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Open in new tab Download slide OBJECTIVES Uncorrected severe mitral regurgitation (MR) due to posterior prolapse leads to left ventricular dilatation. At this stage, mitral valve repair becomes mandatory to avoid permanent myocardial injury. However, which technique among neochoardae implantation and leaflet resection provides the best results in this scenario remains unknown. METHODS We selected 332 patients with left ventricular dilatation and severe degenerative MR due to posterior leaflet (PL) prolapse who underwent neochoardae implantation (85 patients) or PL resection (247 patients) at our institution between 2008 and 2020. A propensity score matching analysis was carried on to decrease the differences at baseline. RESULTS Matching yielded 85 neochordae implantations and 85 PL resections. At 10 years, freedom from cardiac death and freedom from mitral valve reoperation were 92.6 ± 6.1% vs 97.8 ± 2.1% and 97.7 ± 2.2% vs 95 ± 3% in the neochordae group and in the PL resection group, respectively. The MR ≥2+ recurrence rate was 23.9 ± 10% in the neochordae group and 20.8 ± 5.8% in the PL resection group (P  = 0.834) at 10 years. At the last follow-up, the neochordae group showed a higher reduction of left ventricular end-diastolic diameter (44 vs 48 mm; P  = 0.001) and a better ejection fraction (60% vs 55%; P  < 0.001) compared to PL resection group. CONCLUSIONS In this subgroup of patients, both neochordae implantation and leaflet resection provide excellent durability of the repair in the long term. Neochordae implantation might have a better effect on dilated left ventricle. [ABSTRACT FROM AUTHOR]

Cardiac resynchronization therapy (CRT) is a cornerstone of therapy for patients with heart failure, reduced left ventricular (LV) ejection fraction, and a wide QRS complex. However, not all patients respond to CRT: 30% of CRT implanted patients are currently considered clinical non-responders and up to 40% do not achieve LV reverse remodelling. In order to achieve the best CRT response, appropriate patient selection, device implantation, and programming are important factors. Optimization of CRT pacing intervals may improve results, increasing the number of responders, and the magnitude of the response. Echocardiography is considered the reference method for atrioventricular and interventricular (VV) intervals optimization but it is time-consuming, complex and it has a large interobserver and intraobserver variability. Previous studies have linked QRS shortening to clinical response, echocardiographic improvement and favourable prognosis. In this review, we describe the electrocardiographic optimization methods available: 12-lead electrocardiogram; fusion-optimized intervals (FOI); intracardiac electrogram-based algorithms; and electrocardiographic imaging. Fusion-optimized intervals is an electrocardiographic method of optimizing CRT based on QRS duration that combines fusion with intrinsic conduction. The FOI method is feasible and fast, further reduces QRS duration, can be performed during implant, improves acute haemodynamic response, and achieves greater LV remodelling compared with nominal programming of CRT. [ABSTRACT FROM AUTHOR]

Aims: There are previous studies on quality of life (QoL) in cardiac resynchronization therapy (CRT) patients; however, there are no data with the short EuroQol-five dimensions (EQ-5D) questionnaire predicting outcomes. We aimed to assess the predictive role of baseline QoL and QoL change at 6 months after CRT with EQ-5D on 5-year mortality and response.Methods and results: In our prospective follow-up study, 130 heart failure (HF) patients undergoing CRT were enrolled. Clinical evaluation, echocardiography, and EQ-5D were performed at baseline and at 6 months of follow-up, continued to 5 years. Primary endpoint was all-cause mortality at 5 years. Secondary endpoints were (i) clinical response with at least one class improvement in New York Heart Association without HF hospitalization and (ii) reverse remodelling with 15% reduction in left ventricular end-systolic volume at 6 months. Fifty-four (41.5%) patients died during 5 years, 85 (65.3%) clinical responders were identified, and 63 patients (48.5%) had reverse remodelling. Baseline issues with mobility were associated with lower response [odds ratio (OR) 0.36, 95% confidence interval (CI) 0.16-0.84; P = 0.018]. Lack of reverse remodelling correlated with self-care issues at baseline (OR 0.10, 95% CI 0.01-0.94; P = 0.04). Furthermore, self-care difficulties [hazard ratio (HR) 2.39, 95% CI 1.17-4.86; P = 0.01) or more anxiety (HR 1.51, 95% CI 1.00-2.26; P = 0.04) predicted worse long-term survival. At 6 months, mobility (HR 3.95, 95% CI 1.89-8.20; P < 0.001), self-care (HR 7.69, 95% CI 2.23-25.9; P = 0.001), or ≥ 10% visual analogue scale (VAS) (HR 2.24, 95% CI 1.27-3.94; P = 0.005) improvement anticipated better survival at 5 years.Conclusion: EuroQol-five dimension is a simple method assessing QoL in CRT population. Mobility issues at baseline are associated with lower clinical response, whereas self-care issues predict lack of reverse remodelling. Problems with mobility or anxiety before CRT and persistent issues with mobility, self-care, and VAS scale at 6 months predict adverse outcome. [ABSTRACT FROM AUTHOR]

