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A fejlett országokban a hirtelen szívhalál napjainkban is a vezető kardiovaszkuláris halálokok közé tartozik. Európában gyakorisága évente mintegy 84/100 000 fő. Az elmúlt évtizedekben számos rizikófaktort azonosítottak, amelyeknek ismeretével a prognózis javítható. Írásunkban a kórházon belül (IHCA), illetve a kórházon kívül (OHCA) kialakult hirtelen szívhalál incidenciáját, major prognosztikai faktorait és a túlélést javító lehetséges eszközöket mutatjuk be. Ezentúl összegeztük a 2021-es új irányelveket az alap- és emeltszintű újraélesztési protokollokat illetően.

Áttekintő közleményünkben a szívelégtelen betegek körében végzett pitvarfibrilláció-abláció témában rendelkezésre álló evidenciákat és az újabb vizsgálatok eredményeit foglaljuk össze. Az antiaritmiás gyógyszeres kezelés, valamint a katéterabláció közötti különbségeken túl a csökkent és megtartott ejekciós frakciójú szívelégtelen betegcsoportra vonatkozó eredményeket is tárgyaljuk. A jelenleg érvényben lévő európai pitvarfibrillációs irányelv alapvetően tünetorientáltan közelíti meg a betegség kezelését, azonban a szívelégtelenséggel szövődött esetekben a rendkívül magas halálozási rizikó miatt nagy szükség van a mortalitást is csökkentő terápiás lehetőségekre. A jelenlegi tudásunk alapján a klinikai kimenetel javítására megfontolandó ebben a betegcsoportban az abláció, mint elsővonalbeli terápia, azonban a különböző klinikai vizsgálatok eltérő eredménnyel zárultak. Tekintettel arra, hogy a gyógyszeres terápiának számos limitációja létezik, az ablációs stratégiának kiemelt jelentősége van. Mindazonáltal egyelőre kevés bizonyíték áll rendelkezésre arra vonatkozóan, hogy az egyes addicionális ablációs technikák mekkora klinikai haszonnal járnak. Valószínűsítjük, hogy a standardizált terápia helyett a személyre szabott gyógyszeres és eszközös kezelési stratégia javíthatja a szívelégtelen betegek klinikai kimenetelét.

Purpose: Safety, efficacy, and patient comfort are the primary expectations during pulmonary vein isolation (PVI). We aimed to validate the combined advantages of pre-and periprocedural anticoagulation with non-vitamin K anticoagulants (NOACs) and rigorous left atrial appendage thrombus (LAAT) exclusion with computed tomography (CT). Moreover, we assessed the effect of pre-and periprocedural workups and the catheter ablation on the patients' quality of life. Methods: Consecutive patient population was collected between March 2018 and June 2020, who underwent cardiac CT within 24 hours before PVI to plan and guide the ablation and rule out LAAT. NOAC was omitted 24 hours before the ablation. If CT was inconclusive regarding the presence of a thrombus, transoesophageal echocargiography (TOE) was performed. All patients underwent PVI using point-by-point radiofrequency ablation. All patients had a routine follow up at 3 months. Quality of life questionnaires were obtained postprocedurally to evaluate the periprocedural discomfort of the patients. Results: 187 patients (63% male) underwent CT before PVI. TOE was used in 11 (6%) cases. None of the patients experienced stroke during or after the procedure. Based on the quality of life questionnaires, the worst patient discomfort was caused by atrial fibrillation itself, followed by the TOE, then the ablation procedure, hospital stay, and finally the CT. Complication rate was low, with no symptomatic thromboembolic event and 2.1% major bleeding event. Conclusion: Omitting NOAC 24 hours before the ablation might be safe. Moreover, patient comfort may be increased by replacing the TOE examination with CT.

Cardiac resynchronization therapy (CRT) for selected heart failure (HF) patients improves symptoms and reduces morbidity and mortality; however, the prognosis of HF is still poor. There is an emerging need for tools that might help in optimal patient selection and provide prognostic information for patients and their families. Several risk scores have been created in recent years; although, no literature review is available that would list the possible scores for the clinicians. We identified forty-eight risk scores in CRT and provided the calculation methods and formulas in a ready-to-use format. The reviewed score systems can predict the prognosis of CRT patients; some of them have even provided an online calculation tool. Significant heterogeneity is present between the various risk scores in terms of the variables incorporated and some variables are not yet used in daily clinical practice. The lack of cross-validation of the risk scores limits their routine use and objective selection. As the number of prognostic markers of CRT is overwhelming, further studies might be required to analyze and cross-validate the data.

