AIMS: Several studies have evaluated the use of electrically- or imaging-guided left ventricular (LV) lead placement in cardiac resynchronization therapy (CRT) recipients. We aimed to assess evidence for a guided strategy that targets LV lead position to the site of latest LV activation. METHODS AND RESULTS: A systematic review and meta-analysis was performed for randomized controlled trials (RCTs) until March 2023 that evaluated electrically- or imaging-guided LV lead positioning on clinical and echocardiographic outcomes. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization, and secondary endpoints were quality of life, 6-min walk test (6MWT), QRS duration, LV end-systolic volume, and LV ejection fraction. We included eight RCTs that comprised 1323 patients. Six RCTs compared guided strategy (n = 638) to routine (n = 468), and two RCTs compared different guiding strategies head-to-head: electrically- (n = 111) vs. imaging-guided (n = 106). Compared to routine, a guided strategy did not significantly reduce the risk of the primary endpoint after 12-24 (RR 0.83, 95% CI 0.52-1.33) months. A guided strategy was associated with slight improvement in 6MWT distance after 6 months of follow-up of absolute 18 (95% CI 6-30) m between groups, but not in remaining secondary endpoints. None of the secondary endpoints differed between the guided strategies. CONCLUSION: In this study, a CRT implantation strategy that targets the latest LV activation did not improve survival or reduce heart failure hospitalizations.
- MeSH
- diagnostické techniky kardiovaskulární MeSH
- echokardiografie metody MeSH
- fibróza diagnostické zobrazování MeSH
- kardiologické zobrazovací techniky * MeSH
- kardiomyopatie diagnostické zobrazování MeSH
- koronární angiografie metody MeSH
- lidé MeSH
- magnetická rezonanční tomografie metody MeSH
- myokarditida diagnostické zobrazování MeSH
- nemoci srdečních chlopní diagnostické zobrazování MeSH
- počítačová rentgenová tomografie metody MeSH
- SPECT/CT metody MeSH
- srdeční selhání * diagnostické zobrazování MeSH
- zátěžová echokardiografie metody MeSH
- Check Tag
- lidé MeSH
BACKGROUND: Use of the current echocardiography-based indications for aortic regurgitation (AR) surgery might result in late valve replacement at the stage of irreversible myocardial damage. Therefore, we aimed to identify simple models combining multiple echocardiography or magnetic resonance imaging (MRI)-derived indices and natriuretic peptides (BNP [brain natriuretic peptide] or NT-proBNP [N-terminnal pro-B type natriuretic peptide]) to predict early disease decompensation in asymptomatic severe AR. METHODS: This prospective and multicenter study included asymptomatic patients with severe AR, preserved left ventricular ejection fraction (>50%), and sinus rhythm. The echocardiography and MRI images were analyzed centrally in the CoreLab. The study end point was the onset of indication for aortic valve surgery as per current guidelines. RESULTS: The derivative cohort consisted of 127 asymptomatic patients (age 45±14 years, 84% males) with 41 (32%) end points during a median follow-up of 1375 (interquartile range, 1041-1783) days. In multivariable Cox regression analysis, age, BNP, 3-dimensional vena contracta area, MRI left ventricular end-diastolic volume index, regurgitant volume, and a fraction were identified as independent predictors of end point (all P<0.05). However, a combined model including one parameter of AR assessment (MRI regurgitant volume or regurgitant fraction or 3-dimensional vena contracta area), 1 parameter of left ventricular remodeling (MRI left ventricular end-diastolic volume index or echocardiography 2-dimensional global longitudinal strain or E wave), and BNP showed significantly higher predictive accuracy (area under the curve, 0.74-0.81) than any parameter alone (area under the curve, 0.61-0.72). These findings were confirmed in the validation cohort (n=100 patients, 38 end points). CONCLUSIONS: In asymptomatic severe AR, multimodality and multiparametric model combining 2 imaging indices with natriuretic peptides, showed high accuracy to identify early disease decompensation. Further prospective studies are warranted to explore the clinical benefit of implementing these models to guide patient management. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02910349.
