Aim
The objective of this study was to investigate the prognostic importance of right ventricular dysfunction (RVD) and tricuspid regurgitation (TR) in patients with moderate–severe functional mitral ...regurgitation (FMR) receiving MitraClip procedure. RVD and TR grade are associated with cardiovascular mortality in the general population and other cardiovascular diseases. However, there are limited data from observational studies on the prognostic significance of RVD and TR in FMR receiving MitraClip procedure.
Methods and results
A systemic review and meta‐analysis were performed using MEDLINE, Scopus, and Embase to assess the prognostic value of RVD and TR grade for mortality in patients with functional mitral regurgitation (FMR) receiving MitraClip procedure. Hazard ratios were extracted from multivariate models reporting on the association of RVD and TR with mortality and described as pooled estimates with 95% confidence intervals. A total of eight non‐randomized studies met the inclusion criteria with seven studies having at least 12 months follow‐up with a mean follow‐up of 20.9 months. Among the aforementioned studies, a total of 1112 patients (71.5% being male) were eligible for being included in our meta‐analysis with an overall mortality rate of 28.4% (n = 316). Of the enrolled patients, RVD was present in 46.1% and moderate–severe TR in 29.2%. RVD was significantly associated with mortality compared to normal RV function (HR, 1.79, 95% CI, 1.39–2.31, P < 0.001, I2 = 0). Patients with moderate–severe TR showed increased risk of mortality compared with those in the none‐mild TR group (HR, 1.61. 95% CI, 1.11–2.33, P = 0.01, I2 = 14).
Conclusions
This meta‐analysis demonstrates the prognostic importance of RVD and TR grade in predicting all‐cause mortality in patients with significant FMR. RV function and TR parameters may therefore be useful in the risk stratification of patients with significant FMR undergoing MitraClip procedure.
Introduction
Left atrial (LA) low voltage areas (LVA) are a controversial target in atrial fibrillation ablation procedures. However, LVA and LA volume are good predictors of arrhythmia recurrence in ...ablation‐naïve patients. Their predictive value in progressively diseased pre‐ablated atria is uncertain.
Methods
Consecutive patients with recurrent atrial fibrillation (AF) or atrial tachycardia (AT), who were scheduled for repeat LA ablation, were enrolled in the prospective Bernau ablation registry between 2016 and 2020. All patients received a complete LA ultrahigh‐density map before ablation. Maps were analyzed for LA size, LVA percentage and distribution. The predictive value of demographic, anatomic, and mapping variables on AF recurrence was analyzed.
Results
160 patients (50.6% male, 1.3 pre‐ablations, 60% persistent AF) with complete LA voltage maps were included. Mean follow‐up time was 16 ± 11 months. Mean recorded electrograms (EGMs) per map were 9754 ± 5808, mean LA volume was 176.1 ± 35.9 ml and mean rate of LVAs <0.5 mV was 30.6% ± 23.1%. During follow‐up recurrence rate of AF or AT >30 s was 55.6%. Patients with recurrence had a significant higher percentage of LVAs (40.0% vs. 18.8%, p < .001) but no relevant difference in LA volume (172 vs. 178 mL, p = .299). ROC curves revealed LVA as a good predictor for recurrence (AUC = 0.79, p < .001) and a cut‐off of 22% LVAs with highest sensitivity (73.0%) and specificity (71.8%). Based on this cut off, event free survival was significantly higher in the Low LVA group (p < .01).
Conclusion
Total LVA percentage has a good predictive power on arrhythmia recurrence in a cohort of advanced scarred left atria in repeat procedures independent of the applied ablation strategy. Left atrial volume seems to have minor impact on the rhythm outcome in our study cohort.
The amount of left atrial low voltage areas (LVA) rather than left atrial volume predicts arrhythmia recurrence in repeat ablation on procedures. A thorough 3‐D mapping and LVA assessment of the left atrium should be accomplished by default to optimize patient selection for further interventions.
Gender-related aspects in cardiac arrhythmias have gained increasing attention, still the understanding of peripartum electrical disorders remains vague.
