Cardiovascular Conference at Snowmass

SNOWMASS, COLO.– The sun may be setting on the use of aspirin for thromboprophylaxis in patients with nonvalvular atrial fibrillation. The 2014 American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines are unique among the major international guidelines in giving a modest IIb, Level of Evidence C endorsement to the option of aspirin or no treatment in patients with atrial fibrillation (AF) and a CHA₂DS₂-VASc score of 1. In contrast, the 2014 U.K. NICE (National Institute for Health and Care Excellence) guidelines, the 2013 Asian Pacific Heart Rhythm Society guidelines, and the 2012 European Society of Cardiology guidelines all recommend consideration of oral anticoagulation – eschewing aspirin – in patients with a CHA₂DS₂-VASc score of 1 or more, Dr. Bernard J. Gersh noted at the Annual Cardiovascular Conference at Snowmass.

The NICE guidelines put the matter succinctly, stating, “The main departure from prior guidelines is that aspirin should not be used in AF simply to reduce the risk of stroke, as it is not as effective as NOACs [novel oral anticoagulants] ... and can cause more bleeding side effects.”

Dr. Gersh was coauthor of a recently published think piece that argued that exaggerated misperceptions of aspirin’s efficacy and safety have led to its inappropriate status as “the easy option” for stroke prevention in AF (Eur. Heart J. 2015;36:653-6).

“By giving physicians a soft option of aspirin in CHA₂DS₂-VASc 1 patients, we’re allowing them an excuse not to use an oral anticoagulant, which is what they should be using,” Dr. Gersh explained at the conference.

He noted that an analysis of more than 41,000 Medicare beneficiaries with AF in 2007-2008 showed that only 66.8% were on warfarin.

“There’s no doubt that warfarin, and for that matter the NOACs, are underutilized, and it’s possible that the misperception that aspirin is effective may contribute to that underutilization,” asserted Dr. Gersh, professor of medicine at the Mayo Clinic, Rochester, Minn.

The cardiologist added that the widely held belief that aspirin reduces stroke risk by roughly 20%, compared with placebo, in patients with AF is based upon seriously flawed data. True, a meta-analysis of six placebo-controlled randomized trials done in an earlier era concluded that aspirin reduced the relative risk of stroke by 19%, but what’s often overlooked is that aspirin significantly outperformed placebo in only one of those six studies – the SPAF 1 trial – where in one arm aspirin achieved an “almost implausible” 94% relative risk reduction.

“Nothing reduces risk by 94%,” Dr. Gersh observed, adding that the SPAF 1 methodology was, upon careful examination, “completely unacceptable” by contemporary standards.

He was a coinvestigator in a study of 7,347 AF patients on oral anticoagulation therapy in 176 U.S. practices participating in the ORBIT-AF registry (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation). The analysis showed that concomitant use of aspirin and an oral anticoagulant in patients with AF is common in everyday clinical practice, being employed in 35% of the study population. Of note, 39% of these patients had no history of CAD and therefore weren’t on aspirin for secondary cardiovascular prevention, and 17% of them were at elevated bleeding risk because of an ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) bleeding risk score of 5 or more.

The key, disturbing finding was this: The adjusted risks of major bleeding and hospitalization for bleeding were 53% and 52% greater, respectively, in patients on an oral anticoagulant plus aspirin than with an oral anticoagulant alone (Circulation 2013;128:721-8).

On the basis of this study and other evidence, Dr. Gersh believes the use of aspirin in patients with AF should be considered only in those with CAD, where a case can be made for its use in secondary prevention alongside an oral anticoagulant to reduce stroke risk. But even then, aspirin’s use is reasonable only in those at low risk of bleeding, and extra vigilance and prophylaxis with a proton pump inhibitor are called for.

“If a patient is at high risk of bleeding, I personally would not give aspirin,” the cardiologist added.