Aims: Clinical experience indicates that limited or no reverse left ventricular (LV) remodelling may not necessarily imply non-response to cardiac resynchronization therapy (CRT). We investigated the association of the extent of LV remodelling, mechanical dyssynchrony, and survival in patients undergoing CRT. Methods and results: In 356 CRT candidates, three blinded readers visually assessed the presence of mechanical dyssynchrony (either apical rocking and/or septal flash) before device implantation and also its correction by CRT 12 ± 3 months post-implantation. To assess LV reverse remodelling, end-systolic volumes (ESV) were measured at the same time points. Patients were divided into four subgroups: no LV remodelling (ESV change 0 ± 5%), mild LV reverse remodelling (ESV reduction 5-15%), significant LV reverse remodelling (ESV reduction ≥ 5%), and LV volume expansion (ESV increase ≥5%). Patients were followed for all-cause mortality during the median follow-up of 36 months. Patients with LV remodelling as in the above defined groups showed 58, 54, and 84% reduction in all-cause mortality compared to patients with volume expansion. In multivariable analysis, LVESV change remained independently associated with survival, with an 8% reduction in mortality for every 10% decrease in LVESV (P = 0.0039), but an optimal cut-off point could not be established. In comparison, patients with corrected mechanical dyssynchrony showed 71% reduction in all-cause mortality (P < 0.001). Conclusion: Volumetric response assessed at 1-year after CRT is strongly associated with long-term mortality. However, an optimal cut-off cannot be established. The association of the correction of mechanical dyssynchrony with survival was stronger than that of any volumetric cut-off. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We investigated the impact of mechanical unloading with a left ventricular assist device (LVAD) on the myocardial proteome. METHODS: We collected 11 patient-matched samples of myocardial left ventricular tissue of patients with non-ischaemic dilate cardiomyopathy, harvested at time of LVAD implant ('pre-LVAD') and heart transplant ('post-LVAD'). Samples were studied by quantitative proteomics. Further we performed histological assessment of deposited collagens and immune infiltration in both pre- and post-LVAD samples. RESULTS: A core set of >1700 proteins was identified and quantified at a false discovery rate <1%. The previously established decrease post-LVAD of alpha-1-antichymotrypsin was corroborated. We noted a post-LVAD decrease of matricellular proteins and proteoglycans such as periostin and versican. Also, proteins of the complement system and precursors of cardiac peptide hormones were decreased post-LVAD. An increase post-LVAD was evident for individual proteins linked to the innate immune response, proteins involved in diverse metabolic pathways, and proteins involved in protein synthesis. Histological analysis did not reveal significant alterations post-LVAD of deposited collagens or immune infiltration. The proteomic data further highlighted a pronounced inter-patient heterogeneity with regards to the impact of LVAD therapy on the left ventricular myocardial proteome. Finally, the proteomic data showed differential proteolytic processing in response to LVAD therapy. CONCLUSIONS: Our findings underline a strong impact of LVAD therapy on the left ventricular myocardial proteome. Together with previous studies, protein markers of LVAD therapy such as alpha-1-antichymotrypsin are becoming apparent. Further, matricellular proteins are emerging as important components in response to LVAD therapy. [ABSTRACT FROM AUTHOR]

