Publications by authors named "Davide Castagno"

65 Publications

In-hospital myocardial infarction and adherence to evidence-based drug therapies: a real-world evaluation.

BMJ Open 2021 Feb 5;11(2):e042878. Epub 2021 Feb 5.

Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.

Objectives: This study aimed to measure adherence to chronic polytherapy following an acute myocardial infarction (AMI) and to find out associations between adherence and the setting of AMI onset (in vs out of hospital) as well as other determinants.

Design: Retrospective follow-up study.

Setting: Population living in the Lazio Region, Italy.

Participants: This study included 25 779 hospitalised patients with a first diagnosis of AMI in 2012-2016, after the exclusion of those with hospital admission for AMI or related causes in the previous 5 years.

Primary And Secondary Outcome Measures: Patients were classified as in-hospital AMI (IH-AMI) or out of hospital AMI (OH-AMI) according to present-on-admission codes. Adherence was measured based on prescription claims during a 6-month follow-up after hospital discharge, using medication possession ratio (MPR). Adherence to chronic polytherapy was defined as MPR ≥75% to at least 3 of the following medications: antithrombotics, betablockers, ACE inhibitors/angiotensin receptor blockers and statins.

Results: Among the entire cohort, 1 044 (4%) patients suffered IH-AMI. Overall, 15 440 (60%) patients were deemed adherent to chronic polytherapy. Female gender, older age, mental disorders, renal disease, asthma and ongoing concomitant treatments were factors associated with poor adherence. By contrast, patients with more severe AMI and those already taking evidence-based (E-B) drugs were more likely to be adherent. A strong association between the setting of AMI onset and adherence was observed: IH-AMI patients were 46% less likely to be adherent to E-B medications during their 6-month follow-up as compared with OH-AMI patients (OR 0.54; 95% CI 0.47 to 0.62; p<0.001).

Conclusion: Pharmacotherapy is not consistent with clinical guidelines, especially for IH-AMI patients. Our findings provide evidence on a previously unidentified groups of patients at risk for poor adherence, who might benefit from greater medical attention and dedicated healthcare interventions.
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http://dx.doi.org/10.1136/bmjopen-2020-042878DOI Listing
February 2021

Transcatheter ablation for atrial fibrillation in patients with hypertrophic cardiomyopathy: Long-term results and clinical outcomes.

J Cardiovasc Electrophysiol 2021 Jan 11. Epub 2021 Jan 11.

Division of Cardiology, Department of Medical Sciences, "Città della Salute della Scienza" Hospital, University of Turin, Turin, Italy.

Introduction: Radiofrequency transcatheter ablation (RFCA) for atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM) has been proven feasible. However, the long-term results of RFCA and its impact on clinical course of HCM are unknown. The aim of this study was to analyse clinical outcomes and long-term efficacy of RFCA in a multicentre cohort of patients with HCM and concomitant AF.

Methods: Patients with HCM and AF consecutively undergoing RFCA were included. Ablation failure was defined as recurrence of AF, atrial tachycardia, or flutter lasting more than 3 min and occurring after the blanking period.

Results: Overall, 116 patients with symptomatic AF refractory to antiarrhythmic drugs were included. Over a median follow-up of 6.0 years (interquartile range: 3.0-8.9 years) recurrence rate after a single RFCA was 32.3 per 100 patient/years with 26% of patients free from AF relapses at 6-year follow-up. Among patients experiencing AF recurrence, 51 (66%) underwent at least one redo-procedure. The overall recurrence rate considering redo-procedures was 12.6 per 100 patients/years with 53% of patients free from AF relapses at 6 years. At last follow-up, with an average of 1.6 procedures, 67 (61%) patients were in sinus rhythm (SR). Patients remaining in SR showed better functional status compared with those experiencing arrhythmic recurrences (NYHA Class 1.6 ± 0.1 vs. 2.0 ± 0.1, p = .009).

Conclusions: RFCA of AF in HCM patients is an effective and safe strategy favoring long-term SR maintenance, reduction of atrial arrhythmic events, and improved functional status. However, most patients need repeat procedures and continuation of antiarrhythmic drugs.
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http://dx.doi.org/10.1111/jce.14880DOI Listing
January 2021

Prognostic role of left atrial enlargement in patients with implantable cardioverter defibrillators for primary prevention.

Acta Cardiol 2020 Dec 14:1-6. Epub 2020 Dec 14.

Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza di Torino Hospital, Turin, Italy.

Purpose: Left atrial volume index (LAVI) is a predictor of heart failure and adverse events, irrespective of left ventricular systolic function. The role of LAVI in the prediction of appropriate implantable cardioverter-defibrillator (ICD) therapies is currently unclear and was the focus of this study.

Methods: Consecutive heart failure patients with ischaemic (ICM) or idiopathic (DCM) aetiology receiving ICD for primary prevention were included. The primary endpoint was the occurrence of appropriate ICD therapies (ATs): shocks or antitachycardia pacing (ATP). Inappropriate ICD shocks were also assessed as secondary endpoint.

Results: Among 198 included patients, severe left atrial dilatation (SLAE = LAVI ≥ 60 ml/m) was present in 54 (27%). SLAE patients had a higher prevalence of NYHA class ≥ III, severe mitral regurgitation and atrial fibrillation history. During a median follow-up of 45 months (IQR 25-68), ATs occurred more frequently in SLAE group (33% vs. 15%,  = .007) as well as appropriate shocks (24% vs. 10%,  = .014). At multivariate analysis SLAE was an independent predictor of ATs (OR 3.19, 95% CI 1.38-7.38,  = .007). Inappropriate shocks were associated with AF during implantation ( = .03), but not with SLAE ( = .009).

Conclusion: In DCM or ICM patients candidate to receive an ICD for primary prevention, a severely enlarged left atrium is a predictive factor for ATs (shocks or ATP). The risk of inappropriate shocks was increased in patients with atrial fibrillation, rather than SLAE.
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http://dx.doi.org/10.1080/00015385.2020.1856491DOI Listing
December 2020

Electrocardiographic and clinical predictors for permanent pacemaker requirement after transcatheter aortic valve implantation: a 10-year single center experience.