The big remaining question – and an area of current controversy – concerns the safety of halting aspirin in AF patients on an oral anticoagulant who’ve undergone coronary stenting. Ongoing studies are looking at this issue, and answers are expected within a year or 2.

Dr. Gersh reported serving as a consultant to Merck and Ortho-McNeil-Janssen and on data safety monitoring boards for Baxter, Medtronic, and Teva.

SNOWMASS, COLO.– The sun may be setting on the use of aspirin for thromboprophylaxis in patients with nonvalvular atrial fibrillation. The 2014 American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines are unique among the major international guidelines in giving a modest IIb, Level of Evidence C endorsement to the option of aspirin or no treatment in patients with atrial fibrillation (AF) and a CHA₂DS₂-VASc score of 1. In contrast, the 2014 U.K. NICE (National Institute for Health and Care Excellence) guidelines, the 2013 Asian Pacific Heart Rhythm Society guidelines, and the 2012 European Society of Cardiology guidelines all recommend consideration of oral anticoagulation – eschewing aspirin – in patients with a CHA₂DS₂-VASc score of 1 or more, Dr. Bernard J. Gersh noted at the Annual Cardiovascular Conference at Snowmass.

The NICE guidelines put the matter succinctly, stating, “The main departure from prior guidelines is that aspirin should not be used in AF simply to reduce the risk of stroke, as it is not as effective as NOACs [novel oral anticoagulants] ... and can cause more bleeding side effects.”

Dr. Gersh was coauthor of a recently published think piece that argued that exaggerated misperceptions of aspirin’s efficacy and safety have led to its inappropriate status as “the easy option” for stroke prevention in AF (Eur. Heart J. 2015;36:653-6).

“By giving physicians a soft option of aspirin in CHA₂DS₂-VASc 1 patients, we’re allowing them an excuse not to use an oral anticoagulant, which is what they should be using,” Dr. Gersh explained at the conference.

He noted that an analysis of more than 41,000 Medicare beneficiaries with AF in 2007-2008 showed that only 66.8% were on warfarin.

“There’s no doubt that warfarin, and for that matter the NOACs, are underutilized, and it’s possible that the misperception that aspirin is effective may contribute to that underutilization,” asserted Dr. Gersh, professor of medicine at the Mayo Clinic, Rochester, Minn.

The cardiologist added that the widely held belief that aspirin reduces stroke risk by roughly 20%, compared with placebo, in patients with AF is based upon seriously flawed data. True, a meta-analysis of six placebo-controlled randomized trials done in an earlier era concluded that aspirin reduced the relative risk of stroke by 19%, but what’s often overlooked is that aspirin significantly outperformed placebo in only one of those six studies – the SPAF 1 trial – where in one arm aspirin achieved an “almost implausible” 94% relative risk reduction.

“Nothing reduces risk by 94%,” Dr. Gersh observed, adding that the SPAF 1 methodology was, upon careful examination, “completely unacceptable” by contemporary standards.

He was a coinvestigator in a study of 7,347 AF patients on oral anticoagulation therapy in 176 U.S. practices participating in the ORBIT-AF registry (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation). The analysis showed that concomitant use of aspirin and an oral anticoagulant in patients with AF is common in everyday clinical practice, being employed in 35% of the study population. Of note, 39% of these patients had no history of CAD and therefore weren’t on aspirin for secondary cardiovascular prevention, and 17% of them were at elevated bleeding risk because of an ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) bleeding risk score of 5 or more.

The key, disturbing finding was this: The adjusted risks of major bleeding and hospitalization for bleeding were 53% and 52% greater, respectively, in patients on an oral anticoagulant plus aspirin than with an oral anticoagulant alone (Circulation 2013;128:721-8).

On the basis of this study and other evidence, Dr. Gersh believes the use of aspirin in patients with AF should be considered only in those with CAD, where a case can be made for its use in secondary prevention alongside an oral anticoagulant to reduce stroke risk. But even then, aspirin’s use is reasonable only in those at low risk of bleeding, and extra vigilance and prophylaxis with a proton pump inhibitor are called for.