Aims: Sarcoidosis with cardiac involvement is a rare pathological condition, and therefore cardiac resynchronization therapy (CRT) for patients with cardiac sarcoidosis is even further rare. We aimed to clarify the clinical features of patients with cardiac sarcoidosis who received CRT.Methods and results: We retrospectively reviewed the clinical data on CRT at three cardiovascular centres to detect cardiac sarcoidosis patients. We identified 18 (8.9%) patients with cardiac sarcoidosis who met the inclusion criteria out of 202 with systolic heart failure who received CRT based on the guidelines. The majority of the patients were female [15 (83.3%)] and underwent an upgrade from a pacemaker or implantable cardioverter defibrillator [13 (72.2%)]. We found 1 (5.6%) cardiovascular death during the follow-up period (mean ± SD, 4.7 ± 3.0 years). Seven (38.9%) patients had a composite outcome of cardiovascular death or hospitalization from worsening heart failure within 5 years after the CRT. Twelve (66.7%) patients had a history of sustained ventricular arrhythmias or those occurring after the CRT. Among the overall patients, no significant improvement was found in either the end-systolic volume or left ventricular ejection fraction (LVEF) 6 months after the CRT. A worsening LVEF was, however, more likely to be seen in 5 (27.8%) patients with ventricular arrhythmias after the CRT than in those without (P = 0.04). An improved clinical composite score was seen in 10 (55.6%) patients.Conclusions: Cardiac sarcoidosis patients receiving CRT may have poor LV reverse remodelling and a high incidence of ventricular arrhythmias. [ABSTRACT FROM AUTHOR]

Aims: To study the prognostic effect of atrial reverse remodelling on outcome of cardiac resynchronization therapy (CRT).Methods and Results: Patients receiving a CRT device in the University Medical Centre Groningen were included. Atrial reverse remodelling was defined as a ≥10% reduction in left atrial volume index at 6-month follow-up. Success of CRT was defined as ventricular reverse remodelling with a reduction in left ventricular end-systolic volume of ≥15% at 6-month follow-up. Primary endpoint was all-cause mortality or heart failure hospitalizations. A total of 365 patients (mean age 65.1 ± 11.0 years, 73% men) were included; among them, 221 (61%) were in sinus rhythm and had no prior atrial fibrillation (AF), and 144 patients (39%) had a history of AF. During a mean follow up of 2.0 ± 1.0 years, 49 patients died. Cox regression analysis revealed that patients with no atrial and no ventricular reverse remodelling had the worst outcome (hazard ratio 3.1, 95% confidence interval 1.4-7.1, P = 0.006). Outcome in patients with only atrial reverse remodelling was comparable with outcome in patients with both atrial and ventricular reverse remodelling (hazard ratio 2.0, 95% confidence interval 0.7-5.6, P = 0.21).Conclusion: Patients without atrial and ventricular reverse remodelling have the worst outcome. Patients with only atrial reverse remodelling have improved left ventricular diastolic filling during follow-up and demonstrate a comparable outcome with patients with both atrial and ventricular reverse remodelling. Assessment of atrial reverse remodelling may provide additional prognostic information in determining CRT outcome. [ABSTRACT FROM AUTHOR]

AIMS: TGF-β regulates tissue fibrosis: TGF-β promotes fibrosis, whereas bone morphogenetic protein (BMP)-7 is antifibrotic. To demonstrate that (i) left ventricular (LV) remodelling after pressure overload is associated with disequilibrium in the signalling mediated by these cytokines, and (ii) BMP-7 exerts beneficial effects on LV remodelling and reverse remodelling. METHODS AND RESULTS: We studied patients with aortic stenosis (AS) and mice subjected to transverse aortic constriction (TAC) and TAC release (de-TAC). LV morphology and function were assessed by echocardiography. LV biopsies were analysed by qPCR, immunoblotting, and histology. Pressure overload reduced BMP-7 and pSmad1/5/8 and increased TGF-β and pSmad2/3 in AS patients and TAC mice. BMP-7 correlated inversely with collagen, fibronectin, and β-MHC expressions, and with hypertrophy and diastolic dysfunction, and directly with the systolic function. Multiple linear regression disclosed BMP-7 and TGF-β as hypertrophy predictors, negative and positive, respectively. BMP-7 prevented TGF-β-elicited hypertrophic program in cardiomyocytes, and Col1A1 promoter activity in NIH-3T3 fibroblasts. The treatment of TAC mice with rBMP-7 attenuated the development of structural damage and dysfunction, and halted ongoing remodelling. The reverse remodelling after pressure overload release was facilitated by rBMP-7, and hampered by disrupting BMP-7 function using a neutralizing antibody or genetic deletion. CONCLUSION: The disequilibrium between BMP-7 and TGF-β signals plays a relevant role in the LV remodelling response to haemodynamic stress in TAC mice and AS patients. Our observations may provide new important insights aimed at developing novel therapies designed to prevent, halt, or reverse LV pathological remodelling in pressure overload cardiomyopathy. [ABSTRACT FROM AUTHOR]

