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Background: More and more heart failure (HF) patients aged ≥ 75 years undergo cardiac resynchronization therapy (CRT) device implantation, however the data regarding the outcomes and their predictors are scant. We investigated the mid- to long-term outcomes and their predictors in CRT patients aged ≥ 75 years. Methods: Patients in the Cardiac Resynchronization Therapy Modular (CRT MORE) Registry were divided into three age-groups: &lt, 65 (group A), 65–74 (group B) and ≥75 years (group C). Mortality, hospitalization, and composite event rate were evaluated at 1 year and during long-term follow-up. Results: Patients (n = 934) were distributed as follows: group A 242, group B 347, group C 345. On 12-month follow-up examination, 63% of patients ≥ 75 years displayed a positive clinical response. Mortality was significantly higher in patients ≥ 75 years than in the other two groups, although the rate of hospitalizations for HF worsening was similar to that of patients aged 65–74 (7 vs. 9.5%, respectively, p = 0.15). Independent predictors of death and of negative clinical response were age &gt, 80 years, chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD). Over long-term follow-up (1020 days (IQR 680-1362)) mortality was higher in patients ≥ 75 years than in the other two groups. Hospitalization and composite event rates were similar in patients ≥ 75 years and those aged 65–74 (9 vs. 11.8%, p = 0.26, and 26.7 vs. 20.5%, p = 0.06). Conclusion: Positive clinical response and hospitalization rates do not differ between CRT recipients ≥ 75 years and those aged 65–74. However, age &gt, 80 years, COPD and CKD are predictors of worse outcomes.

Aim Ventricular fibrillation amplitude spectral area (AMSA) and end-tidal carbon dioxide (ETCO2) are predictors of shock success, understood as restoration of an organized rhythm, and return of spontaneous circulation (ROSC). However, little is known about their combined use. We aimed to assess the prediction accuracy when combined, and to clarify if they are correlated in out of hospital cardiac arrest' victims. Materials and Methods Records acquired by external defibrillators in out-of-hospital cardiac arrest patients of the Lombardia Cardiac Arrest registry were processed. The 1-min pre-shock ETCO2 median value (METCO2) was computed from the capnogram and AMSA (2–48 mV.Hz range) computed applying the Fast Fourier Transform to a 2-second pre-shock filtered ECG interval (0.5−30 Hz). Support Vector Machine (SVM) predictive models based on METCO2, AMSA and their combination were fit; results were given as the area under the curve (AUC) of the receiver operating characteristic (ROC) curves. Results We considered 112 patients with 391 shocks delivered. METCO2 and AMSA were predictors of shock success [AUC (IQR) of the ROC curve: 0.59 (0.56−0.62); 0.68 (0.65−0.72), respectively] and of ROSC [0.56 (0.53−0.59); 0.74 (0.71−0.78),]. Their combination in a SVM model increased the accuracy for predicting shock success [AUC (IQR) of the ROC curve: 0.71 (0.68−0.75)] and ROSC [0.77 (0.73−0.8)]. AMSA and METCO2 were significantly correlated only in patients who achieved ROSC (rho = 0.33 p = 0.03). Conclusions AMSA and ETCO2 predict shock success and ROSC after every shock, and their predictive power increases if combined. Notably, they were correlated only in patients who achieved ROSC.

Background Professional guidelines are based on the best available evidence. However, patients treated in clinical practice may differ from those included in reference trials. Objective The aim of this study was to evaluate the effects of cardiac resynchronization therapy (CRT) in a large population of patients implanted with a CRT device stratified in accordance with the 2016 European heart failure (HF) guidelines. Methods We collected data on 930 consecutive patients from the Cardiac Resynchronization Therapy MOdular REgistry. The primary end point was a composite of death and HF hospitalization. Results Five hundred sixty-three (60.5%) patients met class I indications, 145 (15.6%) class IIa, 108 (11.6%) class IIb, and 114 (12.3%) class III. After a median follow-up of 1001 days, 120 (14.7%) patients who had an indication to CRT had died and 71 (8.7%) had been hospitalized for HF. The time to the end point was longer in patients with a class I indication (hazard ratio 0.55; 95% confidence interval 0.39–0.76; P = .0001). After 12 months, left ventricular (LV) end-systolic volume had decreased by ≥15% in 61.5% (320/520) of patients whereas in 57.5% (389/676) of patients the absolute LV ejection fraction improvement was ≥5%. Adherence to class I was also associated with an absolute LV ejection fraction increase of >5% (P = .0142) and an LV end-systolic volume decrease of ≥15% (P = .0055). Conclusion In our population, ∼60% of patients underwent implantation according to the 2016 European HF guidelines class I indication. Adherence to class I was associated with a lower death and HF hospitalization rates and better LV reverse remodeling.

