668 State of the Art – Arrhythmias: the future of cardiac...

668
State of the Art – Arrhythmias: the future of cardiac arrhythmias / State of the Art – Heart failure therapies: hope on the horizon?
Methods and results: Nineteen dogs were randomized into sham-operated (7
dogs), HF (6 dogs) and HF+ renal artery ablation (RAA, 6 dogs) groups. Shamoperated dogs were implanted with transvenous cardiac pacemakers without pacing. Dogs in the HF group were implanted with pacemakers and underwent right
ventricular pacing for 3 weeks at 240 bpm to induce HF. The dogs in the HF+
RAA group received double renal artery ablation. The dogs recovered for 8 weeks
and underwent the same HF-inducing procedure. Compared to the baseline, the
atrial dimensions increased and the right atrial ERP (131±14 ms to 112±12 ms,
p=0.02) decreased significantly after 3 weeks in the HF dogs but not the HF+ RAA
dogs. A greater number of AFs were induced in the HF dogs than the HF+ RAA
dogs (2.2±0.6 vs. 0.3±0.3, p=0.03). The atrium from HF hearts revealed a large
amount of fibrosis, whereas control and HF+ RAA dogs showed minimal fibrous
tissue. The levels of BNP, Ang II, TNF-α and expression of TGF-β and Cx43 in
atrial tissue were increased in the HF dogs compared to the sham-operated and
HF+ RAA dogs.
Conclusion: RAA suppressed the atrial substrate remodeling and the AF vulnerability that was induced by long-term rapid ventricular pacing.
3710 | BEDSIDE
Combined endo and epicardial substrate ablation (scar
dechanneling) in arrhythmogenic cardiomyopathy: a prospective
multicenter study
J. Fernandez-Armenta Pastor 1 , L. Mont 1 , J. Brugada 1 , A. Pedrote 2 , I. Anguera 3 ,
L. Tercedor 4 , A. Barrera 5 , A. Berruezo 1 . 1 University of Barcelona, Hosp. Clinic,
Thorax Institute, Department of Cardiology/Arrhythmia Section, Barcelona,
Spain; 2 University Hospital of Virgen del Rocio, Seville, Spain; 3 Hospital de
Bellvitge, L’Hospitalet de Llobregat, Spain; 4 University Hospital Virgen de las
Nieves, Granada, Spain; 5 University Hospital Virgen de la Victoria, Malaga,
Spain
STATE OF THE ART – HEART FAILURE THERAPIES:
HOPE ON THE HORIZON?
Conclusions: In our study, mechanical revascularization by PCI for CTO lesions
in pts with new onset heart failure as compared with OMT seems to have no
benefit in reducing 12-month mortality. Long-term follow up with a larger study
population will be necessary for further determination.
3722 | BEDSIDE
Renal effects of lcz696 in patients with heart failure and preserved
ejection fraction: results from paramount
A.A. Voors 1 , M. Gori 2 , C.Y.L. Liu 1 , M. Zile 3 , B. Pieske 4 , J.J.V. Mc Murray 5 ,
M. Packer 6 , T. Bransford 7 , M. Lefkowitz 7 , S.D. Solomon 2 . 1 University Medical
Center Groningen, Groningen, Netherlands; 2 Brigham and Women’s Hospital,
Department of Medicine, Cardiovascular Division, Boston, United States of
America; 3 Medical University of South Carolina, Charleston, United States of
America; 4 Medical University of Graz, Graz, Austria; 5 University of Glasgow,
Glasgow, United Kingdom; 6 University of Texas Southwestern Medical Center,
Dallas, United States of America; 7 Novartis Pharmaceuticals, East Hanover,
United States of America
Background: In a randomized double blind trial, the angiotensin receptor
neprilysin Inhibitor (LCZ696) reduced NT-proBNP and was associated with left
atrial reverse remodeling and improvement in symptoms in patients with heart failure with preserved ejection fraction (HFpEF). We assessed the effect of LCZ696
on renal function.
Methods: 301 HFpEF patients (NYHA II-III, left ventricular ejection fraction
≥45%, NT-proBNP>400 pg/mL) were randomly assigned to LCZ696 (200 mg
b.i.d.) or valsartan (160 mg b.i.d.). We studied renal function (detected as eGFR,
urinary albumin creatinine ratio [UACR], cystatin C) at baseline, and after 36
weeks of treatment.