J Cardiovasc Surg (Torino) 2020 Sep 4. Epub 2020 Sep 4.

Division of Cardiology, Department of Internal Medicine, University of Turin, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy.

Background: Aim of this study is to identify clinical, electrocardiographic (ECG) and procedural predictors for permanent pacemaker (PPM) requirement after transaortic valve implantation (TAVI).

Methods: All consecutive patients with severe symptomatic aortic stenosis (SSAS) undergoing TAVI at our single centre were included in the study and prospectively followed. All patients had standard 12-leads ECGs recordings before and after TAVI and continuous ECG monitoring during hospital stay. Primary endpoint was to identify electrocardiographic predictors of PPM implantation after TAVI; secondary endpoint was to ascertain other clinical or procedure-related predictive factors of PPM need. PPM implantation was further arbitrarily divided into early and late one (beyond the 3rd day).

Results: Among the 431 patients undergoing TAVI between 2008 and 2018, 77 (18%) needed PPM implantation; 47 (11%) had an early procedure, and 30 (7%) a late implant. Pre-operative RBBB implies more than five-fold increase of the risk of PPM implantation (OR 5.19, CI 1.99 - 13.56, P=0.001), whereas the use of a selfexpandable prosthesis is associated with an almost three-fold increase of the risk (OR 2.60, CI 1.28 - 5.28, P=0.008). In the late PPM implantation subgroup, only the history of syncope retains a significant association with such an increased risk (OR 2.71, CI 1.09 - 6.75, P=0.032).

Conclusions: The need of a PPM in the individual TAVI patient is hardly predictable. However, the finding of pre-existing RBBB, the use of self-expandable prosthesis and history of syncope can individuate patients at increased risk.
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http://dx.doi.org/10.23736/S0021-9509.20.11342-9DOI Listing
September 2020

Prevalence and incidence of intra-ventricular conduction delays and outcomes in patients with heart failure and reduced ejection fraction: insights from PARADIGM-HF and ATMOSPHERE.

Eur J Heart Fail 2020 12 14;22(12):2370-2379. Epub 2020 Sep 14.

BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.

Aims: The importance of intra-ventricular conduction delay (IVCD), the incidence of new IVCD and its relationship to outcomes in heart failure and reduced ejection fraction (HFrEF) are not well studied. We addressed these questions in the PARADIGM-HF and ATMOSPHERE trials.

Methods And Results: The risk of the primary composite outcome of cardiovascular death or heart failure hospitalization and all-cause mortality were estimated by use of Cox regression according to baseline QRS duration and morphology in 11 861 patients without an intracardiac device. At baseline, 1789 (15.1%) patients had left bundle branch block (LBBB), 524 (4.4%) right bundle branch block (RBBB), 454 (3.8%) non-specific IVCD, 2588 (21.8%) 'mildly abnormal' QRS (110-129 ms) and 6506 (54.9%) QRS <110 ms. During a median follow-up of 2.5 years, the risk of the primary composite endpoint was higher among those with a wide QRS, irrespective of morphology: hazard ratios (95% confidence interval) LBBB 1.36 (1.23-1.50), RBBB 1.54 (1.31-1.79), non-specific IVCD 1.65 (1.40-1.94) and QRS 110-129 ms 1.35 (1.23-1.47), compared with QRS duration <110 ms. A total of 1234 (15.6%) patients developed new-onset QRS widening ≥130 ms (6.1 per 100 patient-years). Incident LBBB occurred in 495 (6.3%) patients (2.4 per 100 patient-years) and was associated with a higher risk of the primary composite outcome [hazard ratio 1.42 (1.12-1.82)].

Conclusion: In patients with HFrEF, a wide QRS was associated with worse clinical outcomes irrespective of morphology. The annual incidence of new-onset LBBB was around 2.5%, and associated with a higher risk of adverse outcomes, highlighting the importance of repeat electrocardiogram review.

Trial Registration: ClinicalTrials.gov Identifier NCT0083658 (ATMOSPHERE) and NCT01035255 (PARADIGM-HF).
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http://dx.doi.org/10.1002/ejhf.1972DOI Listing
December 2020

Long-term percentage of ventricular pacing in patients requiring pacemaker implantation after transcatheter aortic valve replacement: A multicenter 10-year experience.

Heart Rhythm 2020 Nov 5;17(11):1897-1903. Epub 2020 Jun 5.

Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.

Background: Recent studies suggest that atrioventricular (AV) conduction may recover after pacemaker (PM) implantation following transcatheter aortic valve replacement (TAVR), but little is known about long-term follow-up of such patients.

Objective: The purpose of this study was to evaluate the long-term percentage of right ventricular pacing in patients who underwent TAVR and required PM implantation stratified based on the indication for permanent pacing.

Methods: Retrospective analysis of all consecutive patients who underwent TAVR from February 2008 to August 2019 at 3 centers was performed. Patients already implanted with a PM/implantable cardioverter-defibrillator (ICD) before TAVR, implanted with a cardiac resynchronization therapy device, or implanted >30 days after TAVR were excluded. Eligible patients were divided into 2 groups based on the presence (persistent atrioventricular block [AVB] group) or absence (nonpersistent AVB group) of persistent third-degree AVB after TAVR.

Results: A total of 1594 patients underwent TAVR. Two hundred four patients were implanted with a PM or ICD after TAVR and 32 met exclusion criteria, so 172 patients were eligible (median time TAVR-PM implant 4 days) for a total of 352 follow-up visits analyzed. A significant difference in the percentage of ventricular pacing was observed at follow-up performed 7-90 days after implantation (98% persistent AVB group vs 8% nonpersistent AVB group; P <.001). This difference remained significant at follow-up performed 91-270 days (95% vs 3.5%; P <.001), 271-540 days (95.5% vs 3%; P = .006), and 541-900 days (97.4% vs 2.2%; P <.001) after implantation.

Conclusion: Patients requiring PM implantation due to persistent third-degree AVB after TAVR were less likely to show AV conduction recovery, whereas patients implanted for other indications showed a low percentage of pacing during follow-up.
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http://dx.doi.org/10.1016/j.hrthm.2020.05.040DOI Listing
November 2020

S-ICD lead dislodgement in a young isometric athlete: A rare complication.