Latency during left ventricle (LV) pacing has been suggested as a potential cause of ineffectual biventricular pacing. We assessed the incidence, predictors, and impact on outcome of increased LV latency in 274 patients undergoing cardiac resynchronization therapy (CRT). On implantation, the latency interval was defined as the shortest stimulus-to-QRS onset interval in any lead of the 12-lead ECG. A stimulus-to-QRS onset interval ≥ 40 ms was used to define the presence of increased LV latency. Increased LV latency was observed in 55 patients (20%). On multivariate analysis, only ischemic etiology proved to be a predictor of increased LV latency. On 12-month echocardiographic evaluation, 68% patients showed a ≥ 15% decrease in LV end systolic volume (74% patients with increased LV latency, 67% patients without increased LV latency (p = 0.58). The presence of increased LV latency was not associated with a different clinical response to CRT. Increased LV latency occurred in almost 20% of patients undergoing CRT and was more frequent in patients with ischemic heart disease. The presence of increased LV latency does not seem to have an impact on echocardiographic or clinical response to CRT.

Objectives The aim of the study was to confirm the value of the VALID‐cardiac resynchronization therapy (CRT) risk score in predicting outcome and to assess its association with clinical response (CR) in an unselected real‐world CRT population. Methods and Results The present analysis comprised all consecutive CRT patients (pts) enrolled in the CRT‐MORE registry from 2011 to 2013. Pts were stratified into five groups (quintiles 1‐5) according to the VALID‐CRT risk predictor index applied to the CRT‐MORE population. In the analysis of clinical outcome, adverse events comprised death from any cause and non‐fatal heart failure (HF) events requiring hospitalization. CR at 12‐month follow‐up was also assessed. We enrolled 905 pts. During a median follow‐up of 1005 [627‐1361] days, 134 patients died, and 79 had at least one HF hospitalization. At 12 months, 69% of pts displayed an improvement in their CR. The mean VALID‐CRT risk score derived from the CRT‐MOdular Registry (MORE) population was 0.317, ranging from −0.419 in Q1 to 2.59 in Q5. The risk‐stratification algorithm was able to predict total mortality after CRT (survival ranging from 93%‐Q1 to 77%‐Q5; hazards ratio [HR] = 1.42, 95% confidence interval [CI]: 1.25‐1.61, P

Background Several studies have investigated the association between native QRS duration (QRSd) or QRS narrowing and response to biventricular pacing. However, their results have been conflicting. The aim of our study was to determine the association between the relative change in QRS narrowing index (QI) and clinical outcome and prognosis in patients who undergo cardiac resynchronization therapy (CRT) implantation. Methods and results We included 311 patients in whom a CRT device was implanted in accordance with current guidelines for CRT. On implantation, the native QRS, the QRSd and the QI during CRT were measured. After 6months, 220 (71%) patients showed a 10% reduction in LVESV. The median [25th–75th] QI was 14.3% [7.2–21.4] and was significantly related to reverse remodeling (r=+0.22; 95%CI: 0.11–0.32, p=0.0001). The cut-off value of QI that best predicted LV reverse remodeling after 6months of CRT was 12.5% (sensitivity=63.6%, specificity=57.1%, area under the curve=0.633, p=0.0002). The time to the event death or cardiovascular hospitalization was significantly longer among patients with QI>12.5% (log-rank test, p=0.0155), with a hazard ratio (HR) of 0.3 [95%CI: 0.11–0.78]. In the multivariate regression model adjusted for baseline parameters, a 10% increment in QI (HR=0.61[0.44–0.83], p=0.002) remained significantly associated with CRT response. Conclusions Patients with a larger decrease in QRSd after CRT initiation showed greater echocardiographic reverse remodeling and better outcome from death or cardiovascular hospitalization. QI is an easy-to-measure variable that could be used to predict CRT response at the time of pacing site selection or pacing configuration programming.

