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Journal Club 23 September 2015

September 25, 2015 Leave a comment

Paper

Percutaneous Implantation of an Entirely Intracardiac Leadless Pacemaker

Presenter

PM

Summary

BACKGROUND

Cardiac pacemakers are limited by device-related complications, notably infection
and problems related to pacemaker leads. We studied a miniaturized, fully selfcontained
leadless pacemaker that is nonsurgically implanted in the right ventricle
with the use of a catheter.

METHODS

In this multicenter study, we implanted an active-fixation leadless cardiac pacemaker
in patients who required permanent single-chamber ventricular pacing. The primary
efficacy end point was both an acceptable pacing threshold (≤2.0 V at 0.4 msec)
and an acceptable sensing amplitude (R wave ≥5.0 mV, or a value equal to or
greater than the value at implantation) through 6 months. The primary safety end
point was freedom from device-related serious adverse events through 6 months.
In this ongoing study, the prespecified analysis of the primary end points was
performed on data from the first 300 patients who completed 6 months of followup
(primary cohort). The rates of the efficacy end point and safety end point were
compared with performance goals (based on historical data) of 85% and 86%,
respectively. Additional outcomes were assessed in all 526 patients who were enrolled
as of June 2015 (the total cohort).

RESULTS

The leadless pacemaker was successfully implanted in 504 of the 526 patients in
the total cohort (95.8%). The intention-to-treat primary efficacy end point was met
in 270 of the 300 patients in the primary cohort (90.0%; 95% confidence interval
[CI], 86.0 to 93.2, P = 0.007), and the primary safety end point was met in 280 of
the 300 patients (93.3%; 95% CI, 89.9 to 95.9; P<0.001). At 6 months, device-related
serious adverse events were observed in 6.7% of the patients; events included device
dislodgement with percutaneous retrieval (in 1.7%), cardiac perforation (in 1.3%),
and pacing-threshold elevation requiring percutaneous retrieval and device replacement
(in 1.3%).

CONCLUSIONS

The leadless cardiac pacemaker met prespecified pacing and sensing requirements
in the large majority of patients. Device-related serious adverse events occurred in approximately
1 in 15 patients.

Supplementary Material

Supplementary material is available here.

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Journal Club 16 September 2015

September 25, 2015 Leave a comment

Paper

Marfan Sartan: a randomized, double-blind, placebo-controlled trial

Presenter

CB

Summary

AIMS

To evaluate the benefit of adding Losartan to baseline therapy in patients with Marfan syndrome (MFS).

METHODS AND RESULTS

A double-blind, randomized, multi-centre, placebo-controlled, add on trial comparing Losartan (50 mg when 10 years old, and receiving standard therapy. 303 patients, mean age 29.9 years old, were randomized. The two groups were similar at baseline, 86% receiving β-blocker therapy. The median follow-up was 3.5 years. The evolution of aortic diameter at the level of the sinuses of Valsalva was not modified by the adjunction of Losartan, with a mean increase in aortic diameter at the level of the sinuses of Valsalva of 0.44 mm/year (s.e. = 0.07) (-0.043 z/year, s.e. = 0.04) in patients receiving Losartan and 0.51 mm/year (s.e. = 0.06) (-0.01 z/year, s.e. = 0.03) in those receiving placebo (P = 0.36 for the comparison on slopes in millimeter per year and P = 0.69 for the comparison on slopes on z-scores). Patients receiving Losartan had a slight but significant decrease in systolic and diastolic blood pressure throughout the study (5 mmHg). During the study period, aortic surgery was performed in 28 patients (15 Losartan, 13 placebo), death occurred in 3 patients [0 Losartan, 3 placebo, sudden death (1) suicide (1) oesophagus cancer (1)].

CONCLUSION

Losartan was able to decrease blood pressure in patients with MFS but not to limit aortic dilatation during a 3-year period in patients >10 years old. β-Blocker therapy alone should therefore remain the standard first line therapy in these patients.

ESC/ERS Pulmonary Arterial Hypertension Guidelines

September 17, 2015 Leave a comment

The ESC/ERS guidelines for diagnosis and management of pulmonary arterial hypertension is available here.

This is a comprehensive and instructive guideline. Riociguat appears to be a notable absence. Use of exercise right heart catheterization is a class III indication.

