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Background Adaptive cardiac resynchronization therapy (aCRT) is known to have clinical benefits over conventional CRT, but the mechanisms are unclear. Objective Compare effects of aCRT and conventional CRT on electrical dyssynchrony. Methods A prospective, double-blind, 1:1 parallel-group assignment randomized controlled trial in patients receiving CRT for routine clinical indications. Participants underwent cardiac computed tomography and 128-electrode body surface mapping. The primary outcome was change in electrical dyssynchrony measured on the epicardial surface using noninvasive electrocardiographic imaging before and 6 months post-CRT. Ventricular electrical uncoupling (VEU) was calculated as the difference between the mean left ventricular (LV) and right ventricular (RV) activation times. An electrical dyssynchrony index (EDI) was computed as the standard deviation of local epicardial activation times. Results We randomized 27 participants (aged 64 ± 12 years; 34% female; 53% ischemic cardiomyopathy; LV ejection fraction 28% ± 8%; QRS duration 155 ± 21 ms; typical left bundle branch block [LBBB] in 13%) to conventional CRT (n = 15) vs aCRT (n = 12). In atypical LBBB (n = 11; 41%) with S waves in V5-V6, conduction block occurred in the anterior RV, as opposed to the interventricular groove in strict LBBB. As compared to baseline, VEU reduced post-CRT in the aCRT (median reduction 18.9 [interquartile range 4.3–29.2 ms; P = .034]), but not in the conventional CRT (21.4 [-30.0 to 49.9 ms; P = .525]) group. There were no differences in the degree of change in VEU and EDI indices between treatment groups. Conclusion The effect of aCRT and conventional CRT on electrical dyssynchrony is largely similar, but only aCRT harmoniously reduced interventricular dyssynchrony by reducing RV uncoupling., Graphical abstract

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Introduction Venous stenosis is a late complication of the atrial switch (Mustard/Senning) procedure seen in patients with transposition of the great arteries ( d-TGA). Many atrial switch patients require cardiac implantable electronic devices (CIEDs) which further increases the incidence of venous stenosis. Stenosis of the superior limb of the systemic venous pathway (SLSVP) in the presence of CIED leads presents a management challenge. We propose a method for navigating SLSVP stenosis in atrial switch patients with CIEDs. Methods The pulse generator and leads were removed using standard extraction techniques. Axillary access was retained via existing leads or new access was obtained. The interventional cardiology team, via groin access, performed stent-angioplasty of the stenotic SLSVP. After stent deployment, the axillary access wire was snared from below, guided through the stent, and pulled into a long groin sheath. A sheath was then advanced over the axillary wire and into the groin sheath creating a path for passage of leads through the stent. New leads were advanced through the axillary sheath into the heart. Leads were secured using standard techniques. Results All patients had a history of d-TGA and prior atrial switch procedures. In each case, there was stenosis of the SLSVP in the setting of a CIED lead. There were no immediate complications and there was no restenosis on follow-up. Conclusion Post-atrial switch patients with CIEDs can develop stenosis of the SLSVP. A collaboration between electrophysiology and interventional cardiology can allow for device extraction, stent-angioplasty, and lead reimplantation to avoid "jailing" the leads.

Limited data exist on the association of obesity with both hospitalization and mortality in patients with heart failure with preserved ejection fraction (HFpEF), especially in the real-world ambulatory setting. We hypothesized that increasing body-mass index (BMI) in ambulatory heart failure with preserved ejection fraction would have a protective effect on these patients leading to decreased mortality and hospitalizations. We studied the relationship between BMI and the time to all-cause mortality, time to heart failure (HF) hospitalization, and time to all-cause hospitalization over a 2-year follow-up in a national cohort of 2501 ambulatory HFpEF patients at 153 Veterans Affairs medical centers. Compared with normal BMI, overweight (HR 0.72; 95% CI 0.57–0.91), obesity class I (HR 0.59; 95% CI 0.45–0.77), obesity class II (HR 0.56; 95% CI 0.40–0.77), and obesity class III (HR 0.53; 95% CI 0.36–0.77) were associated with improved survival after adjustment for demographics and comorbidities. In contrast, the time to HF hospitalization showed an inverse relationship, with shorter time to HF hospitalization with increasing BMI compared with normal BMI; overweight (adjusted HR 1.30; 95% CI 0.88–1.90), obesity class I (HR 1.57; 95% CI 1.05–2.34), obesity class II (HR 1.79; 95% CI 1.15–2.78), and obesity class III (HR 1.96; 95% CI 1.23–3.12). However, time to first all-cause hospitalization was not significantly different by BMI groups. In a large, national ambulatory HFpEF cohort, despite the presence of the obesity paradox with respect to survival, increasing BMI was independently associated with an increased risk of HF hospitalization and similar risk of all-cause hospitalization. Future longer-term prospective trials evaluating the safety and efficacy of weight loss on morbidity and mortality, in patients with severe obesity and HFpEF are needed.