A variable proportion, up to 30%, of patients who undergo cardiac resynchronization therapy (CRT) do not benefit from treatment. The aim of the Cardiac Resynchronization Therapy MOdular REgistry (CRT MORE) is to determine whether specific electrocardiographic and radiographic parameters can be used to predict clinical and echocardiographic response to CRT.The CRT MORE is a prospective, single-arm, multicenter cohort study designed to evaluate the electrocardiographic and radiographic predictors of response to CRT. All study patients receive a pacemaker or implantable defibrillator for CRT delivery in accordance with current guidelines. Enrollment started in December 2011 and is scheduled to end in November 2013. Approximately 1100 consecutive patients will be enrolled in 30 Italian centers and will be followed up for 60 months after implantation. The primary endpoint is the improvement in clinical (Clinical Composite Score) and echocardiographic (a decrease of ≥ 15% in left ventricular end-systolic volume) parameters at the 6-month follow-up visit.This study might provide important information about which electrocardiographic and radiographic parameters better predict CRT response.

Accurate selection of patients with left bundle branch block (LBBB) may help increasing response to cardiac resynchronization therapy (CRT). There is no agreement on LBBB definition. The aim of the study was to investigate the prevalence of 'true-LBBB' according to Strauss in patients undergoing CRT.The study population included 414 consecutive patients (71.9% men; mean age 69.7 ± 9.6 years), who underwent CRT according to 2010 European Society of Cardiology (ESC) guidelines. Patients were classified into three groups: traditional LBBB according to American Heart Association, LBBB according to Strauss and intraventricular conduction delay (IVCD). Subsequently, they were re-classified into classes of recommendations, according to the current 2013 ESC Guidelines. Traditional LBBB was recorded in 229 patients (55%), an LBBB according to Strauss in 153 (37%) and an IVCD in 32 (8%). Patients with an LBBB according to Strauss showed a significantly more prolonged QRS duration (P 0.001), greater baseline end-systolic and end-diastolic volumes (P = 0.011 and P = 0.013, respectively) compared with those with IVCD. The prevalence of mid-QRS notching in at least two contiguous leads was 100% in LBBB according to Strauss; 24% in traditional LBBB and 21.9% in IVCD (P 0.001). At multivariate analysis, PR interval less than 200 ms and QRS of at least 150 ms were independent predictors of mid-QRS notching [odds ratio (OR) 1.78; 95% confidence interval (95% CI) 1.10-2.88; P = 0.02 and OR 2.88; 95% CI 1.80-4.62;P 0.0001]. Applying stricter criteria for LBBB according to Strauss, a significant reduction in Class I recommendation and an increase in Class II was observed (90.1 vs. 37%; P 0.0001 and 9.9 vs. 63%; P 0.0001).Applying stricter criteria, only 37% of patients undergoing CRT showed a true-LBBB according to Strauss. Accurate identification of true-LBBB may have a potential additional value in better selecting patients.

Background The implantation strategy appears to play a pivotal role in determining response to cardiac resynchronization therapy (CRT). Objective The aim of our study was to determine the association between anatomic and electrical interlead distance and clinical outcome after CRT implantation. Methods We included 216 first-time CRT recipients with left bundle branch block and sinus rhythm. On implantation, the electrical interlead distance (EID), defined as the time interval between spontaneous peak R waves detected at the right ventricular (RV) and left ventricular (LV) pacing sites, was measured. The anatomic distance between the RV and LV lead tips was determined on chest radiographs. Results The mean EID was 74 ± 41 ms, and the mean horizontal corrected interlead distance (HCID) was 125 ± 73 mm. After 12 months, 87 patients (40%) displayed an improvement in their clinical composite score. The cutoff values that best predicted an improved clinical status were as follows: 84 ms for EID (area under the curve 0.59; confidence interval [CI] 0.52-0.66; P =.026) and 90 mm for HCID (area under the curve 0.62; CI 0.55-0.69; P =.004). On multivariate analysis, only EID >84 ms (hazard ratio 0.36; CI 0.14-0.89; P =.028) and HCID >90 mm (hazard ratio 0.45; CI 0.23-0.90; P =.025) were significantly associated with the composite endpoint of death or cardiovascular hospitalization. In particular, the presence of both conditions (EID