Purpose Our purpose was to compare the procedural characteristics, success rate, and complication rate of the conventional fluoroscopic (CF) and the zero-fluoroscopic (ZF) approach in patients undergoing catheter ablation AVNRT or typical atrial flutter (Aflu). Methods 186 consecutive patients with an indication for AVNRT or Aflu ablation were enrolled. Based on the operator's preference, the patients were assigned to either CF or ZF group. In the ZF group EnSite NavX, Carto3, or Rhythmia EAMS were used for catheter guidance. Results The median age was 56 (IQR= 42-68) years, 144 patients had AVNRT, and 42 had Aflu ablation. CF approach was chosen in 123 cases, while ZF in 63 cases. ZF approach was used more often in case of AVNRT patients [56 (39%) vs. 7 (17%), p=0.006] and in the case of female patients [43 (43%) vs. 20 (23%), p=0.025]. Acute procedural success was obtained in all cases. There was no difference in the complication rate (1 vs. 1, p>0.99) between the two groups. No difference was found regarding the procedure time between the CF and ZF groups [CF: 55 (46-60) min, ZF 60 (47-65) min; p=0.487] or in the procedure time for the different EAMS [EnSite NavX: 58 (50-63) min, Carto3: 60 (44.5-66.3) min, Rhythmia: 55 (35-69) min; p=0.887]. Similar mid-term success rate was seen in the two groups [41 (100%) vs. 96 (97%); p=0.55]. Conclusion The ZF approach demonstrated non-inferiority in safety and efficacy compared with CF for the AVNRT and Aflu ablations.

Comparative data are virtually missing about the performance of different electro-anatomical mapping (EAM) system platforms on outflow tract (OT) premature ventricular complex (PVC) ablation outcomes with manual ablation catheters. We aimed to compare the acute success-, complication-, and long-term recurrence rates of impedance-based (IMP) and magnetic field-based (MAG) EAM platforms in manual OT PVC ablation. Single-centre, propensity score matched data of 39–39 patients ablated for OT PVCs in 2015–17 with IMP or MAG platforms were analysed. Acute success rate, peri-procedural complications, post-ablation daily PVC burden, and long-term recurrence rates were compared on intention-to-treat basis. Acute success rate was similar in the IMP and MAG group (77 vs. 82%, p = 0.78). There was a single case of femoral pseudo-aneurysm and no cardiac tamponade occurred. PVC burden fell significantly from baseline 24.0% [15.0–30.0%] to 3.3% [0.25–10.5%] (p p = 0.60). There was no significant difference in recurrence-free survival of the intention-to-treat cohort of the IMP and MAG groups (54 vs. 60%, p = 0.82, respectively) during 12 months of follow-up. Ablation with the aid of both impedance- and magnetic field-based EAM platforms can considerably reduce OT PVC burden and give similar acute- and long-term freedom from arrhythmia.

Background and Aims. Resynchronization therapy (CRT) improves mortality and induces reverse remodeling in heart failure (HF) patients with reduced ejection fraction and wide QRS. Nonetheless, some patients do not improve despite the optimal medical therapy and right indications for device implantation. Therefore, finding biomarkers suitable for identification of those patients is crucial. Vitamin D plays a classic hormonal role in the regulation of bone metabolism and also has physiological functions in wide range of nonskeletal tissues. Based on recent studies, low levels of vitamin D seem to directly contribute to pathogenesis and worsening of HF. We planned to assess the role of vitamin D levels on clinical outcomes of HF patients undergoing CRT. Methods and Results. We enrolled 136 HF patients undergoing CRT. Total plasma vitamin D levels were measured at baseline and 6 months later. Primary endpoint was 5-year all-cause mortality; secondary endpoint was lack of good clinical response, defined as less than 15% increase of left ventricular ejection fraction after six months. During follow-up, 58 patients reached the primary, and 45 patients reached the secondary endpoint. Vitamin D levels less than 24.13 ng/mL predicted 5-year mortality (p=0.045) and poor clinical response (p=0.03) after adjusting to all significant baseline predictors. Conclusion. Our study showed that vitamin D deficiency has a significant impact in heart failure patients; it is an independent predictor of lack of midterm clinical response and long-term mortality in patients undergoing CRT. Therefore, monitoring vitamin D status of heart failure patients could be of clinical significance.