Pacing Clin Electrophysiol 2020 08 3;43(8):898-900. Epub 2020 Jun 3.

Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza di Torino Hospital, University of Turin, Torino, Italy.

The subcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to transvenous ICD in patients who do not need cardiac pacing. We report the case of a young isometric athlete who received S-ICD for primary prevention of sudden death. Lead dislodgement and myopotential noise oversensing during isometric training led to inappropriate shock, and a surgical revision was performed. During the procedure, strong fibrous adhesions were found, requiring polytetrafluoroethylene dilator sheaths. The S-ICD was finally reimplanted. Despite continued isometric training, no more myopotential oversensing occurred after 1-year follow-up. The present case highlights the possible higher risks of lead complication in an isometric athlete and the uncommon effort in removing an old-generation subcutaneous defibrillator lead.
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http://dx.doi.org/10.1111/pace.13965DOI Listing
August 2020

Cardiovascular Considerations in Treating Patients With Coronavirus Disease 2019 (COVID-19).

J Cardiovasc Pharmacol 2020 05;75(5):359-367

Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA.

A novel betacoronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread rapidly across the globe since December 2019. Coronavirus disease 2019 (COVID-19) has a significantly higher mortality rate than seasonal influenza and has disproportionately affected older adults, especially those with cardiovascular disease and related risk factors. Adverse cardiovascular sequelae, such as myocarditis, acute myocardial infarction, and heart failure, have been reported in patients with COVID-19. No established treatment is currently available; however, several therapies, including remdesivir, hydroxychloroquine and chloroquine, and interleukin (IL)-6 inhibitors, are being used off-label and evaluated in ongoing clinical trials. Considering these therapies are not familiar to cardiovascular clinicians managing these patients, this review describes the pharmacology of these therapies in the context of their use in patients with cardiovascular-related conditions.
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http://dx.doi.org/10.1097/FJC.0000000000000836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219860PMC
May 2020

Zero-fluoroscopy atrial fibrillation ablation in the presence of a patent foramen ovale: a multicentre experience.

J Cardiovasc Med (Hagerstown) 2020 Apr;21(4):292-298

Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin.

Introduction: Atrial fibrillation ablation has historically been guided by fluoroscopy, with the related enhanced risk deriving from radiation. Fluoroscopy exposure may be confined to guide the transseptal puncture. Small sample size study presented a new methodology to perform a totally fluoroless atrial fibrillation ablation in the case of a patent foramen ovale (PFO). We evaluated this methodology in a large sample size of patients and a multicentre experience.

Methods And Results: Two hundred and fifty paroxysmal atrial fibrillation patients referred for first atrial fibrillation ablation with a CARTO3 electroanatomic mapping system were enrolled. In 58 out of 250 patients, a PFO allowed crossing of the interatrial septum, and a completely fluoroless ablation was performed applying the new method (Group A). In the remaining patients, a standard transseptal puncture was performed (Group B). Pulmonary vein isolation was achieved in all patients with comparable procedural and clinical outcomes at short- and long-term follow-up.

Conclusion: The presence of a PFO may allow a completely fluoroless well tolerated and effective atrial fibrillation ablation. Probing the fossa ovalis looking for the PFO during the procedure is desirable, as it is not time-consuming and can potentially be done in every patient undergoing atrial fibrillation ablation.
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http://dx.doi.org/10.2459/JCM.0000000000000943DOI Listing
April 2020

Relationship between heart rate and outcomes in patients in sinus rhythm or atrial fibrillation with heart failure and reduced ejection fraction.

Eur J Heart Fail 2020 03 17;22(3):528-538. Epub 2019 Dec 17.

BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.

Aims: To investigate the relationship between heart rate and outcomes in heart failure and reduced ejection fraction (HFrEF) patients in sinus rhythm (SR) and atrial fibrillation (AF) adjusting for natriuretic peptide concentration, a powerful prognosticator.

Methods And Results: Of 13 562 patients from two large HFrEF trials, 10 113 (74.6%) were in SR and 3449 (25.4%) in AF. The primary endpoint was the composite of cardiovascular death or heart failure hospitalization. Heart rate was analysed as a categorical (tertiles, T1-3) and continuous variable (per 10 bpm), separately in patients in SR and AF. Outcomes were adjusted for prognostic variables, including N-terminal prohormone of B-type natriuretic peptide (NT-proBNP), and also examined using change from baseline heart rate to 1 year (≤ -10 bpm, ≥ +10 bpm, < ±10 bpm). SR patients with a higher heart rate had worse symptoms and quality of life, more often had diabetes and higher NT-proBNP concentrations. They had higher risk of the primary endpoint [T3 vs. T1 adjusted hazard ratio (HR) 1.50, 95% confidence interval (CI) 1.35-1.66; P < 0.001; per 10 bpm: 1.12, 95% CI 1.09-1.16; P < 0.001]. In SR, heart rate was associated with a relatively higher risk of pump failure than sudden death (adjusted HR per 10 bpm 1.17, 95% CI 1.09-1.26; P < 0.001 vs. 1.07, 95% CI 1.02-1.13; P = 0.011). Heart rate was not predictive of any outcome in AF.

Conclusions: In HFrEF, an elevated heart rate was an independent predictor of adverse cardiovascular outcomes in patients in SR, even after adjustment for NT-proBNP. There was no relationship between heart rate and outcomes in AF.

Clinical Trial Registration: ClinicalTrials.gov Identifiers NCT01035255 and NCT00853658.
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http://dx.doi.org/10.1002/ejhf.1682DOI Listing
March 2020

Left Atrial Function after Atrial Fibrillation Cryoablation Concomitant to Minimally Invasive Mitral Valve Repair: A Pilot Study on Long-Term Results and Clinical Implications.

Medicina (Kaunas) 2019 Oct 21;55(10). Epub 2019 Oct 21.

Division of Cardiology, "Città della Salute e della Scienza di Torino" Hospital, Department of Medical Sciences, University of Turin, 10124 Torino, Italy.