- MeSH
- aortální insuficience * diagnostické zobrazování etiologie chirurgie MeSH
- dospělí MeSH
- echokardiografie MeSH
- funkce levé komory srdeční MeSH
- lidé středního věku MeSH
- lidé MeSH
- magnetická rezonanční tomografie MeSH
- natriuretický peptid typu B MeSH
- tepový objem MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
Dilatace kořene a/nebo ascendentní aorty je spjata s vyšším rizikem akutní disekce. U nemocných bez chlopenní vady, kteří nesplňují kritéria pro její náhradu, byla v posledních letech zavedena do praxe metoda PEARS (personalized external aortic root support). Spočívá v implantaci na míru vyrobené dakronové síťky, která zabrání progresi dilatace aorty. V práci jsou prezentovány výsledky prvních 100 implantací této síťky u pacientů v České republice. Soubor nemocných a metodika: Soubor tvořilo 77 mužů a 23 žen, průměrného věku 40,4 ± 15,3 roku. U 87 pacientů byla prokázána geneticky podmíněná aortopatie (porucha pojivové tkáně a/nebo bikuspidální aortální chlopeň). U 14 pacientů byla aortální regurgitace větší než 1. st, ale u žádného větší než 2. st. Maximální rozměry aortálního kořene a ascendentní aorty byly 60, resp. 59 mm. Výsledky: U všech pacientů byla síťka úspěšně implantována, u 35 za srdeční akce bez mimotělního oběhu. V časném pooperačním průběhu byly u 35 pacientů přítomny klinické nebo laboratorní známky zánětu, u 23 pacientů přechodné supraventrikulární poruchy srdečního rytmu. Průměrná doba hospitalizace činila 8,4 ± 2,4 dne a žádný pacient v časném pooperačním průběhu nezemřel. Pacienti byli sledováni v průměru 18,1 ± 17,2 měsíce a na kontrolním vyšetření došlo ve srovnání s předoperačními hodnotami k signifikantnímu zmenšení rozměrů kořene, sinotubulární junkce i ascendentní aorty. Závěr: Střednědobé sledování pacientů s dilatací aorty po implantaci PEARS ukázalo, že tato metoda brání dilataci aorty a je dobrým preventivním opatřením před možnou aortální disekcí.
Dilatation of the aortic root and/or ascending aorta is associated with an increased risk of acute dissection. Personalized external aortic root support (PEARS) is a new method that was introduced in last years for these patients without any significant valve disease who do not fulfil the criteria for aortic root or ascending aorta replacement. It is a custom-made macroporous mesh that stabilises the aortic wall. We present the results of the first 100 consecutive patients in whom PEARS was implanted.
- MeSH
- chirurgické síťky MeSH
- disekce aorty * chirurgie MeSH
- lidé MeSH
- retrospektivní studie MeSH
- Check Tag
- lidé MeSH
BACKGROUND: Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with severe AS and normal left ventricular function remain debated. METHODS: The AVATAR trial (Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm2 with aortic jet velocity >4 m/s or a mean transaortic gradient ≥40 mm Hg), and with normal left ventricular function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite end point of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries. RESULTS: Between June 2015 and September 2020, 157 patients (mean age, 67 years; 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in the conservative treatment group. In the early surgery group, 72 patients (92.3%) underwent SAVR with operative mortality of 1.4%. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite end point than those in the conservative arm (hazard ratio, 0.46 [95% CI, 0.23-0.90]; P=0.02). There was no statistical difference in secondary end points, including all-cause mortality, first heart failure hospitalizations, major bleeding, or thromboembolic complications, but trends were consistent with the primary outcome. CONCLUSIONS: In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02436655.
- MeSH
- aortální stenóza mortalita terapie MeSH
- chirurgická náhrada chlopně * MeSH
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- následné studie MeSH
- prospektivní studie MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- srdeční chlopně umělé * MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- klinické zkoušky MeSH
- multicentrická studie MeSH
- randomizované kontrolované studie MeSH
- srovnávací studie MeSH
Reliable quantification of aortic regurgitation (AR) severity is essential for clinical management. We aimed to compare quantitative and indirect echo-Doppler indices to quantitative cardiac magnetic resonance (CMR) parameters in asymptomatic chronic severe AR. Methods and Results: We evaluated 104 consecutive patients using echocardiography and CMR. A comprehensive 2D, 3D, and Doppler echocardiography was performed. The CMR was used to quantify regurgitation fraction (RF) and volume (RV) using the phase-contrast velocity mapping technique. Concordant grading of AR severity with both techniques was observed in 77 (74%) patients. Correlation between RV and RF as assessed by echocardiography and CMR was relatively good (rs = 0.50 for RV, rs = 0.40 for RF, p < 0.0001). The best correlation between indirect echo-Doppler and CMR parameters was found for diastolic flow reversal (DFR) velocity in descending aorta (rs = 0.62 for RV, rs = 0.50 for RF, p < 0.0001) and 3D vena contracta area (VCA) (rs = 0.48 for RV, rs = 0.38 for RF, p < 0.0001). Using receiver operating characteristic analysis, the largest area under curve (AUC) to predict severe AR by CMR RV was observed for DFR velocity (AUC = 0.79). DFR velocity of 19.5 cm/s provided 78% sensitivity and 80% specificity. The AUC for 3D VCA to predict severe AR by CMR RV was 0.73, with optimal cut-off of 26 mm2 (sensitivity 80% and specificity 66%). Conclusions: Out of the indirect echo-Doppler indices of AR severity, DFR velocity in descending aorta and 3D vena contracta area showed the best correlation with CMR-derived RV and RF in patients with chronic severe AR.