Aims: Ablation for atrial fibrillation (AF) has been suggested to be associated with 'reverse left atrial remodelling'. Reduction in left atrial volume index (LAVIR) is regarded as a determinant of reverse remodelling following pulmonary vein isolation (PVI). However, there is paucity on data about the predictors for LAVIR after PVI. In this study, we aimed to investigate predictors of LAVIR at 12 months in AF patients undergoing cryoballoon-based PVI.Methods and Results: Patients with symptomatic paroxysmal or persistent AF despite ≥1 antiarrhythmic drug(s), who were scheduled for cryoballoon-based AF ablation procedure per the recent consensus recommendations, were enrolled and followed-up for 12 months in this prospective observational study. Left atrial volume was derived using the biplane area-length method. A total of 160 patients (54.25 ± 7.66 years, 44.40% female) were involved in the study. Reduction in left atrial volume index occurred in 120 patients. Age [hazard ratio (HR): 0.901, 95% confidence interval (CI): 0.828-0.981, P = 0.017], hypertension (HR: 0.151, 95% CI: 0.048-0.471, P = 0.001), mild mitral regurgitation (MR) (HR: 5.327, 95% CI: 1.489-19.058, P = 0.010), and AF recurrence (HR: 0.017, 95% CI: 0.005-0.065, P< 0.001) were found to be independent predictors for LAVIR.Conclusion: To the best of our knowledge, this is the largest study in the literature investigating the predictors of LAVIR following AF ablation. According to this data, younger patients without hypertension or moderate MR are most likely to experience LAVIR following ablation. [ABSTRACT FROM AUTHOR]

Aims Substantial portion of early arrhythmia recurrence after catheter ablation for atrial fibrillation (AF) is considered to be due to irritability in left atrium (LA) from the ablation procedure. We sought to evaluate whether 90-day use of antiarrhythmic drug (AAD) following AF ablation could reduce the incidence of early arrhythmia recurrence and thereby promote reverse remodelling of LA, leading to improved long-term clinical outcomes. Methods and results A total of 2038 patients who had undergone radiofrequency catheter ablation for paroxysmal, persistent, or long-lasting AF were randomly assigned to either 90-day use of VaughanWilliams class I or III AAD (1016 patients) or control (1022 patients) group. The primary endpoint was recurrent atrial tachyarrhythmias lasting for >30 s or those requiring repeat ablation, hospital admission, or usage of class I or III AAD at 1 year, following the treatment period of 90 days post ablation. Patients assigned to AAD were associated with significantly higher event-free rate from recurrent atrial tachyarrhythmias when compared with the control group during the treatment period of 90 days [59.0 and 52.1%, respectively; adjusted hazard ratio (HR) 0.84; 95% confidence interval (CI) 0.73-0.96; P = 0.01]. However, there was no significant difference in the 1-year event-free rates from the primary endpoint between the groups (69.5 and 67.8%, respectively; adjusted HR 0.93; 95% CI 0.79-1.09; P = 0.38). Conclusion Short-term use of AAD for 90 days following AF ablation reduced the incidence of recurrent atrial tachyarrhythmias during the treatment period, but it did not lead to improved clinical outcomes at the later phase. [ABSTRACT FROM AUTHOR]

OBJECTIVES: During support with a left ventricular assist device (LVAD), partial reverse remodelling takes place in which fibrosis plays an important role. In this study, we analysed the histological changes and expression of fibrotic markers in patients with advanced heart failure (HF) during continuous-flow LVAD (cf-LVAD) support. METHODS: In 25 patients, myocardial tissue at the time of LVAD implantation (pre-LVAD) was compared with tissue from the explanted left ventricle (post-LVAD). Interstitial fibrosis and cardiomyocyte size were analysed pre- and post-LVAD. Plasma was obtained from all patients before and during LVAD support. Plasma levels, cardiac mRNA and protein expression of brain natriuretic peptide (BNP), galectin- 3 (Gal-3), connective tissue growth factor (CTGF), osteopontin (OPN) and transforming growth factor β-1 were determined. RESULTS: Fibrosis increased during cf-LVAD unloading (P < 0.05). Cardiomyocytes elongated (P < 0.05), whereas cross-sectional area did not change. BNP, Gal-3, CTGF and OPN were significantly elevated pre-LVAD in comparison with controls. BNP decreased significantly after 1 month of cf-LVAD support (P < 0.001) to near-normal levels. Pro-fibrotic markers remained elevated in comparison with controls. CONCLUSIONS: cf-LVAD support is associated with lengthening of cardiomyocytes, without alterations in diameter size. Remarkably, myocardial fibrosis increased as well as circulating pro-fibrotic markers. Whether the morphological changes are a direct effect of reduced pulsatility during cf-LVAD support or due to HF progression requires further investigation. [ABSTRACT FROM AUTHOR]