Surgical atrial fibrillation (AF) ablation concomitant to minimally invasive mitral valve repair has been proven to offer improved short- and long-term sinus rhythm (SR) maintenance compared to mitral valve surgery only. The objective of the present study was to explore, by thorough echocardiographic assessment, long-term morphological and functional left atrial (LA) outcomes after this combined surgical procedure. : From October 2006 to November 2015, 48 patients underwent minimally invasive mitral valve repair and concomitant surgical AF cryoablation. After 3.8 ± 2.2 years, 30 (71.4%) of those completing the follow-up ( = 42, 87.5%) presented SR. During follow-up, four (9.5%) patients suffered from cerebrovascular accidents and two of these subjects had a long-standing persistent AF relapse and were in AF at the time of the event, while the other two were in SR. An echocardiographic study focused on LA characteristics was performed in 29 patients (69.0%). Atrial morphology and function (e.g., maximal LA volume indexed to body surface area and total LA emptying fraction derived from volumes) in patients with stable SR (60.6 ± 13.1 mL/mq and 25.1 ± 7.3%) were significantly better than in those with AF relapses (76.8 ± 16.2 mL/mq and 17.5 ± 7.4%; respectively, = 0.008 and = 0.015). At follow-up, patients who suffered from ischemic cerebral events had maximal LA volume indexed to body surface area 61 ± 17.8 mL/mq, with total LA emptying fraction derived from volumes 23.6 ± 13.7%; patients with strokes in SR showed very enlarged LA volume (>70 mL/mq). : AF cryoablation concomitant with minimally invasive mitral valve repair provides a high rate of SR maintenance and this relates to improved long-term morphological and functional LA outcomes. Further prospective studies are needed to define the cut-off values determining an increase in the risk for thromboembolic complications in patients with restored stable SR.
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http://dx.doi.org/10.3390/medicina55100709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6843475PMC
October 2019

Same-day CIED implantation and discharge: Is it possible? The E-MOTION trial (Early MObilization after pacemaker implantaTION).

Int J Cardiol 2019 08 8;288:82-86. Epub 2019 Apr 8.

Division of Cardiology, A.O.U. Città della Salute e della Scienza di Torino-Molinette, Department of Medical Sciences, University of Turin, Turin, Italy.

Background: Despite the increasing number of cardiac implantable electronic devices (CIED) procedures worldwide, no guideline assessed postoperative mobilization protocols. Lacking evidences in literature, many centers require 24-hour immobilization and bed rest to minimize the risk of pacing lead (PL) dislodgement. Prolonged immobilization may futilely delay discharge, induce pain and reduced joint mobility especially in elderly patients. We examined whether early mobilization at 3-h after CIED surgery would result in higher complication rates, compared with standard 24-hour immobilization.

Methods: Consecutive patients undergoing CIED implantation were randomized to early (3-h) mobilization protocol with an arm sling support (E-motion group, EMG) vs. standard (24-h) immobilization (control group, CG). The primary end-point was 24-month PL dislodgement. Secondary safety end-point was any major intra-procedural complication (cardiac perforation, pericardial tamponade, valve damage, haemothorax, pneumothorax, myocardial infarction, peripheral embolus, TIA/stroke or death).

Results: Among 200 enrolled patients, 86% underwent pacemaker implantation (28% single-chamber, 72% dual-chamber device), 14% underwent ICD implantation (75% single-chamber, 25% dual-chamber device). PL fixation was mostly passive (97% atrial PL, 88% ventricular PL), without differences between EMG and CG (p = 0.99). No differences were observed in the incidence of 24-month PL dislodgement (3% in the EMG vs. 4% in the CG, p = 0.99). No major intra-procedural complications were observed.

Conclusions: Early mobilization at 3-h following CIED surgery is safe and feasible compared with standard immobilization and is not associated with an increased risk of intra-procedural complications or 24-month lead dislodgment. So, same-day implantation and discharge might be possible.
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http://dx.doi.org/10.1016/j.ijcard.2019.04.020DOI Listing
August 2019

Prevalence and prognosis of lead masses in patients with cardiac implantable electronic devices without infection.

J Cardiovasc Med (Hagerstown) 2019 Jun;20(6):372-378

Division of Cardiology, Department of Internal Medicine, University of Turin, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy.

Background: Finding of intracardiac lead masses in patients with cardiac implantable electronic devices remains controversial, as such masses have been observed in cases of exclusively local infections whereas they have not been recognized in patients with positive cultures of intravascular lead fragments. In this study, we aim to describe the prevalence of intracardiac lead masses in true asymptomatic patients with cardiac implantable electronic devices, to identify their predictive factors and to define their prognostic impact at long-term follow-up.

Methods: Seventy-eight consecutive patients admitted over a 6-month period for elective generator replacement without clinical evidence of infection were evaluated by transthoracic and transesophageal echocardiography and prospectively followed at in-clinic follow-up visits.

Results: Lead masses were found in 10 patients (12.8%). These patients had more frequently right ventricular dysfunction at univariate analysis (OR 2.71, P = 0.010) and after baseline variables adjustment (hazard ratio 6.25, P = 0.012). At 5-year follow-up without any specific therapy, none of the patients suffered from any cardiac device infections, or developed clinical signs of infections.

Conclusion: There is an evidence of clinical lead masses in asymptomatic patients with cardiac implantable electronic devices. The value of these findings is still debated for aetiological interpretation and for therapeutic strategy, but they are not necessarily associated with an infection.
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http://dx.doi.org/10.2459/JCM.0000000000000797DOI Listing
June 2019

Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial.

Eur J Heart Fail 2019 06 28;21(6):754-766. Epub 2019 Jan 28.

Division of Emergency Medicine and High Dependency Unit, AOU Città della Salute e della Scienza di Torino, Turin, Italy.

Aims: Although acute decompensated heart failure (ADHF) is a common cause of dyspnoea, its diagnosis still represents a challenge. Lung ultrasound (LUS) is an emerging point-of-care diagnostic tool, but its diagnostic performance for ADHF has not been evaluated in randomized studies. We evaluated, in patients with acute dyspnoea, accuracy and clinical usefulness of combining LUS with clinical assessment compared to the use of chest radiography (CXR) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in conjunction with clinical evaluation.

