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Selected Abstracts

The Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 7p1 2003
Bruce L. Wilkoff
Introduction: The devices used to prove the benefit of ICD therapy had only VVI pacing but most current ICD devices provide dual chamber pacing therapy. The DAVID trial sought to measure the impact of dual chamber pacing at 70 bpm (DDDR-70) vs. ventricular backup pacing at 40 bpm (VVI-40) in patients with standard indications for ICD implantation but without indications for bradycardia pacing. Methods: This single-blind, multicenter, parallel-group, randomized clinical trial enrolled 506 patients with indications for ICD therapy between 10/2000 and 9/2002. All patients had an LVEF ,0.40, no indication for pacemaker therapy and no persistent atrial arrhythmias. ICDs with dual chamber, rate-responsive pacing capability were implanted and programmed to VVI-40 or DDDR-70. Results: The combined endpoint of mortality or hospitalization for congestive heart failure (CHF) at one year was 16.1% (VVI-40) vs. 26.7% (DDDR-70), (p , 0.03), mortality 6.5% vs. 10.1% (p , 0.15) and CHF hospitalization 13.3% vs. 22.5% (p , 0.07). Conclusion: For ICD patients, DDDR-70 pacing exhibits no clinical advantage over VVI-40 pacing and may increase CHF and mortality. [source]

Extracorporeal membrane oxygenation as a rescue therapy for leukaemic children with pulmonary failure

BRITISH JOURNAL OF HAEMATOLOGY, Issue 1 2010
Bernhard Meister
Summary In patients with leukaemia, acute respiratory distress syndrome (ARDS) secondary to intensified chemotherapy-induced immunosuppression is a devastating disorder resulting in high morbidity and mortality. Compared to standard indications for extracorporeal membrane oxygenation (ECMO), cytopenia further increases the risks of infection and bleeding. We describe the use of ECMO in four children with ARDS and leukaemia. Two patients (50%) survived, pulmonary function recovered and they are in prolonged first remission. The two other patients died from ARDS and pulmonary leukaemic infiltration. Although ECMO support is a high-risk setup for nosocomial infection we observed no additional septic episodes. All patients had a highly increased demand for packed platelet and red blood cell transfusions. This increased demand and unmanageable chronic bleeding into both lungs in one patient were probably caused by a combination of coagulopathy from the primary illness, the use of anticoagulants, chemotherapy-induced cytopenia, and a reduced survival rate of platelets and red cells due to permanent contact to foreign surface. We concluded that ECMO is a supportive tool to reduce the incidence of early death, treatment-related mortality and, ultimately, to improve overall survival in childhood leukaemia. [source]

Beta-blocker Utilization and Outcomes in Patients Receiving Cardiac Resynchronization Therapy

CLINICAL CARDIOLOGY, Issue 7 2010
Andrew Voigt MD
Introduction Optimal pharmacologic therapy (OPT) is considered a prerequisite to consideration for cardiac resynchronization therapy (CRT). Hypothesis Medications such as beta-blockers (BB) with demonstrated benefit in heart failure (HF) are being under utilized in patients receiving CRT. Methods Consecutive patients receiving a CRT-capable defibrillator in 2004 at a tertiary care center for standard indications were studied. Clinical data and medications upon hospital discharge were recorded. Patients were followed for endpoints of death or transplantation. Results Of 177 patients receiving a CRT device, 129 (73%) received BB therapy (group 1). Of the 48 patients not on BBs (group 2), relative contraindications were documented in 21 (allergy in 3, hypotension or inotrope-dependent HF in 4, chronic obstructive pulmonary disease [COPD] in 6, and amiodarone therapy in 8). The remaining 27 patients (group 3) did not receive BB therapy despite absence of documented justification. Compared to group 1, group 3 patients were similar in terms of clinical characteristics and angiotensin-converting enzyme inhibitor (ACEI) use, but were less likely to be on statin therapy. Patients were followed for a mean of 19.9 ± 9.2 mo. After adjusting for age, QRS duration, creatinine, left ventricular ejection fraction (LVEF), statin use, and presence of ischemic HF etiology, patients not receiving BB therapy in the absence of contraindication had increased risk of death or transplantation (odds ratio [OR]: 3.1, p = 0.043). Conclusions Absence of BB therapy appears to be independently associated with poor outcome in CRT recipients. These results suggest that a crucial component of OPT may be underutilized in a population of HF patients receiving CRT. Copyright © 2009 Wiley Periodicals, Inc. [source]

Usefulness of Brain Natriuretic Peptide Level at Implant in Predicting Mortality in Patients with Advanced But Stable Heart Failure Receiving Cardiac Resynchronization Therapy

CLINICAL CARDIOLOGY, Issue 11 2009
Aiman El-Saed MD
Abstract Background Brain natriuretic peptide (BNP) level has emerged as a predictor of death and hospital readmission in patients with heart failure (HF). The value of baseline BNP assessment in advanced HF patients receiving cardiac resynchronization defibrillator therapy (CRT-D) has not been firmly established. Hypothesis We hypothesized that a baseline BNP level would predict all cause mortality and HF hospitalization in HF patients receiving cardiac resynchronization therapy. Methods A retrospective chart review of all patients having BNP assessment prior to implantation of a CRT-D for standard indications during 2004 and 2005 was conducted at the Veterans Affairs Pittsburgh Healthcare System. The primary endpoint was all-cause mortality and the secondary endpoint was HF-related hospitalization. We used findings from the receiver operating characteristic (ROC) curve to define low (<492 pg/mL) and high (,492 pg/mL) BNP groups. Results Out of 173 CRT-D recipients, 115 patients (mean age 67.0 ± 10.7 years, New York Heart Association [NYHA] class 2.9 ± 0.3, left ventricular ejection fraction [LVEF] 22.5% ± 9.6%, QRS 148.3 ± 30.4 ms) had preimplantation BNP measured (mean 559 ± 761 pg/mL and median 315 pg/mL). During a mean follow-up time of 17.5 ± 6.5 mo, 27 deaths (23.5%) and 31 HF hospitalizations (27.0%) were recorded. Compared to those with low BNP (n = 74), those of high BNP (n = 41) were older, had lower LVEF, higher creatinine levels, suffered more deaths, and HF hospitalizations. In multivariate regression models, higher BNP remained a significant predictor of both the primary endpoint (hazard ratio [HR]: 2.89, 95% confidence interval [CI] 1.06,7.88, p = 0.038) and secondary endpoint (HR: 4.23, 95% CI: 1.68,10.60, p = 0.002). Conclusions Baseline BNP independently predicted mortality and HF hospitalization in a predominantly older white male population of advanced HF patients receiving CRT-D. Elevated BNP levels may identify a vulnerable HF population with a particularly poor prognosis despite CRT-D. Copyright © 2009 Wiley Periodicals, Inc. [source]