“If a patient is at high risk of bleeding, I personally would not give aspirin,” the cardiologist added.

The big remaining question – and an area of current controversy – concerns the safety of halting aspirin in AF patients on an oral anticoagulant who’ve undergone coronary stenting. Ongoing studies are looking at this issue, and answers are expected within a year or 2.

Dr. Gersh reported serving as a consultant to Merck and Ortho-McNeil-Janssen and on data safety monitoring boards for Baxter, Medtronic, and Teva.

SNOWMASS, COLO.– The sun may be setting on the use of aspirin for thromboprophylaxis in patients with nonvalvular atrial fibrillation. The 2014 American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines are unique among the major international guidelines in giving a modest IIb, Level of Evidence C endorsement to the option of aspirin or no treatment in patients with atrial fibrillation (AF) and a CHA₂DS₂-VASc score of 1. In contrast, the 2014 U.K. NICE (National Institute for Health and Care Excellence) guidelines, the 2013 Asian Pacific Heart Rhythm Society guidelines, and the 2012 European Society of Cardiology guidelines all recommend consideration of oral anticoagulation – eschewing aspirin – in patients with a CHA₂DS₂-VASc score of 1 or more, Dr. Bernard J. Gersh noted at the Annual Cardiovascular Conference at Snowmass.

The NICE guidelines put the matter succinctly, stating, “The main departure from prior guidelines is that aspirin should not be used in AF simply to reduce the risk of stroke, as it is not as effective as NOACs [novel oral anticoagulants] ... and can cause more bleeding side effects.”

Dr. Gersh was coauthor of a recently published think piece that argued that exaggerated misperceptions of aspirin’s efficacy and safety have led to its inappropriate status as “the easy option” for stroke prevention in AF (Eur. Heart J. 2015;36:653-6).

“By giving physicians a soft option of aspirin in CHA₂DS₂-VASc 1 patients, we’re allowing them an excuse not to use an oral anticoagulant, which is what they should be using,” Dr. Gersh explained at the conference.

He noted that an analysis of more than 41,000 Medicare beneficiaries with AF in 2007-2008 showed that only 66.8% were on warfarin.

“There’s no doubt that warfarin, and for that matter the NOACs, are underutilized, and it’s possible that the misperception that aspirin is effective may contribute to that underutilization,” asserted Dr. Gersh, professor of medicine at the Mayo Clinic, Rochester, Minn.

The cardiologist added that the widely held belief that aspirin reduces stroke risk by roughly 20%, compared with placebo, in patients with AF is based upon seriously flawed data. True, a meta-analysis of six placebo-controlled randomized trials done in an earlier era concluded that aspirin reduced the relative risk of stroke by 19%, but what’s often overlooked is that aspirin significantly outperformed placebo in only one of those six studies – the SPAF 1 trial – where in one arm aspirin achieved an “almost implausible” 94% relative risk reduction.

“Nothing reduces risk by 94%,” Dr. Gersh observed, adding that the SPAF 1 methodology was, upon careful examination, “completely unacceptable” by contemporary standards.

He was a coinvestigator in a study of 7,347 AF patients on oral anticoagulation therapy in 176 U.S. practices participating in the ORBIT-AF registry (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation). The analysis showed that concomitant use of aspirin and an oral anticoagulant in patients with AF is common in everyday clinical practice, being employed in 35% of the study population. Of note, 39% of these patients had no history of CAD and therefore weren’t on aspirin for secondary cardiovascular prevention, and 17% of them were at elevated bleeding risk because of an ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) bleeding risk score of 5 or more.

The key, disturbing finding was this: The adjusted risks of major bleeding and hospitalization for bleeding were 53% and 52% greater, respectively, in patients on an oral anticoagulant plus aspirin than with an oral anticoagulant alone (Circulation 2013;128:721-8).