Methods And Results: This was a randomized trial conducted in two emergency departments. After initial clinical evaluation, patients with acute dyspnoea were classified by the treating physician according to presumptive aetiology (ADHF or non-ADHF). Patients were subsequently randomized to continue with either LUS or CXR/NT-proBNP. A new diagnosis, integrating the results of both initial assessment and the newly obtained findings, was then recorded. Diagnostic accuracy and clinical usefulness of LUS and CXR/NT-proBNP approaches were calculated. A total of 518 patients were randomized. Addition of LUS had higher accuracy [area under the receiver operating characteristic curve (AUC) 0.95] than clinical evaluation alone (AUC 0.88) in identifying ADHF (P < 0.01). In contrast, use of CXR/NT-proBNP did not significantly increase the accuracy of clinical evaluation alone (AUC 0.87 and 0.85, respectively; P > 0.05). The diagnostic accuracy of the LUS-integrated approach was higher then that of the CXR/Nt-proBNP-integrated approach (AUC 0.95 vs. 0.87, p < 0.01). Combining LUS with the clinical evaluation reduced diagnostic errors by 7.98 cases/100 patients, as compared to 2.42 cases/100 patients in the CXR/Nt-proBNP group.

Conclusion: Integration of LUS with clinical assessment for the diagnosis of ADHF in the emergency department seems to be more accurate than the current diagnostic approach based on CXR and NT-proBNP.
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http://dx.doi.org/10.1002/ejhf.1379DOI Listing
June 2019

Use of implantable cardioverter defibrillator in nonischaemic cardiomyopathy: a U-turn?

J Cardiovasc Med (Hagerstown) 2018 Feb;19 Suppl 1:e63-e67

Division of Cardiology, 'Città della Salute e della Scienza' Hospital.

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http://dx.doi.org/10.2459/JCM.0000000000000580DOI Listing
February 2018

Hyperthyroidism in patients with ischaemic heart disease after iodine load induced by coronary angiography: Long-term follow-up and influence of baseline thyroid functional status.

Clin Endocrinol (Oxf) 2018 02 20;88(2):272-278. Epub 2017 Nov 20.

Division of Endocrinology, Diabetology, and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy.

Objective: To study the effect of a iodine load on thyroid function of patients with ischaemic heart disease (IHD) and the long-term influence of unknown subclinical hyperthyroidism.

Context: Subclinical hyperthyroidism is considered an independent risk factors for cardiovascular morbidity of patients with IHD. They routinely undergo coronary angiography with iodine contrast media (ICM) which may induce or even worsen hyperthyroidism.

Design: A cross-sectional study followed by a longitudinal study on patients with subclinical hyperthyroidism.

Patients: 810 consecutive IHD outpatients without known thyroid diseases or treatment with drugs influencing thyroid activity undergoing elective coronary angiography.

Measurements: We evaluated thyroid function either before and 1 month after ICM; patients with thyrotoxicosis at baseline or after ICM were then followed up for 1 year.

Results: 58 patients had hyperthyroidism at baseline (HB, 7.2%), independently associated to FT4 levels, thyroid nodules and family history of thyroid diseases. After ICM, the prevalence of hyperthyroidism was 81 (10%). Hyperthyroidism after ICM was positively predicted by baseline fT4 levels, thyroid nodules, age over 60, male gender, family history of thyroid diseases. Three months after ICM, 34 patients (4.2%) still showed hyperthyroidism (22 from HB, 13 treated with methimazole). One year after ICM, hyperthyroidism was still present in 20 patients (2.5%, all from HB, 13 treated).

Conclusions: The prevalence of spontaneous subclinical hyperthyroidism in IHD is surprisingly elevated and is further increased by iodine load, particularly in patients with thyroid nodules and familial history of thyroid diseases, persisting in a not negligible number of them even after one year.
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http://dx.doi.org/10.1111/cen.13494DOI Listing
February 2018

Combining electromagnetic navigation and 3-D mapping to reduce fluoroscopy time and achieve optimal CRT response.

Pacing Clin Electrophysiol 2018 05 28;41(5):557-560. Epub 2017 Dec 28.

Division of Cardiology, Cardio-Thoracic Department, Azienda Ospedaliero-Universitaria Città della Salute E della Scienza di Torino, Corso A. M. Dogliotti 14, 10126, Turin, Italy.

Implantation of cardiac resynchronization therapy (CRT) devices can be challenging, time consuming, and associated with high-dose x-ray exposure. We present the technique in which an electromagnetic navigation system (MediGuideTM, St. Jude Medical) and an electroanatomical three-dimensional mapping system (EnSite NavX, St Jude Medical) are usefully combined for implanting implantable cardioverter defibrillator CRT devices with strong reduction of x-ray exposure, and for targeting the most delayed regions in the activation maps avoiding scars for optimal CRT response.
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http://dx.doi.org/10.1111/pace.13209DOI Listing
May 2018

Etiological diagnosis, prognostic significance and role of electrophysiological study in patients with Brugada ECG and syncope.

Int J Cardiol 2017 Aug;241:188-193

Division of Cardiology, University of Torino, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, C.so A.M. Dogliotti 14, 10126 Torino, Italy.

Background: Syncope is considered a risk factor for life-threatening arrhythmias in Brugada patients. Distinguishing a benign syncope from one due to ventricular arrhythmias is often difficult, unless an ECG is recorded during the episode. Aim of the study was to analyze the characteristics of syncopal episodes in a large population of Brugada patients and evaluate the role of electrophysiological study (EPS) and the prognosis in the different subgroups.

Methods And Results: One hundred ninety-five Brugada patients with history of syncope were considered. Syncope were classified as neurally mediated (group 1, 61%) or unexplained (group 2, 39%) on the basis of personal and family history, clinical features, triggers, situations, associated signs, concomitant therapy. Most patients underwent EPS; they received ICD or implantable loop-recorder on the basis of the result of investigations and physician's judgment. At 62±45months of mean follow-up, group 1 showed a significantly lower incidence of arrhythmic events (2%) as compared to group 2 (9%, p<0.001). Group 2 patients with positive EPS showed the highest risk of arrhythmic events (27%). No ventricular events occurred in subjects with negative EPS.