Objectives: Describe an alternative to conventional LV lead placement. Background: Conventional left ventricular (LV) lead placement is not always possible due to anatomic and technical limitations. In selected patients LV endocardial lead placement is a viable alternative. Methods: Five patients on warfarin with unsuccessful coronary sinus lead placements and contraindications to epicardial lead placement elected to undergo addition of an LV endocardial lead. The left ventricle was accessed through the interatrial septum via a combined superior and inferior approach resulting in an active fix lead placed on the LV endocardial surface. Results: All patients underwent successful LV endocardial lead placement. There were no acute procedural complications. Two patients died 2 years following the procedure from unrelated causes. The other patients were alive and well at a mean follow up of 2.8 years, with significant symptomatic improvement and no evidence of cardioembolic complications. Conclusions: The placement of LV endocardial leads is a viable alternative in highly selected patients with limited options.

BACKGROUND Among patients with heart failure and left ventricular (LV) dysfunction despite guideline directed medical therapy, cardiac resynchronization (CRT) is an effective technology to reverse LV remodeling. Given that a large portion of patients are non-responders, alternatives to traditional LV-lead placement have been explored. A promising alternative is image targeted placement of an LV-lead to latest mechanically activated segment without scar. METHODS Electronic database search for randomized controlled trials (RCTs) that evaluated the imaging-guided LV-lead placement on clinical, echocardiographic, and functional outcomes. The primary outcome was a composite of mortality and heart failure hospitalization. The secondary outcomes included CRT responders, New York Heart Association (NYHA), 6-minute walk test, Minnesota Living with Heart Failure Questionnaire (MLHFQ), and ejection fraction (EF) changes. RESULTS Analysis included 4 RCTs of 691 patients with an average follow-up of 2 years (age 69.5 ± 10.3 years, 76% males, 54% ischemic cardiomyopathy, 81% with NYHA classes III/IV, and EF of 24.4% ± 8). The most common site for LV-lead paced segment was the anterolateral segment (45%) and at mid-LV (49%). Compared with the control, imaging-guided LV-lead placement was associated with a significant reduction of the primary outcome (hazard ratio [HR] = 0.60; 95% CI = 0.40-0.88; p = .01), higher CRT responders (odd ratio [OR] = 2.10; p

IntroductionAdaptive cardiac resynchronization therapy (aCRT) is known to have clinical benefits over conventional CRT; however, their effects on the electrical dyssynchrony have not been compared.MethodsWe conducted a double-blind, randomized controlled trial in patients receiving CRT for routine clinical indications. Participants underwent cardiac computed tomography and 128-electrodes body surface mapping. We measured electrical dyssynchrony on the epicardial surface using noninvasive electrocardiographic imaging (ECGI) before and 6 months post-CRT. Ventricular electrical uncoupling (VEU) was calculated as the difference between the mean left ventricular (LV) and right ventricular (RV) activation times. An electrical dyssynchrony index (EDI) was computed as the standard deviation of local epicardial activation times.ResultsWe randomized 27 participants (mean age 64±12 y; 34% female; 53% ischemic cardiomyopathy; LV ejection fraction 28±8%; QRS duration 155±21 ms; strict left bundle branch block (LBBB) in 13%). In atypical LBBB (n=11;41%) with S-waves in V5-V6, conduction block occurred in the anterior RV, as opposed to the interventricular groove in those who met the strict LBBB criteria. As compared to baseline, VEU reduced post-CRT in aCRT (median reduction 18.9(interquartile range 4.3-29.2 ms; P=0.034), but not in conventional CRT (21.4(−30.0 to 49.9 ms; P=0.525) group. There were no differences in the degree of change in VEU and EDI indices between treatment groups.ConclusionThe effect of aCRT and conventional CRT on electrical dyssynchrony is largely similar. Further studies are needed to investigate if atypical LBBB with prominent S wave in V5-V6responds to His bundle pacing.