Results: Mean age of the patients was 71±9.1 years, and mean eGFR at baseline was 65.4±20.4 ml/min/1.73m2 . At 36 weeks blood pressure dropped to a
greater extent in the LCZ696 treated patients (7.5±15/ 5.1±10.8 in the LCZ group
vs. 1.5±16/0.34±11.5 in the valsartan groups; p = 0.006 for systolic and p = 0.001
for diastolic differences). In the LCZ696 treated patients eGFR declined less than
in the valsartan group (LCZ696, –1.6 mL/min per 1.73 m2 vs valsartan, –5.2
mL/min per 1.73 m2 ; p=0.007), which was paralleled by changes in Cystatin C
(LCZ696 group, 0.06±0.22 vs valsartan group, 0.12±0.31 mg/L; p = 0.012). Over
36 weeks UACR increased to a greater extent in the LCZ696 group (LCZ696,
1.9 mg/mmol at baseline, 2.9 mg/mmol at week 36; valsartan, 2.0 mg/mmol at
baseline, 2.0 mg/mmol at week 36; p=0.02).
3721 | BEDSIDE
Impact of percutaneous coronary intervention for chronic total
occlusion in patients with new onset heart failure
S.W. Rha 1 , B.G. Choi 1 , S.Y. Choi 1 , C.U. Choi 1 , E.J. Kim 1 , C.G. Park 1 ,
H.S. Seo 1 , D.J. Oh 1 , S.H. Park 2 , J.Y. Park 3 . 1 Korea University Guro Hospital,
Seoul, Korea, Republic of; 2 Soonchunhyang University Cheonan Hospital,
Cheonan, Korea, Republic of; 3 Eulji University, Seoul Eulji Hospital, Seoul,
Korea, Republic of
Background: Heart failure is known to be associated with increased adverse clinical outcomes in coronary artery diseases. The impact of percutaneous coronary
intervention (PCI) for chronic total occlusion (CTO) in patients (pts) with new onset heart failure is not clear. We compared the 12-month clinical outcomes of pts
treated by PCI with optimal medical therapy (OMT) for CTO lesions in pts with
new onset heart failure.
Methods: A total of 458 consecutive CTO pts newly diagnosed with heart failure
or showing symptoms of heart failure (NYHA ≥class 2 or CCS ≥class 2) were
divided into 2 groups; one group underwent PCI (PCI group; n=246) and the other
group was treated with OMT (OMT group; n=212). Major clinical outcomes were
compared between the two groups up to 12 months.
eGFR trend by treatment
Conclusion: In patients with HFpEF, therapy with LCZ696 for 36 weeks was associated with maintenance of eGFR compared to valsartan therapy, despite increases in UACR.
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Background: Ventricular tachycardia (VT) ablation in patients with arrhythmogenic cardiomyopathy (AC) has a high rate of recurrence. Recent studies suggest
that a more extensive epicardial arrhythmogenic substrate could explain these results. We report the results of combined endocardial and epicardial susbtrate VT
ablation (using the "scar dechanneling technique") in patients with AC.
Methods and results: Thirty-two consecutive patients with AC and VT (mean
14±8 VT episodes/patient) were included in 9 centers. Six patients (19%) had
left-dominant AC. A high-density endo (372±152 sites mapped) and epicardial (523±299 sites) electroanatomical voltage map was obtained during sinus
rhythm. Electrograms with delayed components (E-DCs) were tagged and classified as entrance or inner conducting channels (CCs) points, depending on the
delayed component precocity. The procedural endpoint was the isolation of all
identified CCs firstly, by discrete ablation at CC entrance, and the abolition of
residual inducible VTs afterwards. The mean procedure and fluoroscopy time
were 215±80 min and 18±7 min, respectively. Epicardial maps showed larger
scars (94±81 cm2 vs. 18±22 cm2 , p<0.01) and more E-DCs (68±56 vs. 13±16,
p<0.01) in both right and left-dominant AC. Nine (28%) patients showed neither
scar nor E-DCs at endocardium. A mean of 26±10 RF applications were required.
Non-inducibility of the clinical VT and of any monomorphic VT was achieved in
100% and 93.5% of patients respectively. Iatrogenic pericardial effusion requiring pericardiocentesis occurred in one patient. During a median follow-up of 20
months (IQR 6-32 months), 5 (16%) patients suffered any VT episode. Three patients required a redo procedure. After redo procedures 91% of patients remained
without VT recurrence.
Conclusion: Arrhythmogenic substrate in AC is mainly epicardial. These findings
support the use of a combined endo and epicardial substrate guided approach
for the catheter ablation of VT in AC patients.
Results: At baseline, the OMT group had a higher prevalence of elderly, cerebrovascular accidents, de novo lesion, left main disease, multivessel disease,
multivessel CTO, RCA-CTO, and abundant collaterals (≥grade 2), whereas the
PCI group had a higher prevalence of male gender, prior MI, prior PTCA and
LAD-CTO lesions. Clinical outcomes at 12 months were similar between the 2
groups except lower mortality in the PCI group (Table). After baseline adjustment
by multivariate analysis, however, there was no difference between the 2 groups.