Conclusion: Etiological definition of syncope in Brugada patients is important, as it allows identifying two groups with different outcome. Patients with unexplained syncope and ventricular fibrillation induced at EPS have the highest risk of arrhythmic events. Patients presenting with neurally mediated syncope showed a prognosis similar to that of the asymptomatic and the role of EPS in this group is unproven.
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http://dx.doi.org/10.1016/j.ijcard.2017.03.019DOI Listing
August 2017

Anticoagulant cessation following atrial fibrillation ablation: limits of the ECG-guided approach.

Expert Rev Cardiovasc Ther 2017 Jun 29;15(6):473-479. Epub 2017 May 29.

a Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital , University of Turin , Turin , Italy.

Introduction: Long-term cessation of oral anticoagulation (OAC) following successful catheter or surgical ablation of atrial fibrillation (AF) is debated. Usually, in the presence of sinus rhythm at serial ECG recordings, the CHADS2, CHA2DS2VASc, and HAS-BLED scores are adopted to guide decision regarding OAC management. Areas covered: The safety of OAC cessation in patients without recurrent AF but with historically elevated risk for thromboembolism remains largely unknown. Taking the cue from two clinical cases, we provide an updated summary of the latest evidence regarding how to manage OAC after a successful atrial fibrillation ablation. Expert commentary: The present clinical perspective suggests that, at least within patients with severely enlarged left atrium, previous cardiac surgery and catheter or surgical AF ablation, especially if repeated, assessment of atrial contractility by transthoracic echocardiography should be performed before discontinuing OAC in patients who maintain sinus rhythm, confirmed by serial ECG or Holter monitorings.
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http://dx.doi.org/10.1080/14779072.2017.1332993DOI Listing
June 2017

Cooling dynamics: a new predictor of long-term efficacy of atrioventricular nodal reentrant tachycardia cryoablation.

J Interv Card Electrophysiol 2017 Apr 10;48(3):333-341. Epub 2016 Dec 10.

Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy.

Purpose: Catheter ablation of the slow pathway is the most effective treatment for atrioventricular nodal reentrant tachycardia (AVNRT). Cryoenergy, compared to radiofrequency, relates to lower heart block risk but higher incidence of AVNRT recurrences. The aims of this study are to confirm the safety and efficacy of AVNRT cryoablation and to identify predictors of long-term recurrences.

Methods: Among 241 patients undergoing AVNRT cryoablation, 239 (99.2%) experienced acute effective cryoablation of the slow pathway, and no procedure-related complications were reported.

Results: After a follow-up of 44.9 ± 31.7 months, 28 (11.7%) patients presented AVNRT recurrences. A shorter preablation (p = 0.05) and postablation anterograde Wenckebach cycle length (p < 0.01), a shorter postablation atrioventricular node refractory period (p = 0.04), and persistence of the crossover sign (p = 0.03) were associated with higher incidence of long-term recurrences. Considering cooling dynamics, a longer time to reach temperature ≤-70 °C (p = 0.03) and a higher minimal temperature during ablation (p = 0.04) were related to recurrences. Patients without residual markers of dual AV node physiology (AH jump, single atrial echo beat, crossover) reported a lower recurrence rate (p = 0.05) compared to those without. At multivariate analysis, a longer time to -70 °C was the strongest independent predictor of long-term recurrence (OR 1.75, 95% CI 1.01-3.03, p = 0.04).

Conclusions: AVNRT cryoablation is safe and effective. Long-term recurrence rate was 11.7%. An ablation approach directed to the complete elimination of dual AV node physiology, along with assessment of the tissue's cooling dynamics, holds the potential to improve long-term AVNRT cryoablation efficacy.
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http://dx.doi.org/10.1007/s10840-016-0208-4DOI Listing
April 2017

Do supraventricular premature beats identify patients at high risk for atrial fibrillation?

J Cardiovasc Med (Hagerstown) 2017 01;18 Suppl 1:e117-e120

Cardiology Unit, Città della Salute e della Scienza, Torino Department of Medical Science, University of Torino, Torino, Italy.

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http://dx.doi.org/10.2459/JCM.0000000000000473DOI Listing
January 2017

Anatomic relationship between left coronary artery and left atrium in patients undergoing atrial fibrillation ablation.

J Cardiovasc Med (Hagerstown) 2017 Jul;18(7):528-533

aDivision of Cardiology, Department of Medical Sciences, University of Torino, 'Città della Salute e della Scienza' Hospital, Turin bDepartment of Cardiovascular and Neurological Sciences, University of Cagliari, Cagliari cDivision of Cardiology, Policlinico Casilino, ASL, Rome, Italy.

Background: Atrial fibrillation transcatheter ablation (TCA) is, within available atrial fibrillation rhythm control strategies, one of the most effective. To potentially improve ablation outcome in case of recurrent atrial fibrillation after a first procedure or in presence of structural myocardial disease, isolation of the pulmonary veins may be associated with extensive lesions within the left atrium. To avoid rare, but potentially life-threatening, complications, thorough knowledge and assessment of left atrium anatomy and its relation to structures in close proximity are, therefore, mandatory. Aim of the present study is to describe, by cardiac computed tomography, the anatomic relationship between aortic root, left coronary artery and left atrium in patients undergoing atrial fibrillation TCA.

Methods And Results: The cardiac computed tomography scan of 21 patients affected by atrial fibrillation was elaborated to segment left atrium, aortic root and left coronary artery from the surrounding structures and the following distances measured: left atrium and aortic root; left atrium roof and aortic root; left main coronary artery and left atrium; circumflex artery and left atrium appendage; and circumflex artery and mitral valve annulus. Above all, the median distance between left atrium and aortic root (1.9, 1.5-2.1 mm), and between circumflex artery and left atrium appendage ostium (3.0, 2.1-3.4 mm) were minimal (≤3 mm). None of measured distances significantly varied between patients presenting paroxysmal versus persistent atrial fibrillation.