Selected graphics from the guideline follow:

 

 

 

Pulmonary arterial hypertension: definitions

Pulmonary arterial hypertension: definitions

Updated classification of pulmonary arterial hypertension

Updated classification of pulmonary arterial hypertension

Diagnostic algorithm Pulmonary Arterial Hypertension

Diagnostic algorithm Pulmonary Arterial Hypertension

pah04

pah05

pah06

Categories: Uncategorized

Modification of Valsalva for Emergency Treatment of SVT

A modified Valsalva manouvre for terminating SVT is compared with standard Valsalva in this study suggesting greater efficacy.

Categories: Uncategorized

Journal Club 9 September 2015

Paper

Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy

Presenter

KK

Summary

BACKGROUND

The natural history, management, and outcome of takotsubo (stress) cardiomyopathy
are incompletely understood.

METHODS

The International Takotsubo Registry, a consortium of 26 centers in Europe and
the United States, was established to investigate clinical features, prognostic predictors,
and outcome of takotsubo cardiomyopathy. Patients were compared with
age- and sex-matched patients who had an acute coronary syndrome.

RESULTS

Of 1750 patients with takotsubo cardiomyopathy, 89.8% were women (mean age,
66.8 years). Emotional triggers were not as common as physical triggers (27.7%
vs. 36.0%), and 28.5% of patients had no evident trigger. Among patients with
takotsubo cardiomyopathy, as compared with an acute coronary syndrome, rates
of neurologic or psychiatric disorders were higher (55.8% vs. 25.7%) and the mean
left ventricular ejection fraction was markedly lower (40.7±11.2% vs. 51.5±12.3%)
(P<0.001 for both comparisons). Rates of severe in-hospital complications including
shock and death were similar in the two groups (P = 0.93). Physical triggers,
acute neurologic or psychiatric diseases, high troponin levels, and a low ejection
fraction on admission were independent predictors for in-hospital complications.
During long-term follow-up, the rate of major adverse cardiac and cerebrovascular
events was 9.9% per patient-year, and the rate of death was 5.6% per patient-year.

CONCLUSIONS

Patients with takotsubo cardiomyopathy had a higher prevalence of neurologic or
psychiatric disorders than did those with an acute coronary syndrome. This condition
represents an acute heart failure syndrome with substantial morbidity and
mortality.

Supplementary Material

The following supplementary material is provided by Dr Koitka:

Journal Club 2 September 2015

Paper

Does Timing of Coronary Artery Bypass Surgery Affect Early and Long-Term Outcomes in Patients With Non–ST-Segment–Elevation Myocardial Infarction?

Presenter

SH

Summary

Background

Current guidelines do not provide recommendations for optimal timing of coronary artery bypass surgery (CABG) in patients with non–ST-segment–elevation myocardial infarction. Our study aimed to determine the impact of CABG timing on early and late outcomes in patients with non–ST-segment–elevation myocardial infarction.

Methods and Results

A total of 758 patients underwent CABG within 21 days after non–ST-segment–elevation myocardial
infarction between January 2008 and December 2012 at our institution. The patients were divided into 3 groups according to the time interval between symptom onset and CABG: group A, 72 hours to 21 days (433 patients). Predictors of in-hospital and long-term mortality were identified by logistic and Cox regression analyses, respectively. Overall in-hospital mortality was 5.1% (39 patients):
6.0%, 4.7%, and 5.1% in groups A, B, and C (P=0.9), respectively. A total of 118 patients died during follow-up. The 5-year survival was 73.1±2%, with a nonsignificant trend toward better survival in groups A (78.2±4%) and C (75.4±3%) compared with group B (63.6±5%; log-rank P=0.06). Renal insufficiency and LMD were independent predictors of in-hospital (odds ratio, 3.1; P=0.001; and odds ratio, 3.1; P=0.002) and long-term mortality (hazard ratio, 1.7; P=0.004;
and hazard ratio, 1.5; P=0.02), whereas administration of P2Y12 inhibitors was protective (odds ratio, 0.3; P=0.01).

Conclusions

Emergent CABG within 24 hours of non–ST-segment–elevation myocardial infarction is associated with in-hospital mortality and long-term outcomes similar to those of CABG performed after 3 days, despite a higher risk profile. CABG performed between 24 to 72 hours showed a nonsignificant trend toward poorer long-term outcomes. Dual antiplatelet therapy until surgery is beneficial, whereas renal insufficiency and left main disease increase the risk of early
and late death.

Categories: Journal Club

Long term outcome of patients with stress cardiomyopathy.

An international registry of stress cardiomyopathy has published case characterization and long term outcome here.

Categories: Uncategorized