Aims Intraventricular dyssynchrony and commonly associated prolonged atrioventricular conduction both reduce diastolic filling time (DFT), which can be improved by cardiac resynchronization therapy (CRT). Our aim was to investigate whether change in DFT corrected for RR interval (DFTC) after CRT might serve to assess the mechanistic response to CRT. Methods and results Echocardiography data of consecutive patients in sinus rhythm (n = 91) were studied before and 6 months after implantation. Mortality and heart failure hospitalization data were collected. Patients with vs. without DFTC increase after 6 months were compared. The programmed atrioventricular delay, percentage of biventricular pacing, and change in PR interval were similar in both groups. DFTC increase after 6 months reflected favourable reverse left ventricular remodelling and was significantly associated with freedom from death or heart failure admission (P = 0.008). In multivariate analysis including guideline criteria for CRT (i.e. QRS width, presence of left bundle branch block, and ejection fraction), interventricular mechanical delay, and Tei index, baseline DFTC was the strongest predictor of adverse outcome. Notably, while patients with impaired relaxation had a large and highly significant reduction in all-cause mortality and heart failure admissions when DFTC increased [hazard ratio (HR), 95% confidence interval (CI) = 0.24, 0.08–0.73; P = 0.012], this benefit was less pronounced and did not reach statistical significance in patients with pseudonormal or restrictive filling (HR, 95% CI = 0.64, 0.23–1.77; P = 0.388). Conclusion DFTC increase after CRT reflects favourable reverse remodelling and is associated with better clinical outcome. [ABSTRACT FROM PUBLISHER]

Aims Ivabradine (Iva) has shown beneficial structural and functional effects in clinical and experimental heart failure (HF), but its action in combination with mechanical unloading (MU), such as during treatment with left ventricular assist devices (LVAD), is unknown. The aim of this study was to investigate the effects of Iva during MU, in a rodent model of HF. Methods and results We studied the chronic effects (4 weeks) of Iva (10 mg/kg/day) alone and in combination with MU [induced by heterotopic abdominal heart transplantation (HATx)] on whole-heart and cellular structure, function, and excitation–contraction (E–C) coupling in a rodent (rat) model of HF, 12 weeks post-left coronary artery (LCA) ligation. Effects of Iva were compared with those of β-blockade using metoprolol [(Met), 250 mg/kg/day]. Iva, but not Met, reversed myocardial fibrosis, alone and in combination with MU. MU-induced restoration of deranged E–C coupling was enhanced by Iva to a greater extent than Met: both Iva and Met enhanced the recovery of the Ca2+ transient amplitude and the sarcoplasmic reticulum (SR) Ca2+ content, but Iva alone maintained MU-induced normalization of L-type Ca2+ current and t-tubule abnormalities. Met prevented MU-induced reduction in the myocardial size (myocardial atrophy); Iva had no effect on this parameter. Conclusion Iva shows beneficial structural and E–C coupling effects during MU: Iva reverses myocardial fibrosis and enhances the restoration of deranged E–C coupling, displaying more beneficial effects than that of Met. These results suggest that Iva may prove effective in enhancing functional recovery in heart failure patients receiving LVAD therapy. [ABSTRACT FROM AUTHOR]

Aims To investigate the influence of left ventricular (LV) lead position on LV dyssynchrony in cardiac resynchronization therapy (CRT). Methods and results The LV lead was prospectively targeted to the latest activated LV segment (concordant) evaluated by two-dimensional speckle tracking radial strain (ST-RS) echocardiography in 103 CRT recipients (67 ± 12 years). Mechanical dyssynchrony was assessed by anteroseptal-to-posterior (AS-P) delay and interventricular mechanical delay (IVMD). Concordant LV leads were obtained in 72 (70%) patients. Superior LV reverse remodelling (LV-RR; ≥15% LV end-systolic volume reduction at 6-month follow-up) was observed in the concordant LV leads compared with the discordant LV leads [51 (76%) vs. 13 (45%); P = 0.003]. Mechanical resynchronization responders (≥50% AS-P delay reduction at 6-month follow-up) obtained in the concordant LV leads [44 (66%)] was greater than in the discordant LV leads [10 (34%); P = 0.005]. The discordant LV leads located adjacent to the concordant LV leads (+1 segment; n = 22) and 2 segments apart (+2 segments; n = 9) were evaluated in a subgroup analysis. Mechanical resynchronization responders 6 months after CRT were as follows: in +1 segment [n = 10 (48%)] and in +2 segments (n = 0; P = 0.001). The concordant LV lead was the only independent predictor of LV-RR at 6-month follow-up (odds ratio, 4.177; P = 0.004). Independent predictors of mechanical resynchronization responders were AS-P delay (odds ratio, 1.007; P = 0.032), IVMD (odds ratio, 1.024; P = 0.038), and concordant LV lead (odds ratio, 4.691; P = 0.004). Conclusion Concordant LV leads in CRT provided more responders according to both LV reverse remodelling and mechanical resynchronization. [ABSTRACT FROM AUTHOR]