Aim The present study aimed to prospectively evaluate whether application of the concept of fractional flow reserve (FFR) guides the immediate decision to perform or to defer coronary angioplasty in unselected consecutive patients with one or more angiographically intermediate (50-70%) stenoses and non-conclusive or lacking non-invasive testing. Methods We studied 112 patients (81 males and 31 females, aged 31-81 years) including 71 multivessel disease patients (63%) and 30 patients (27%) with unstable symptoms. FFR was measured with the use of a pressure-wire after adenosine-induced hyperaemia and compared with quantitative coronary angiography in 171 stenoses. Coronary angioplasty was performed in the presence of an FFR or = 0.75. Cardiac events including death, myocardial infarction, recurrent angina or symptoms requiring repeated hospitalization and target vessel revascularization (TVR) were recorded during a median period of 34 months (interquartile range 9-54 months). Results Coronary angioplasty was deferred based on FFR results in 54 patients (group I). In the remaining 58 patients, angioplasty was performed in one or more stenoses that were significant by FFR and deferred in non-significant stenoses (group II). Overall, coronary angioplasty was performed in 71 vessels (41%) and deferred in 100 (59%). Cumulative cardiac events occurred in 12.9% of group I patients and in 24.1% of group II patients (chi-squared = 1.57, P = 0.20). TVR was required in 5% of the stenoses untreated based on FFR result in both groups and in 12.6% of stenoses that underwent coronary angioplasty (chi-squared = 3.25, P = 0.07; relative risk = 2.5, 95% confidence interval = 0.88-8.61). Conclusions In patients with angiographically intermediate stenoses, functional evaluation by FFR to select lesions that do not need to be treated invasively is safe. Unnecessary angioplasty and stenting may be saved in more than one half of individual coronary stenoses. The risk of major cardiac events and TVR of functionally non-significant stenoses is lower than the risk associated with coronary angioplasty. Our observations further support the use of pressure wire for physiological assessment of coronary artery stenosis in the catheterization room.

Between August 1991 and May 1993, 14 patients affected by chronic, poorly tolerated atrial fibrillation (AF) were submitted to high energy transcatheter cardioversion. Mean duration of AF was 27.4 +/- 45.1 months. In nine patients (56%), AF lasted for > 1 year. All patients had underlying heart disease, with a mean LVEF of 45.2% +/- 11.8% and a NYHA Class > or = II. Previously, a mean of 2.9 +/- 1.3 patients failed external electrical cardioversion, with and without antiarrhythmics, have been attempted. Transcatheter conversion was performed by pulling the His-bundle catheter back in the right atrial cavity until no His bundle activity was recorded on distal poles, and then delivering the shock between a proximal electrode (cathode) and a back plate (anode). In all patients, transcatheter conversion restored sinus rhythm. Transient complete atrioventricular (AV) block was observed in four patients (28%), and treated by prophylactic temporary pacing. At 1 year, seven patients (50%) were still in sinus rhythm. In this series, only younger age could be related to AF recurrence (46.1 +/- 10.8 vs 63.4 +/- 6.8 years, P < or = 0.004), even if prophylaxis with amiodarone showed a positive trend versus sinus rhythm maintenance (71% vs 14%, P = NS). In conclusion, high energy transcatheter cardioversion is a safe and effective method of restoring sinus rhythm in patients with chronic, poorly tolerated AF. In these patients, high energy transcatheter cardioversion could be considered as an alternative to AV node ablation techniques, avoiding pacemaker implant and embolic risk. Larger studies are needed to determine better patient selection and delineate drug strategy after the procedure.