- Publikační typ
- časopisecké články MeSH
- MeSH
- lidé MeSH
- nemoci srdce * diagnostické zobrazování MeSH
- počítačová rentgenová tomografie * metody MeSH
- srdce diagnostické zobrazování MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- směrnice pro lékařskou praxi MeSH
Kontext: Cílem studie bylo zjistit závažnost zánětlivé odpovědi po výkonu PEARS (personalized external aortic root support) s vytvořením personalizovaného externího stentu pro aortální kořen ve srovnání se standardní profylaktickou operací aortálního kořene (standard prophylactic aortic root surgery, SPARS). Materiál a metody: Studie byla monocentrickou, retrospektivní analýzou nemocničních záznamů pacientů, u nichž byla v období 1998-2017 provedena buď PEARS (skupina PEARS), nebo SPARS (skupina SPARS). U všech pacientů se rutinně stanovovaly hodnoty C-reaktivního proteinu (CRP) a počet bílých krvinek (white blood count, WBC) a provádělo se echokardiografické vyšetření. Horečka byla definována jako tělesná teplota ≥ 38 °C. Diagnóza perikarditidy se stanovovala na základě nejméně tří známek z bolesti na hrudi, perikardiálního výpotku, elevace úseku ST, zvýšených hodnot CRP a tělesné teploty. Výsledky: Do skupin PEARS a SPARS bylo zařazeno 13, resp. 14 pacientů s indikací k profylaktické operaci aortálního kořene. Většina pacientů v obou skupinách měla Marfanův syndrom s kauzální mutací v genu pro fibrilin 1 (FBN1) (62 % vs. 79 %). Vstupní charakteristiky pacientů v obou skupinách byly podobné s výjimkou aortálního kořene, který byl ve skupině SPARS statisticky významně větší než ve skupině PEARS (60 ± 12 mm vs. 48 ± 5 mm; p = 0,003). Všechny operace byly úspěšné a proběhly bez větších komplikací. Nejvyšší hodnoty CRP a WBC byly statisticky významně vyšší ve skupině PEARS (264,5 ± 84,4 mg/l vs. 184,6 ± 89,6 mg/l; p = 0,034, resp. 15,2 ± 3,8 109/l vs. 11,9 ± 3,3 109/l; p = 0,029). Časná a recidivující horečka vyžadující opětovnou hospitalizaci se vyskytla častěji ve skupině PEARS (77 % vs. 36 %; p = 0,032, resp. 46 % vs. 7 %; p = 0,020). Časná a recidivující perikarditida vyžadující hospitalizaci byla rovněž častější ve skupině PEARS (31 % vs. 0 %; p = 0,024, resp. 31 % vs. 0 %; p = 0,024). Závěry: Metoda PEARS je velmi slibná chirurgická metoda; pooperační zánětlivá odpověď se však vyskytuje častěji a ve srovnání s metodou SPARS je závažnější. Tyto výsledky je však samozřejmě nutno dále zkoumat a ověřovat.
Background: The study aimed to determine the severity of inflammatory response after the personalized external aortic root support (PEARS) procedure in comparison to after the standard prophylactic aortic root surgery (SPARS). Materials and methods: The study was a single-centre, retrospective, based on hospital record analysis of patients who underwent the PEARS procedure (PEARS group) or SPARS (SPARS group) during 1998-2017. C-reactive protein (CRP), white blood count (WBC), and echocardiography were routinely obtained. Fever was defined as body temperature ≥38 °C. Diagnosis of pericarditis included a minimum of three signs from chest pain, pericardial effusion, ST elevation, elevated CRP, and body temperature. Results: PEARS and SPARS groups consisted of 13 and 14 patients, respectively, scheduled for prophylactic aortic root. A majority of patients in both groups had Marfan syndrome with causal mutation in the fibrillin 1 (FBN1) gene (62% vs 79%). Patient baseline characteristics were similar in the two groups, except aortic root was significantly larger in the SPARS group than in the PEARS group (60±12 mm vs 48±5 mm; p = 0.003). All surgical procedures were successful and without major complications. The peak values of CRP and WBC were significantly higher in the PEARS group (264.5±84.4 mg/L vs 184.6±89.6 mg/L; p = 0.034 and 15.2±3.8 109/L vs 11.9±3.3 109/L; p = 0.029). Early and recurrent fever requiring hospital readmission was significantlymore frequent in the PEARS group (77% vs 36%; p = 0.032 and 46% vs 7%; p = 0.020). Early and recurrent pericarditis requiring hospital readmission was also more frequent in the PEARS group (31% vs 0%; p = 0.024 and 31% vs 0%; p = 0.024)., Conclusions: The PEARS procedure is an extremely promising surgical technique, but the postoperative inflammatory response occurs frequently and more severely in comparison to SPARS. Clearly, these findings warrant further investigation.