Aims T-wave amplitude variability (TAV) is a promising non-invasive predictor of arrhythmic events in patients with dilated cardiomyopathy. We aimed to evaluate the effect of cardiac resynchronization therapy (CRT) on native TAV, its relation with left ventricular (LV) reverse remodelling and the occurrence of ventricular tachyarrhythmias (VTs). Methods and results In this prospective study, we included 40 heart failure patients with left bundle branch block in sinus rhythm (25 male; 16 with ischaemic aetiology; aged 62.7 ± 9.5 years; New York Heart Association class II–IV). Echocardiographic parameters and TAV were evaluated at baseline and 6 months after implantation of CRT device combined with an implantable cardioverter-defibrillator. T-wave amplitude variability was determined by a 20-min high-resolution electrocardiogram Holter recording during native conduction. After TAV assessment, patients were monitored for 15.7 ± 5.2 months for the occurrence of VTs. Decrease in median TAV [from 40.45 μV (24.75–56.00) to 28.15 μV (20.93–37.95), P = 0.004] was observed after 6 months of CRT. However, decrease of median TAV was only noticed in patients with LV reverse remodelling [46.9 μV (27.5–70.0) to 25.8 μV (20.2–32.4), P < 0.001] and in patients without VTs [40.5 μV (27.5–55.9) to 24.4 μV (17.1–31.5), P < 0.001]. Native median TAV > 35.4 µV after 6 months of CRT had an 83% sensitivity and 93% specificity for predicting the occurrence of VTs. Conclusions Decrease of TAV after CRT is associated with LV reverse remodelling and indicates a reduction of the intrinsic arrhythmogenic substrate. Median TAV after CRT had a good predicting value for VT occurrence in long-term follow-up. [ABSTRACT FROM PUBLISHER]

OBJECTIVE Restrictive mitral annuloplasty (RMA) can often improve heart failure symptoms and induce left ventricular (LV) reverse remodelling in patients with non-ischaemic dilated cardiomyopathy (DCM) and functional mitral regurgitation. However, it is unknown whether the observed LV reverse remodelling translates into better outcomes or not. METHOD Fifty patients with advanced non-ischaemic DCM (age, 64 ± 10 years, 74% men) underwent RMA and were followed up with a mean of 2 years. Preoperatively, all had 3 to 4+ functional mitral regurgitation (MR), an ejection fraction (EF) of 26 ± 8.6 %, an indexed LV end-systolic volume (LVESVI) of 112 ± 47 ml/m2. All patients received complete semi-rigid undersized ring annuloplasty. Correlations between early reduction in LVESVI at 1 month after the operation and mid-term clinical outcomes were analysed. RESULT There was no 30-day mortality. LVESVI significantly decreased to 96 ± 53 ml/m2 and LVEF improved to 31 ± 15%. During follow-up, 16 (32%) recurred heart failure, of whom 7 (14%) died. The receiver operating characteristic (ROC) curve found that a reduction in LVESVI >8.3% had a sensitivity of 80% and a specificity of 78% in predicting all adverse events. With this cut-off value, there were 30 (60%) responders to reverse remodelling. Responders had significantly better survival (96.4 versus 68.7%, P = 0.007) and freedom from heart failure rate (85.4 versus 31.8%, P = 0.0003) than non-responders at 3 years. In a 1-year follow-up echocardiographic study, non-responders had shown no significant LV reverse remodelling with greater degree of residual MR than responders. CONCLUSION The extent of early LV reverse remodelling is related to mid-term mortality, heart failure events and late reverse remodelling and repair durability after RMA for non-ischaemic DCM. [ABSTRACT FROM AUTHOR]