INTRODUCTION AND OBJECTIVES Cardiac resynchronization therapy (CRT) is beneficial for selected heart failure (HF) patients, although nonresponse to therapy is still prevalent. We investigated a set of novel biomarkers associated with various pathophysiological pathways of HF. Our purpose was to assess their ability to predict clinical outcomes after CRT. METHODS We studied 136 chronic HF patients undergoing CRT. We measured the plasma levels of fractalkine, pentraxin-3, hepatocyte growth factor (HGF), carbohydrate antigen-125, and matrix metalloproteinase-9 before and 6 months after CRT. The primary endpoint of the study was 5-year all-cause mortality, and we considered the absence of 6-month reverse remodelling (defined as at least a 15% decrease in end-systolic volume) as a secondary endpoint. RESULTS Fifty-eight patients died during the 5-year follow-up period and 66 patients were categorized as nonresponders. In multivariable models, only an increased HGF was an independent predictor of both mortality (HR, 1.35; 95%CI, 1.11-1.64; P=.003; per 1 standard deviation increase) and the absence of reverse remodelling (OR, 1.83; 95%CI, 1.10-3.04; P=.01; per 1 standard deviation increase). Applying HGF to the basic multivariable model of both mortality (net reclassification improvement=0.69; 95%CI, 0.39-0.99; P

Resumen Introduccion y objetivos La terapia de resincronizacion cardiaca (TRC) es beneficiosa para pacientes seleccionados con insuficiencia cardiaca (IC), aunque la ausencia de respuesta a la terapia es aun prevalente. Se investiga un conjunto de nuevos biomarcadores asociados a varias vias fisiopatologicas de la IC. El proposito fue valorar su capacidad para predecir los resultados clinicos con la TRC. Metodos Se estudio a 136 pacientes con IC cronica y TRC. Se midieron los valores plasmaticos de fractalquina, pentraxina-3, factor de crecimiento hepatocitario (HGF), el antigeno carbohidrato 125 y la metaloproteinasa de matriz 9 tanto antes como 6 meses despues del inicio de la TRC. El objetivo primario del estudio fue la mortalidad por todas las causas a 5 anos, y se considero la ausencia de remodelado inverso a los 6 meses (definido como al menos un 15% de descenso del volumen telesistolico) como un objetivo secundario. Resultados Cincuenta y ocho pacientes fallecieron a lo largo de los 5 anos de seguimiento y 66 pacientes se categorizaron como no respondedores. En modelos multivariables, solo un aumento del HGF resulto un predictor independiente, tanto de mortalidad (HR = 1,35; IC95%, 1,11-1,64; p = 0,003; por cada unidad de incremento de la desviacion estandar) como de ausencia de remodelado inverso (OR = 1,83; IC95%, 1,10-3,04; p = 0,01; por cada unidad de incremento de la desviacion estandar). Aplicando el HGF al modelo basico multivariable tanto de mortalidad (mejora neta de reclasificacion = 0,69; IC95%, 0,39-0,99; p Conclusiones De los biomarcadores investigados, solo el HGF predijo los resultados clinicos despues de la TRC independientemente de otros parametros. Los analisis de reclasificacion mostraron que las mediciones de HGF podrian ser utiles para mejorar la seleccion de pacientes.