A 28-year-old woman developed palpitations ...and presyncopes during the post-partum period after her second pregnancy. Palpitations remained unclear until a self-recorded single-lead smartwatch ECG revealed a complete episode of a fast broad complex tachycardia (260 b.p.m.) that led to hospital admission. Echocardiography, cardiac magnetic resonance imaging, and exercise testing, showed no relevant abnormalities. Recording the tachycardia in a 12-lead-ECG could eventually be achieved revealing an inferior axis and positive concordance in the precordial leads. Episodes of ventricular tachycardia (VT) could be provoked by breast feeding and mental stress, but not induced in two electrophysiological studies. Genetic testing was normal. The patient continued to experience repeated, self-terminating VT episodes, lasting between 10 and 40 s, leading to presyncopes and a syncope with a fall. The beginning of symptoms subsequent to child birth and frequent premature ventricular contractions in her first pregnancy made hormone-induced arrhythmia a tentative diagnosis. Heart rate-corrected QT (QTc) intervals showed significant variability corresponding to the frequency of episodes in a retrospective evaluation. The cessation of breastfeeding led to a termination of arrhythmias. The patient was temporarily equipped with a wearable cardioverter defibrillator vest, an implantable cardioverter defibrillator (ICD) was not implanted.
The case report highlights the potential of self-recorded, patient-activated ECG monitoring in diagnosing recurrent palpitations, and the dilemma of timing for implanting ICDs in young patients with ventricular arrythmias (VTs). Additionally, it underlines the role of post-partum hormones in the susceptibility to ventricular arrhythmias, calling for further research of gender-specific, and pregnancy-associated arrhythmias.
In hospitalized patients, the duration of antibiotic therapy for uncomplicated pneumonia is often longer than recommended in clinical guidelines. Consequences include increased risk of Clostridioides ...difficile infection and the emergence of antibiotic resistance. Reducing the duration of antibiotic therapy is an important goal of antibiotic stewardship (ABS) programs.
To evaluate the impact of a computerized physician order entry (CPOE)-based ABS intervention on treatment duration in respiratory infections and on antibiotic use.
A new type of prescription tool featuring a “soft stop order” was introduced into the CPOE system in the Respiratory Medicine department of a Thorax Center. The effect of this intervention was evaluated after 24 weeks using a retrospective before-and-after study design.
A total of 210 patients were evaluated (preintervention group n = 109, postintervention group n = 101). Mean antibiotic treatment duration decreased from 9.59 days to 7.25 days (p < 0.001). It was reduced from 9.93 to 7.21 days (p < 0.001) in community-acquired pneumonia, 10.21 to 7.81 days (p = 0.05) in hospital-acquired pneumonia and 7.81 to 6.83 days (p = 0.14) in COPD exacerbations. The proportion of patients treated according to clinical guidelines increased from 35.8% to 69.3% (p < 0.001). The mean quarterly antibiotic use density was 41.2 RDD/100 PD (recommended daily doses per 100 patient days) before the intervention and decreased to 34.03 RDD/100 PD after the intervention (p = 0.037).
Our study demonstrates the short-term effectiveness of a CPOE-based ABS intervention to reduce antibiotic treatment duration for uncomplicated pneumonia. This approach may be particularly suitable for hospitals with limited ABS resources.
•Reducing antibiotic treatment duration for respiratory infections is an important target of antibiotic stewardship (ABS).•Electronic medical records and computerized physician order entry (CPOE) have the potential to support ABS programs.•This single-center study describes a CPOE-based ABS intervention featuring “soft stop order” and “clinical decision support”.•After its implementation, a significant decrease in treatment duration was observed in patients treated for pneumonia.•The results encourage further, multicenter investigation of the short- and long-term effects of this ABS approach.
Summary
Background
Cardiac implantable electronic devices (CIED) have become an indispensable part in everyday clinical practice in cardiology. The indications for CIED implantation are based on the ...guidelines of the European Heart Rhythm Association (EHRA). Nevertheless, numbers of CIED implantations in Europe are subject to considerable differences. We hypothesized that reimbursements linked to the respective health systems may influence implantation behavior.
Methods
Based on the EHRA White Book 2017, CIED implantation data as well as socioeconomic key figures were collected, in particular gross domestic product (GDP) and share of gross domestic product spent on healthcare.
Implantation numbers for pacemakers, implantable cardioverter defibrillators and cardiac resynchronization treatment as well as all in total were assessed, compared with the health care expenditures and visualized using heat maps.