Aims Aortic stenosis induces pressure overload and myocardial remodelling with concentric hypertrophy and alterations in extracellular matrix (ECM). Aortic valve replacement leads to reverse remodelling, a process of which knowledge is scarce. The aims of the present study were to examine alterations in myocardial gene expression and subsequently identify molecular alterations important for the early phase of reverse remodelling. Methods and results After 4 weeks of ascending aortic banding, mice were subjected to a debanding operation (DB) and followed for 3, 7, or 14 days. Cardiac function was assessed by echocardiography/tissue Doppler ultrasonography. Myocardial gene expression was examined using Affymetrix microarray and the topGO software and verified by real-time polymerase chain reaction. Quantitative measurements of collagen subtypes were performed. Aortic banding increased left ventricular mass by 60%, with normalization to sham level 14 days after DB. Extracellular matrix genes were the most regulated after DB. Three days after DB, collagen I was transiently increased, whereas collagens III and VIII increased later at 7 days. Conclusion The ECM genes were the most altered during reverse remodelling. There was a change in isoform constitution as collagen type I increased transiently at 3 days followed by a later increase in types III and VIII at 7 days after DB. This might be important for the biomechanical properties of the heart and recovery of cardiac function. [ABSTRACT FROM PUBLISHER]

Aims Cardiac resynchronization therapy (CRT) was shown to reverse left ventricular (LV) remodelling in heart failure (HF) patients. We aimed to investigate whether intraoperative electrical parameters (IEP) were predictive factors of LV reverse remodelling and were correlated with mechanical dyssynchrony indexes. Methods Eighty-six patients with HF underwent CRT. At implant, several electrical and echocardiographic parameters were evaluated and, at 6 months, responders were defined by a relative increase in LV ejection fraction ≥25% compared with baseline. Results Several IEPs were shown to predict LV reverse remodelling. Receiver operating curve analysis revealed the ratio between QRS duration during biventricular pacing (BVp) and right ventricular pacing (RVp) [QRS(BVp)/QRS(RVp)] as the best predictor of LV functional recovery after CRT (AUC = 0.72; 95% confidence limit 0.57–0.82; P < 0.001). Responders showed a lower value of QRS(BVp)/QRS(RVp) when compared with non-responders (0.74 ± 0.05 vs. 0.8 ± 0.1; P < 0.005) and 0.78 was the value associated with the best predictive accuracy. The interval between the onset of RV lead and LV lead electrograms (RVegm–LVegm) during baseline rhythm correlated directly with the interventricular mechanical delay (IVMD) (r = 0.68; P < 0.0001) and with its reduction (delta IVMD) at follow-up (r = 0.66; P < 0.0005). Conclusion Intraoperative electrical parameters can predict LV functional recovery after CRT and they are correlated with interventricular mechanical resynchronization at follow-up. [ABSTRACT FROM PUBLISHER]

Aims To examine whether the presence of pre-pacing functional mitral regurgitation (MR) and its improvement would affect the extent of left ventricular (LV) reverse remodelling after cardiac resynchronization therapy (CRT). Methods and results Echocardiographic assessment was performed in 83 patients before and 3 months after CRT. Total MR volume and the early- and late-systolic MR flow rate were assessed. At 3 months, there was reduction in total MR volume (38 ± 20 vs. 33 ± 21 mL) with decrease in both early- (71 ± 52 vs. 60 ± 51 mL/s) and late-systolic (49 ± 46 vs. 42 ± 46 mL/s) MR flow rate (all P < 0.05). Receiver-operating characteristic curve found that an 11% decrease in total MR volume was associated with LV reverse remodelling [defined by the reduction in LV end-systolic volume (LVESV) of ≥15%] [sensitivity, 90%; specificity, 80%; area under the curve (AUC), 0.85; P < 0.001]. The improvement in early- and late-systolic MR was also associated with LV reverse remodelling, in which improvement in early-systolic MR had higher sensitivity, specificity, and AUC than late-systolic MR. The extent of reverse remodelling with gain in LV ejection fraction and forward stroke volume was greatest in patients with improvement in total MR, intermediate in those with mild or no MR at baseline, and the least in those without improvement in total MR (LVESV, −29.8 ± 12.0 vs. −18.6 ± 16.6 vs. −5.5 ± 8.6%; ejection fraction, 11.8 ± 6.2 vs. 7.0 ± 6.8 vs. 3.0 ± 5.0%; forward stroke volume, 43.1 ± 37.9 vs. 21.1 ± 26.1 vs. 6.8 ± 34.6%; all P < 0.05). Conclusion Improvement of functional MR contributes to LV reverse remodelling after CRT, whereas reduction of early-systolic MR is more powerful than late-systolic MR. [ABSTRACT FROM PUBLISHER]