- MeSH
- aortální aneurysma * chirurgie MeSH
- C-reaktivní protein analýza MeSH
- lidé MeSH
- Marfanův syndrom chirurgie MeSH
- perikarditida chirurgie MeSH
- pooperační komplikace MeSH
- profylaktické chirurgické výkony MeSH
- retrospektivní studie MeSH
- zánět MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- práce podpořená grantem MeSH
OBJECTIVE: There are no data about the prevalence of silent coronary artery disease in asymptomatic severe aortic stenosis patients with normal exercise testing. Importantly, unmasking significant coronary artery disease in patients with aortic stenosis could influence the choice/timing of treatment in these patients. METHOD: Exercise testing was performed on semi-supine ergobicycle. Cardiopulmonary analysis during exercise testing, echocardiography, and laboratory analysis at rest was done. Standard clinical/electrocardiography criteria were assessed for symptoms/signs of ischemia during/after exercise testing. In patients with normal exercise testing coronary angiography was performed using standard femoral/radial percutaneous approach. Coronary stenosis was considered significant if >70% of vessel diameter or 50%-70% with fractional flow reserve ≤0.8. RESULTS: Total of 96 patients with normal exercise testing were included (67.6 years, 50.6% males). No patient had any complication or adverse event. The Pmean was 52.7 mmHg, mean indexed aortic valve area was 0.36 cm/m and left ventricular ejection fraction, 69.5%. 19/96 patients (19.8%) had significant coronary artery disease on coronary angiography. Multivariate logistic regression analysis revealed brain natriuretic peptide and blood glucose as independent predictors of silent coronary artery disease. Brain natriuretic peptide value of 118 pg/ml had sensitivity/specificity of 63%/73% for predicting coronary artery disease (area under the curve 0.727, P = 0.006). CONCLUSION: Our results are the first to show that in patients with severe aortic stenosis, normal left ventricular ejection fraction,, and normal exercise testing, significant coronary artery disease is present in as many as 1/5 patients. In such patients, further prospective studies are warranted to address the diagnostic value of brain natriuretic peptide in detecting silent coronary artery disease.
- MeSH
- aortální stenóza komplikace patofyziologie MeSH
- asymptomatické nemoci * MeSH
- koronární angiografie MeSH
- koronární stenóza komplikace diagnóza epidemiologie metabolismus MeSH
- krevní glukóza metabolismus MeSH
- lidé středního věku MeSH
- lidé MeSH
- logistické modely MeSH
- natriuretický peptid typu B metabolismus MeSH
- nemoci koronárních tepen komplikace diagnóza epidemiologie metabolismus MeSH
- senioři MeSH
- senzitivita a specificita MeSH
- stupeň závažnosti nemoci MeSH
- zátěžový test MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
Background: Determining the value of new imaging markers to predict aortic valve (AV) surgery in asymptomatic patients with severe aortic regurgitation (AR) in a prospective, observational, multicenter study. Methods: Consecutive patients with chronic severe AR were enrolled between 2015-2018. Baseline examination included echocardiography (ECHO) with 2- and 3-dimensional (2D and 3D) vena contracta area (VCA), and magnetic resonance imaging (MRI) with regurgitant volume (RV) and fraction (RF) analyzed in CoreLab. Results: The mean follow-up was 587 days (interquartile range (IQR) 296-901) in a total of 104 patients. Twenty patients underwent AV surgery. Baseline clinical and laboratory data did not differ between surgically and medically treated patients. Surgically treated patients had larger left ventricular (LV) dimension, end-diastolic volume (all p < 0.05), and the LV ejection fraction was similar. The surgical group showed higher prevalence of severe AR (70% vs. 40%, p = 0.02). Out of all imaging markers 3D VCA, MRI-derived RV and RF were identified as the strongest independent predictors of AV surgery (all p < 0.001). Conclusions: Parameters related to LV morphology and function showed moderate accuracy to identify patients in need of early AV surgery at the early stage of the disease. 3D ECHO-derived VCA and MRI-derived RV and RF showed high accuracy and excellent sensitivity to identify patients in need of early surgery.
- Publikační typ
- časopisecké články MeSH