Dual-antiplatelet therapy with aspirin and a P2Y12 inhibitor is the cornerstone therapy for patients with acute coronary syndrome (ACS) and those undergoing percutaneous coronary intervention (PCI). Despite its widespread use, clopidogrel is hindered by inadequate response in up to 30% of white

This review article will summarize the currently available data for ularitide in acute decompensated heart failure (ADHF). Hospitalization for ADHF represents a key prognostic event in the time course of many patients with HF. It is associated with a high risk for rehospitalization (~ 50% at 6 months) and 1-year mortality rate (~ 30%). There is an unmet need for agents that will improve symptoms and outcomes for clinical outcomes in ADHF. Several agents with vasodilating properties have been studied in this population, but there is limited data demonstrating definitive efficacy of currently available therapies. Ularitide is a synthetic form of urodilatin, a natriuretic peptide produced in the distal renal tubule cells.

Limited data exist on the association of obesity with both hospitalization and mortality in patients with heart failure with preserved ejection fraction (HFpEF), especially in the real-world ambulatory setting. We hypothesized that increasing body-mass index (BMI) in ambulatory heart failure with preserved ejection fraction would have a protective effect on these patients leading to decreased mortality and hospitalizations.We studied the relationship between BMI and the time to all-cause mortality, time to heart failure (HF) hospitalization, and time to all-cause hospitalization over a 2-year follow-up in a national cohort of 2501 ambulatory HFpEF patients at 153 Veterans Affairs medical centers.Compared with normal BMI, overweight (HR 0.72; 95% CI 0.57-0.91), obesity class I (HR 0.59; 95% CI 0.45-0.77), obesity class II (HR 0.56; 95% CI 0.40-0.77), and obesity class III (HR 0.53; 95% CI 0.36-0.77) were associated with improved survival after adjustment for demographics and comorbidities. In contrast, the time to HF hospitalization showed an inverse relationship, with shorter time to HF hospitalization with increasing BMI compared with normal BMI; overweight (adjusted HR 1.30; 95% CI 0.88-1.90), obesity class I (HR 1.57; 95% CI 1.05-2.34), obesity class II (HR 1.79; 95% CI 1.15-2.78), and obesity class III (HR 1.96; 95% CI 1.23-3.12). However, time to first all-cause hospitalization was not significantly different by BMI groups.In a large, national ambulatory HFpEF cohort, despite the presence of the obesity paradox with respect to survival, increasing BMI was independently associated with an increased risk of HF hospitalization and similar risk of all-cause hospitalization. Future longer-term prospective trials evaluating the safety and efficacy of weight loss on morbidity and mortality, in patients with severe obesity and HFpEF are needed.

To determine perioperative characteristics of patients undergoing single-level spinal fusion surgery that could help predict discharge to an inpatient rehabilitation facility (IRF). Demographic, peri- and postoperative characteristics were reviewed for 107 patients who underwent single-level spinal fusion surgery at a high-volume level I trauma center between January 2011 and December 2013. The relationships between discharge to IRF and gender, age, body mass index (BMI), Charlson Comorbidity Index (CCI), insurance provider, length of stay (LOS), intra- and postoperative outcomes and readmission rates in patients undergoing single-level spinal fusion surgery were analyzed using unpaired and paired t testing. 21.5 % (n = 23) of patients were discharged to an IRF. By using unpaired and paired t tests, it was determined that age, BMI, CCI, LOS and insurance provider were all correlated with a higher probability of being discharged to an IRF. Additionally, a logistic regression model demonstrated a correlation between lower CCI and discharge to an IRF. Statistically significant differences were seen regarding age, BMI, CCI, LOS and insurance provider when determining the necessity of a patient being discharged to an IRF. These characteristics can be used to begin the process of setting up discharge disposition preoperatively rather than postoperatively. There were no perioperative characteristics that were statistically significant in determining discharge disposition; therefore, physicians can utilize these preoperative demographics in deciding and organizing discharge before the day of surgery, which can diminish LOS and lead to substantial health system savings.