Introduction In patients with chronic heart failure (CHF) left ventricular dysfunction results in elevated left atrial (LA) pressure, triggering pathological atrial remodelling and atrial fibrillation (AF). Nevertheless, it has been reported that some patients with CHF remain in sinus rhythm (SR) despite of the pathological structural alterations (e.g. dilation and fibrosis) of the LA. Of particular interest, data is scarce regarding the molecular explanation for the observed variability in AF development among CHF patients. Recent studies have indicated that alterations in microRNA (miRNA) expression might contribute to the pathogenesis of AF. However, the majority of previous studies focusing on miRNA expression compared healthy LA with SR to pathologically remodelled, dilated LA with AF. Consequently, whether dysregulation of miRNA expression directly contribute to AF and not only to pathological LA remodelling has not been tested before. Purpose The present study aimed to investigate miRNA expression in comparably remodelled LA from end-stage CHF patients with permanent AF (CHF-AF) or SR (CHF-SR). Methods LA samples were collected from male, non-diabetic, ischemic end-stage CHF patients undergoing heart transplantation (n=24). Patients were carefully selected to avoid any differences in age (55±2 vs. 54±2 years, CHF-AF vs. CHF-SR, n.s.), ejection fraction ([EF]: 22.5±1.8 vs. 23.3±2.5%, CHF-AF vs. CHF-SR, n.s.) LA diameters (longitudinal LA diameter: 56±4 vs. 48±5mm.; CHF-AF vs. CHF-SR, n.s.; horizontal LA diameter: 61±2 vs. 54±3, CHF-AF vs. CHF-SR, n.s.) and NYHA stage. As a molecular marker of atrial load, the mRNA expression of atrial natriuretic peptide (ANP) was measured with qRT-PCR. The extent of left atrial fibrosis was assessed on picrosirius red stained histological sections. Global LA miRNA expression profiling (including the measurement of 800 human miRNA) was carried out using a commercially available kit. Results LA mRNA expression of ANP was comparable between the AF-CHF and the SR-CHF groups, suggesting that atrial load occurred to the same level in the two experimental groups. Furthermore, no differences could be observed in the extent of atrial collagen content between the AF-CHF and the SR-CHF groups (collagen area: 20.3±1.3% vs. 23.9±3.1%, n.s.), providing evidence that fibrotic remodelling had occurred to a similar magnitude. The high-throughput miRNA measurement revealed no differences in atrial miRNA expression between the two study groups. Conclusion The present study provides evidence for the first time that AF is not associated with different LA miRNA expression in end-stage CHF patients with comparable level of LA dilatation, ANP expression (atrial load) and interstitial fibrosis. Based on these findings, the potential of miRNA-based therapeutic interventions might be limited in AF patients with ischemic end-stage CHF. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): NVKP_16-1-2016-0017

Rationale The beta-O-linkage of N-acetylglucosamine (i.e., O-GlcNAc) to proteins is a pro-adaptive response to cellular insults. To this end, increased protein O-GlcNAcylation improves short-term survival of cardiomyocytes subjected to acute injury. This observation has been repeated by multiple groups and in multiple models; however, whether increased protein O-GlcNAcylation plays a beneficial role in more chronic settings remains an open question. Objective Here, we queried whether increasing levels of cardiac protein O-GlcNAcylation would be beneficial during infarct-induced heart failure. Methods and results To achieve increased protein O-GlcNAcylation, we targeted Oga, the gene responsible for removing O-GlcNAc from proteins. Here, we generated mice with cardiomyocyte-restricted, tamoxifen-inducible haploinsufficient Oga gene. In the absence of infarction, we observed a slight reduction in ejection fraction in Oga deficient mice. Overall, Oga reduction had no major impact on ventricular function. In additional cohorts, mice of both sexes and both genotypes were subjected to infarct-induced heart failure and followed for up to four weeks, during which time cardiac function was assessed via echocardiography. Contrary to our prediction, the Oga deficient mice exhibited exacerbated—not improved—cardiac function at one week following infarction. When the observation was extended to 4 wk post-MI, this acute exacerbation was lost. Conclusions The present findings, coupled with our previous work, suggest that altering the ability of cardiomyocytes to either add or remove O-GlcNAc modifications to proteins exacerbates early infarct-induced heart failure. We speculate that more nuanced approaches to regulating O-GlcNAcylation are needed to understand its role—and, in particular, the possibility of cycling, in the pathophysiology of the failing heart.

Background Cardiac resynchronization therapy (CRT) in chronic heart failure has been shown to improve mortality and morbidity. However, comprehensive data are not available as concerns how circulating biomarkers reflecting different organ functions, such as serum uric acid, blood urea nitrogen (BUN), albumin, cholesterol, or various liver enzymes, change over time as a consequence of CRT. The aim of this prospective study was to overview these possible changes. Methods A total of 20 routine laboratory parameters were measured in 122 control subjects and in 129 patients with chronic heart failure before CRT, 6 months, and 2 years later. Results The levels of serum uric acid [before: 432 (331–516) mmol/L, 6-month: 372 (304–452) mmol/L, 2-year: 340 (290–433) mmol/L; p