Conclusion: The anatomic relationship between left atrium and coronary arteries is extremely relevant when performing atrial fibrillation TCA by extensive lesions. Therefore, at least in the latter case, preablation imaging should be recommended to avoid rare, but potentially life-threatening, complications with the aim of an as well tolerated as possible procedure.
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http://dx.doi.org/10.2459/JCM.0000000000000484DOI Listing
July 2017

Cryptogenic ischemic stroke and prevalence of asymptomatic atrial fibrillation: a prospective study.

J Cardiovasc Med (Hagerstown) 2016 Dec;17(12):863-869

aDivision of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital and Department of Medical Sciences bStroke Unit, 'Città della Salute e della Scienza' Hospital and University of Turin, Turin, Italy.

Background: Atrial fibrillation is responsible for up to one-third of ischemic strokes, and is also associated with silent cerebral infarctions and transient ischemic attacks (TIAs). The self-terminating and often asymptomatic nature of paroxysmal atrial fibrillation (PAF) may lead to its underdiagnosis. A continuous and long-term heart rhythm monitoring can be useful in unmasking PAF episodes.

Objective: Prevalence of asymptomatic PAF in patients suffering a cryptogenic stroke, at risk for atrial fibrillation but without any history of arrhythmia or palpitations, using a continuous electrocardiographic monitoring.

Methods: One hundred and forty-two consecutive patients were admitted to the Stroke Unit of 'Città della Salute e della Scienza' Hospital of Turin between June 2010 and March 2013 and discharged with the diagnosis of ischemic cryptogenic stroke. Sixty fulfilled predefined inclusion criteria. Follow-up was carried on and completed for the 54 patients who consented to implantable loop recorder (ILR) implantation. After ILR implantation, trans-telephonic data were collected monthly.

Results: Atrial fibrillation episodes lasting more than 5 min were recorded in 25 patients (46%), median detection time was 5.4 months (range 1-18) and median duration of atrial fibrillation episodes was 20 h (range 7 min-8 days) with 19 patients (76%) remaining asymptomatic and the others experiencing weakness and dyspnoea but not palpitations.

Conclusion: Long-term heart rhythm monitoring is successful in unmasking silent atrial fibrillation in 46% of patients suffering a cryptogenic stroke with concomitant atrial fibrillation risk factors, but without history of arrhythmia or palpitations.
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http://dx.doi.org/10.2459/JCM.0000000000000181DOI Listing
December 2016

Arrhythmogenic right ventricular cardiomyopathy: ECG progression over time and correlation with long-term follow-up.

J Cardiovasc Med (Hagerstown) 2016 Jun;17(6):418-24

aDivision of Cardiology, Department of Medical Sciences, 'Città della Salute e della Scienza' Hospital, University of Turin, TurinbDivision of Cardiology, Sant'Andrea Hospital, VercellicCardiology Service, Gradenigo Hospital, Turin, Italy.

Aims: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart muscle disease primarily affecting the right ventricle and potentially causing sudden death in young people. Our aims are to analyse the progression over time of electrocardiographic (ECG) findings and to investigate their prognostic impact.

Methods: Sixty-eight patients (69% men; age 31 ± 19 years) with ARVC diagnosis were followed up for a mean of 17 ± 8 years. Follow-up included baseline ECG, 24-h Holter ECG, signal-averaged ECG, stress test, echocardiography, cardiac magnetic resonance and electrophysiologic study.

Results: During follow-up 12 (18%) patients died: three of sudden cardiac death (SCD), four of end-stage heart failure and five of noncardiac causes. Aborted SCD occurred in 7 (10%) patients, syncope in 31 (46%), sustained ventricular tachycardia in 43 (63%), heart failure in 18 (26%), atrial fibrillation in 16 (24%) and 3 (4%) patients underwent heart transplant. Twenty-four (35%) patients had implantable cardiac defibrillator (15 and 5 of them received both appropriate and inappropriate interventions, respectively and 7 experienced device-related complications). Of the ECG parameters registered at the enrolment, left anterior fascicular block (P = 0.001), QRS duration in lead 1 (P < 0.001), Epsilon wave (P < 0.001), T wave inversion in V4-V5-V6 (P = 0.012, P = 0.001 and P = 0.006) and low QRS voltages (P = 0.001) progressed over time. At multivariate analysis Epsilon wave (odds ratio 20.9, confidence interval 95% 1.8-239.8, P = 0.015) was the only predictor of the composite endpoint of SCD, heart failure-related death or heart transplant.

Conclusion: Apart from playing a pivotal role in ARVC diagnosis, a simple ECG feature such as Epsilon wave is a marker of poor prognosis.
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http://dx.doi.org/10.2459/JCM.0000000000000354DOI Listing
June 2016

Electrophysiologically Guided Substrate Modification During Sinus Rhythm: Personalized Approach to Nonparoxysmal Atrial Fibrillation.

Circ Arrhythm Electrophysiol 2016 Feb;9(2):e003832

From the Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy.

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http://dx.doi.org/10.1161/CIRCEP.116.003832DOI Listing
February 2016

Catheter ablation of atrial fibrillation in chronic heart failure: state-of-the-art and future perspectives.

Europace 2016 May 8;18(5):638-47. Epub 2016 Feb 8.

Division of Cardiology, Department of Medical Sciences, 'Città della Salute e della Scienza' Hospital, University of Turin, Torino, Italy

Catheter ablation of atrial fibrillation (AFCA) is a widely recommended treatment for symptomatic atrial fibrillation (AF) patients refractory to pharmacological treatment. Catheter ablation of AF is becoming a therapeutic option also among patients with chronic heart failure (CHF), on top of optimal medical treatment, being this arrhythmia related to a higher risk of death and/or symptom's worsening. In fact, in this setting, clinical evidences are continuously increasing. The present systematic review pools all published experiences concerning AFCA among CHF patients, or patients with structural cardiomyopathies, in order to summarize procedural safety and efficacy in this specific population. Moreover, the effects of AFCA on functional class and quality of life and the different procedural protocols available are discussed. The present work, therefore, attempts to provide an evidence-based clinical perspective to optimize clinical indication and tailor procedural characteristics and endpoints to patients affected by CHF referred for AFCA.
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http://dx.doi.org/10.1093/europace/euv368DOI Listing
May 2016

J-wave duration and slope as potential tools to discriminate between benign and malignant early repolarization.