On the basis of this study and other evidence, Dr. Gersh believes the use of aspirin in patients with AF should be considered only in those with CAD, where a case can be made for its use in secondary prevention alongside an oral anticoagulant to reduce stroke risk. But even then, aspirin’s use is reasonable only in those at low risk of bleeding, and extra vigilance and prophylaxis with a proton pump inhibitor are called for.

“If a patient is at high risk of bleeding, I personally would not give aspirin,” the cardiologist added.

The big remaining question – and an area of current controversy – concerns the safety of halting aspirin in AF patients on an oral anticoagulant who’ve undergone coronary stenting. Ongoing studies are looking at this issue, and answers are expected within a year or 2.

Dr. Gersh reported serving as a consultant to Merck and Ortho-McNeil-Janssen and on data safety monitoring boards for Baxter, Medtronic, and Teva.

SNOWMASS, COLO. – An ECG can offer a handful of easily interpreted clues that raise to 99% the certainty of diagnosing ventricular tachycardia as the cause of a patient’s wide complex tachycardia, according to Dr. Samuel J. Asirvatham.

The first thing to realize about wide complex tachycardias (WCTs), as defined by a heart rate in excess of 100 bpm and a QRS duration greater than 120 milliseconds, is that the cause is ventricular tachycardia (VT) rather than supraventricular tachycardia in 80% of cases, he  said at the Annual Cardiovascular Conference at Snowmass.

“When you diagnose wide complex tachycardia as not VT, you’re much more likely to make a mistake than if you just closed your eyes and said VT,” said Dr. Asirvatham, professor of medicine and pediatrics at the Mayo Clinic, Rochester, Minn.

The history also provides a valuable clue: “If there’s anything wrong with the heart – a prior MI, structural disease, a scar on the heart from previous surgery, sarcoid – there’s a 95% chance that the WCT is due to VT,” he said.

Key ECG features will boost the diagnostic certainty of VT from 95% to 99%. Here are Dr. Asirvatham’s favorites:

• Atrioventricular dissociation. When the ventricular rate is faster than the atrial rate, the result is atrioventricular dissocation. In the setting of WCT, it’s highly specific for VT, and it’s present on the ECGs of up to 50% of affected patients.

“This is a very useful clue. I like looking for this. If you see it, you can be convinced the patient has VT,” he said.

• The wide QRS. The wider the wide QRS, the more likely it’s VT.If the QRS duration is greater than 150 milliseconds, there’s nearly a 98% likelihood of VT.

• Northwest axis. If both lead I and the inferior leads show negative deflection – that is, the electrical wave is moving away from the positive electrodes located over the left shoulder and closest to the feet – that means the wave is moving toward the northwest on the frontal plane axis. The odds are extremely high that this is VT.

• Chest lead concordance. If all of the chest leads V1-6 are positive or they’re all negative, that’s “powerful information” indicating VT, according to Dr. Asirvatham.

• Time from onset of R wave to S wave nadir. Even if chest concordance isn’t present, VT can be diagnosed with near-absolute certainty simply by measuring the time from onset of the R wave to the lowest point on the S wave. If it’s longer than 100 milliseconds, that finding strongly favors VT.

“Remember these ECG features and 99% of the time you will correctly diagnose VT,” the cardiologist said.

Dr. Asirvatham reported serving as a consultant to a dozen medical device companies.

[email protected]

SNOWMASS, COLO. – An ECG can offer a handful of easily interpreted clues that raise to 99% the certainty of diagnosing ventricular tachycardia as the cause of a patient’s wide complex tachycardia, according to Dr. Samuel J. Asirvatham.

The first thing to realize about wide complex tachycardias (WCTs), as defined by a heart rate in excess of 100 bpm and a QRS duration greater than 120 milliseconds, is that the cause is ventricular tachycardia (VT) rather than supraventricular tachycardia in 80% of cases, he  said at the Annual Cardiovascular Conference at Snowmass.