Results
Total implantation numbers per 100,000 inhabitants varied from 196.53 (Germany) to 2.81 (Kosovo). Higher implantation numbers correlated moderately with a higher GDP (r = 0.456,
p
0.002) and higher health expenditure (r = 0.586,
p
< 0.001). The annual financial resources per inhabitant were also subject to fluctuations ranging from 9476 $ (Switzerland) to 140 $ (Ukraine); however, there were countries with high financial means, such as Switzerland or Scandinavian countries, which showed significantly lower implantation rates.
Conclusion
There were considerable differences in CIED implantations in Europe. These seem to be explained in part by socioeconomic disparities within Europe. Also, a potential influence by the respective remuneration system is likely.
Functional tricuspid regurgitation (TR) is a frequent finding in echocardiography. Despite general consent that right ventricular (RV) dysfunction impacts outcome of patients with TR, it is still ...unknown which echocardiographic parameters most accurately reflect prognosis. In this study we aimed to evaluate the prevalence of RV dysfunction and its prognostic value in patients with TR.
Data from 1089 consecutive patients were analysed. Tricuspid annular plane systolic excursion (TAPSE), fractional area change, and right ventricular free wall longitudinal strain (RV strain) were used to define RV dysfunction. Patients were followed for 2-year all-cause mortality. For prediction of survival, reclassification and C statistics of RV functional parameters using TR grade as reference model were performed.
Among the patients studied, 13.9% showed no TR, 61.2% had mild TR, 19.6% had moderate TR, and 5.3% had severe TR. The TR grade was associated with increased mortality (log rank, P < 0.001). Impaired RV strain and TAPSE were independent predictors for mortality (RV: hazard ratio HR, 1.130; 95% confidence interval CI, 1.099-1.160; P < 0.001; TAPSE: HR, 1.131; 95% CI, 1.085-1.175; P < 0.001). Both RV strain and TAPSE improved the reference model for survival prediction (RV: integrated discrimination improvement IDI, 0.184; 95% CI, 0.146-0.221; P < 0.001; TAPSE: IDI, 0.057; 95% CI, 0.037-0.077; P < 0.001).
Echocardiographic evaluation of RV function appears to useful for patients with TR. Assessment of RV strain provides additional value for prediction of 2-year mortality.
Une insuffisance tricuspide (IT) fonctionnelle est une observation fréquente en échocardiographie. Bien qu'il soit généralement admis que la dysfonction du ventricule droit (VD) a un impact sur le pronostic des patients atteints d'IT, on ne sait toujours pas quels sont les paramètres échocardiographiques qui reflètent le plus précisément ce pronostic. Dans cette étude, nous avons cherché à évaluer la prévalence de la dysfonction du VD et sa valeur pronostique chez les patients atteints d'IT.
Les données obtenues pour 1 089 patients consécutifs ont été analysées. L'excursion systolique du plan de l'anneau tricuspide (TAPSE, de l’anglais « tricuspid annular plane systolic excursion »), la fraction de raccourcissement de surface et la déformation longitudinale de la paroi libre du ventricule droit ont été utilisées pour définir la dysfonction du VD. Les patients ont été suivis pour la mortalité à deux ans toutes causes confondues. Pour la prédiction de la survie, une reclassification et des probabilités de concordance des paramètres fonctionnels du VD en utilisant le niveau d'IT comme modèle de référence ont été réalisées.
Parmi les patients étudiés, 13,9 % ne présentaient aucune IT, 61,2 % présentaient une IT légère, 19,6 % une IT modérée et 5,3% une IR sévère. Le grade d'IT était associé à une mortalité accrue (test logarithmique par rangs, P < 0,001). L'altération de la déformation du VD et du TAPSE était un facteur prédictif indépendant de mortalité (VD : rapport des risques RR, 1,130; intervalle de confiance IC à 95 %, 1,099-1,160; P < 0,001; TAPSE : RR, 1,131; IC à 95 %, 1,085-1,175 ; P < 0,001). La déformation du VD et le TAPSE ont amélioré le modèle de référence pour la prédiction de la survie (déformation du VD : indice d’amélioration de la discrimination intégrée IDI, 0,184 ; IC à 95 %, 0,146-0,221; P < 0,001; TAPSE : IDI, 0,057; IC à 95 %, 0,037-0,077 ; P < 0,001).
L'évaluation échocardiographique de la fonction du VD s’est révélée utile pour les patients atteints d'IT. L'évaluation de la déformation du VD apporte une plus-value pour la prédiction de la mortalité à 2 ans.
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