Aims: Cardiac resynchronization therapy (CRT) improves survival and quality of life in advanced heart failure (HF). Although mitral regurgitation (MR) reduction has been reported, its presence has been associated with non-response to CRT. This study was undertaken to assess the potential role of significant mitral regurgitation (SMR) persistence after CRT on clinical outcome, major arrhythmic events, and echocardiographic response in the mid-long term. [ABSTRACT FROM PUBLISHER]

Aims: Predictors of Response to Cardiac Resynchronization Therapy (CRT) (PROSPECT) was the first large-scale, multicentre clinical trial that evaluated the ability of several echocardiographic measures of mechanical dyssynchrony to predict response to CRT. Since response to CRT may be defined as a spectrum and likely influenced by many factors, this sub-analysis aimed to investigate the relationship between baseline characteristics and measures of response to CRT. [ABSTRACT FROM PUBLISHER]

Abstract: Background: Despite restrictive mitral annuloplasty (RMA) being considered effective for chronic ischaemic mitral regurgitation (CIMR), few data exist on mid-term echocardiographic results with different prosthetic rings. Therefore, comparative echocardiographic analysis has been performed. Methods: Sixty-four consecutive coronary artery bypass graft surgery (CABG)+RMA (downsizing by two-ring sizes; median size: 26mm) for CIMR with a follow-up of at least 6 months were prospectively followed-up with serial echocardiograms (preoperative, discharge, 6 months, follow-up ending). Hospital mortality, follow-up clinical and echocardiographic results were analysed and compared between three groups (group A: semi-rigid band, 17 patients; group B: complete symmetric semi-rigid, 22 patients; group C: complete asymmetric semi-rigid, 25 patients). Results: Hospital mortality was 6.3%; 22.8±14.7 standard deviation (SD) months (range: 6–55) survival was 96.5±2.5%; freedom from re-intervention was 94.2±4.2%, from re-revascularisation 87.5±11.7%, from ≥grade-2 mitral regurgitation 58.2±9.8% and from heart failure (CHF) 71.6±10.5%. Recurrent (≥grade-2) CIMR resulted in lower freedom-from-CHF (p =0.0001), worsened New York Heart Association (NYHA) classification (p =0.0001) and absence of reverse remodelling of the left ventricular end-diastolic diameter (LVEDD; p =0.004), systolic diameter (LVESD; p =0.014), indexed mass (LVMi; p =0.005) and coaptation depth (p =0.0001). Group A showed significant worse freedom from CHF (group A: 42.8±19.5% vs group B: 88.9±10.5% vs group C: 92.3±7.5%; p =0.049) and from recurrent CIMR (17.4±13.8% vs 82.1±11.7% vs 94.1±5.7%, respectively; p =0.0001). Complete rings decreased the hazard of recurrent CIMR (Physio=0.141; Adams=0.089). Higher NYHA during follow-up was found in group A (p =0.002 for group B and p =0.001 for group C) with a progressive reduction of trans-mitral mean gradient (p =0.001), and a lower degree of reverse remodelling of LVEDD (p =0.009 and p =0.010) and coaptation depth (p =0.040 and p =0.002). Conclusions: Recurrent CIMR correlates with absent ventricular reverse remodelling. Despite a higher trans-mitral gradient, complete rings achieve better results in the treatment of CIMR. [Copyright &y& Elsevier]

Aims Cardiac resynchronization therapy (CRT) reduces the degree of functional mitral regurgitation (FMR). However, FMR has also been associated with a lack of clinical response to CRT. We undertook this study to determine whether the presence of FMR influences the reverse remodelling induced by CRT. [ABSTRACT FROM PUBLISHER]

Aims The majority of tissue Doppler indexes proposed to predict left ventricular (LV) reverse remodelling in cardiac resynchronization therapy (CRT) reflects LV asynchrony as assessed in ejection phase. We evaluated the predictive value of a new strain-imaging parameter reflecting the total amount of time spent by 12 LV segments in contracting after aortic valve closure. [ABSTRACT FROM PUBLISHER]

Aims LV reverse remodelling has been shown to be a favourable response after cardiac resynchronization therapy (CRT) in many clinical trials. This study investigated whether left ventricular (LV) reverse remodelling after CRT has any structural benefit, which include the improvement of LV mass or regional wall thickness. [ABSTRACT FROM PUBLISHER]