al. 2018 AATS/ACC/SCAI/STS Expert Consensus Systems of Care Document: Operator and Institutional Recommendations and Requirements for Transcatheter Aortic Valve Replacement, The Annals of Thoracic Surgery, Volume 107, Issue 2, February 2019, Pages 650-684.)

Roberts, W. C., S. Haque and S. A. Hall (2019). “Total 12-Lead QRS Voltage in Patients Having Orthotopic Heart Transplantation for Heart Failure Caused by Adriamycin-Induced Cardiomyopathy.” Cardiology 141(3): 172-175.

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OBJECTIVE: Although several studies have described the effects of adriamycin on the heart, electrocardiographic total 12-lead QRS voltage (distance in millimeters from the peak of the R wave to the nadir of either the Q or S wave, whichever was deeper, with 10 mm [1 mV] being standard) both before and after orthotopic heart transplantation (OHT) has not been reported. This study describes the total 12-lead QRS voltage in 8 patients studied at Baylor University Medical Center at Dallas, from 1994 to June 2018, who underwent OHT for severe heart failure caused by anthracycline-induced cardiomyopathy. METHOD: Prior to OHT, the total 12-lead non-paced QRS voltages ranged from 86 to 189 mm (mean 125 +/- 56) and for paced QRS voltages from 82 to 113 mm (mean 97 +/- 15). The total 12-lead QRS voltages post-OHT ranged from 100 to 190 mm (mean 130 +/- 30). Total 12-lead QRS voltages were lower in patients with a pacemaker than without. RESULTS/CONCLUSION: These low voltages are like those found in patients with carcinoid syndrome, severe cardiac adiposity, cardiac amyloidosis, and cardiac sarcoidosis.