Heart Rhythm 2016 Mar 18;13(3):806-11. Epub 2015 Nov 18.

Division of Cardiology, Department of Medical Science, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy.

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http://dx.doi.org/10.1016/j.hrthm.2015.11.029DOI Listing
March 2016

Starfix lead extraction: Clinical experience and technical issues.

J Cardiol Cases 2016 Jan 14;13(1):25-30. Epub 2015 Nov 14.

Division of Cardiology, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy.

Transvenous lead extraction (TLE) of the Starfix coronary sinus (CS) active-fixation lead may be challenging, due to undeployment of fixation lobes and venous occlusion. We report our experience in Starfix TLE, in comparison with previous data. A 78-year-old male, implanted in 2009 with Starfix lead, was referred to our institution for TLE, due to infective endocarditis with lead-associated vegetations. The tip of Starfix lead was located in distant, anterior position, in the great cardiac vein, close to patent left internal mammary artery-to-left anterior descending artery anastomosis, and first-choice surgical removal had a prohibitive operative risk. Conventional dilatation beyond CS ostium, as well as the use of a standard delivery catheter, was ineffective. An off-label modification of the delivery, by cutting the distal soft tip, was successful. However, the tip of the lead fragmented and was trapped in the innominate vein. Then a gooseneck snare grasped the fragment, allowing complete retrieval. TLE of Starfix leads may be particularly challenging, especially when its tip is located in a distant anterior location. In these cases, important help may be obtained by dilatation within the CS, by means of conventional or modified delivery catheters. Only experienced operators, sometimes with non-conventional techniques, should perform TLE of Starfix leads. < TLE of Starfix leads may be challenging, particularly when the tip is located in a distant anterior position. Dilatation with conventional tools may be precluded. In these cases modifications of the delivery catheters may be useful. Surgery should be avoided as first-choice procedure; only experienced operators, sometimes with non-conventional techniques, should perform TLE of Starfix leads.>.
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http://dx.doi.org/10.1016/j.jccase.2015.09.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281896PMC
January 2016

Do left atrial appendage morphology and function help predict thromboembolic risk in atrial fibrillation?

J Cardiovasc Med (Hagerstown) 2016 Mar;17(3):169-76

Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy.

Clinical scores (i.e. CHA2DS2-VASc) are the mainstay of thromboembolic risk management in nonvalvular atrial fibrillation. Nonetheless, they bear some limitations to precisely define risk-benefit ratio of oral anticoagulation (OAC), both with vitamin K antagonists and with novel direct oral anticoagulants, especially in patients with low-intermediate scores. Cardiovascular imaging, allowing directly visualization of those pathophysiological alterations, which may lead to the formation of intracardiac thrombi, offers itself as a unique tool helping to refine thromboembolic risk stratification. Many parameters have been tested, focusing primarily on functional and morphological variables of the left atrium and left atrial appendage (LAA). Left atrium volume and LAA peak flow velocity have, for a longtime, been associated with increased thromboembolic risk, whereas some new parameters, such as left atrium fibrosis assessed by late-gadolinium enhanced (LGE) MRI, left atrium and LAA strain and LAA morphology have more recently shown some ability in predicting embolic events in atrial fibrillation patients. Overall, however, these parameters have seen, to date, scarce clinical implementation, especially because of the inconsistency of validated cutoffs and/or strong clinical evidence driven by technical limitations, such as expensiveness of the technologies (i.e. MRI or computed tomography), invasiveness (i.e. transesophageal echocardiography) or limited reproducibility (i.e. LGE MRI). In conclusion, to date, cardiovascular imaging plays a limited role; however, validation and diffusion of the new techniques hereby systematically presented hold the potential to refine thromboembolic risk stratification in nonvalvular atrial fibrillation.
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http://dx.doi.org/10.2459/JCM.0000000000000305DOI Listing
March 2016

Is heart rate a risk marker in patients with chronic heart failure and concomitant atrial fibrillation? Results from the MAGGIC meta-analysis.

Eur J Heart Fail 2015 Nov 11;17(11):1182-91. Epub 2015 Sep 11.

BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.

Aim: To investigate the relationship between heart rate and survival in patients with heart failure (HF) and coexisting atrial fibrillation (AF).

Methods And Results: Patients with AF included in the Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) meta-analysis were the main focus of this analysis (3259 patients from 17 studies). The outcome was all-cause mortality at 3 years. Heart rate was analysed as a categorical (tertiles; T1 ≤77 b.p.m., T2 78-98 b.p.m., T3 ≥98 b.p.m.) and continuous variable. Cox proportional hazard models were used to compare the risk of all-cause death between tertiles of baseline heart rate. Patients in the highest tertile were more often female, less likely to have an ischaemic aetiology or diabetes, had a lower ejection fraction but higher blood pressure and New York Heart Association (NYHA) class. Higher heart rate was associated with higher mortality in patients with sinus rhythm (SR) but not in those in AF. In patients with heart failure and reduced ejection fraction (HF-REF) and AF, death rates per 100 patient years were lowest in the highest heart rate tertile (T1 18.9 vs. T3 15.9) but this difference was not statistically significant (P = 0.10). In patients with heart failure and preserved ejection fraction (HF-PEF), death rates per 100 patient years were highest in the highest heart rate tertile (T1 14.6 vs. T3 16.0, P = 0.014). However, after adjustment for other important prognostic variables, higher heart rate was no longer associated with higher mortality in HF-PEF (or HF-REF).

Conclusions: In this meta-analysis of patients with HF, heart rate does not have the same prognostic significance in patients in AF as it does in those in SR, irrespective of ejection fraction or treatment with beta-blocker.
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http://dx.doi.org/10.1002/ejhf.346DOI Listing
November 2015