Background Cardiac Resynchronization Therapy (CRT) has well-known beneficial effects in patients with advanced heart failure, reduced ejection fraction and wide QRS complex. However, mortality rates still remain high in this patient population. Therefore, precise risk stratification would be essential, nonetheless, the currently available risk scores have several shortcomings which hamper their utilization in the everyday clinical practice. Purpose Accordingly, our objective was to design and validate a machine learning based risk stratification system to predict 2-year and 5-year mortality from pre-implant parameters of patients undergoing CRT implantation. Methods We trained two models separately to predict 2-year (model 1) and 5-year mortality (model 2). As training cohort of model 1 we used 1678 patients (67±10 years, 1251 [75%] males) undergoing CRT implantation. From this population, 1320 patients (66±10 years, 1005 [76%] males) also completed 5-year follow-up and they served as the training cohort for model 2. Forty-seven pre-implant parameters (demographics, cardiovascular risk factors and clinical characteristics) were used to train the models. Our models were designed in a way to tolerate missing values. Among non-linear classifiers, random forest demonstrated the best performance. We validated our models, along with the Seattle Heart Failure Model (SHFM), VALID-CRT risk score and EAARN score on an independent cohort of 136 patients (66±10 years, 110 [81%] males). Based on the predicted probability of survival, patients were split into quartiles and survival was plotted via Kaplan-Meier (KM) curves. Results There were 358 (21%) deaths in the 2-year, 697 (53%) deaths in the 5-year training cohort. In the validation cohort, there were 30 (22%) deaths at 2 years and 58 (43%) deaths at 5 years after CRT implantation. For the prediction of 2-year mortality, the Area Under the Receiver-Operating Characteristic Curve (AUC) for model 1 was 0.77 (95% CI: 0.67–0.87; p=0.002), for SHFM was 0.54 (95% CI: 0.39–0.69; p=0.006), for EAARN was 0.57 (95% CI: 0.46–0.68, p=0.002), and for VALID-CRT was 0.62 (95% CI: 0.52–0.71; p=0.002). To predict 5-year mortality, the AUC for model 2 was 0.85 (95% CI: 0.78–0.91; p=0.001), for SHFM was 0.62 (95% CI: 0.51–0.74; p=0.003), for EAARN was 0.61 (95% CI: 0.51–0.70, p=0.002), for VALID-CRT was 0.65 (95% CI: 0.56–0.74; p=0.002). The AUCs of the machine learning based models were significantly higher than the AUCs of the pre-existing scores (DeLong test, all p Conclusion Our results indicate that machine learning algorithms can outperform the already existing linear model based scores. By capturing the non-linear association of predictors, the utilization of these state-of-the-art approaches may facilitate optimal candidate selection and prognostication of patients undergoing CRT implantation.

Changes in the levels of serum creatinine and N-terminal of prohormone brain natriuretic peptide (NT-proBNP) are useful risk markers after cardiac resynchronization therapy (CRT). The diagnostic value of changes in serum uric acid levels has been established in chronic heart failure, but no data are available on the prognostic value of hyperuricemia in a CRT population.We measured markers of renal function [creatinine, blood urea nitrogen (BUN) and uric acid] and NT-proBNP levels of 129 heart failure patients undergoing CRT in a prospective, observational study. The 5-year all-cause mortality and the 6-month clinical response (≥ 15% increase in the left ventricular ejection fraction) were considered as study end points.In multivariable analyses, the uric acid was found to be a statistically significant predictor of the outcome. Uric acid levels exceeding 386 mmol/L before CRT increased the chances of mortality [n = 55, hazard ratio = 2.39 (1.30-4.39), p 0.01] and poor clinical response [n = 37, odds ratio = 2.89 (1.22-6.87), p = 0.01] independently of serum NT-proBNP and other factors.Elevated uric acid concentrations in patients with CRT are associated with an increased risk of mortality and poor clinical response independently of the NT-proBNP levels and other relevant clinical factors.

Cardiac Resynchronization Therapy (CRT) is an effective treatment of chronic heart failure (HF) in patients with wide QRS and reduced ejection fraction. However, not every patient benefits equally from the treatment and still high mortality rates can be observed. Our aim was to identify patients

Background: There are previous studies about the prognostic significance of quality of life (QoL) in CRT-implanted patients measured with complex heart failure questionnaires. However, there is no data with the EuroQol-5 Dimensions (EQ-5D) questionnaire, which provides a simple descriptive profile