“When you diagnose wide complex tachycardia as not VT, you’re much more likely to make a mistake than if you just closed your eyes and said VT,” said Dr. Asirvatham, professor of medicine and pediatrics at the Mayo Clinic, Rochester, Minn.

The history also provides a valuable clue: “If there’s anything wrong with the heart – a prior MI, structural disease, a scar on the heart from previous surgery, sarcoid – there’s a 95% chance that the WCT is due to VT,” he said.

Key ECG features will boost the diagnostic certainty of VT from 95% to 99%. Here are Dr. Asirvatham’s favorites:

• Atrioventricular dissociation. When the ventricular rate is faster than the atrial rate, the result is atrioventricular dissocation. In the setting of WCT, it’s highly specific for VT, and it’s present on the ECGs of up to 50% of affected patients.

“This is a very useful clue. I like looking for this. If you see it, you can be convinced the patient has VT,” he said.

• The wide QRS. The wider the wide QRS, the more likely it’s VT.If the QRS duration is greater than 150 milliseconds, there’s nearly a 98% likelihood of VT.

• Northwest axis. If both lead I and the inferior leads show negative deflection – that is, the electrical wave is moving away from the positive electrodes located over the left shoulder and closest to the feet – that means the wave is moving toward the northwest on the frontal plane axis. The odds are extremely high that this is VT.

• Chest lead concordance. If all of the chest leads V1-6 are positive or they’re all negative, that’s “powerful information” indicating VT, according to Dr. Asirvatham.

• Time from onset of R wave to S wave nadir. Even if chest concordance isn’t present, VT can be diagnosed with near-absolute certainty simply by measuring the time from onset of the R wave to the lowest point on the S wave. If it’s longer than 100 milliseconds, that finding strongly favors VT.

“Remember these ECG features and 99% of the time you will correctly diagnose VT,” the cardiologist said.

Dr. Asirvatham reported serving as a consultant to a dozen medical device companies.

[email protected]

SNOWMASS, COLO. – An ECG can offer a handful of easily interpreted clues that raise to 99% the certainty of diagnosing ventricular tachycardia as the cause of a patient’s wide complex tachycardia, according to Dr. Samuel J. Asirvatham.

The first thing to realize about wide complex tachycardias (WCTs), as defined by a heart rate in excess of 100 bpm and a QRS duration greater than 120 milliseconds, is that the cause is ventricular tachycardia (VT) rather than supraventricular tachycardia in 80% of cases, he  said at the Annual Cardiovascular Conference at Snowmass.

“When you diagnose wide complex tachycardia as not VT, you’re much more likely to make a mistake than if you just closed your eyes and said VT,” said Dr. Asirvatham, professor of medicine and pediatrics at the Mayo Clinic, Rochester, Minn.

The history also provides a valuable clue: “If there’s anything wrong with the heart – a prior MI, structural disease, a scar on the heart from previous surgery, sarcoid – there’s a 95% chance that the WCT is due to VT,” he said.

Key ECG features will boost the diagnostic certainty of VT from 95% to 99%. Here are Dr. Asirvatham’s favorites:

• Atrioventricular dissociation. When the ventricular rate is faster than the atrial rate, the result is atrioventricular dissocation. In the setting of WCT, it’s highly specific for VT, and it’s present on the ECGs of up to 50% of affected patients.

“This is a very useful clue. I like looking for this. If you see it, you can be convinced the patient has VT,” he said.

• The wide QRS. The wider the wide QRS, the more likely it’s VT.If the QRS duration is greater than 150 milliseconds, there’s nearly a 98% likelihood of VT.

• Northwest axis. If both lead I and the inferior leads show negative deflection – that is, the electrical wave is moving away from the positive electrodes located over the left shoulder and closest to the feet – that means the wave is moving toward the northwest on the frontal plane axis. The odds are extremely high that this is VT.

• Chest lead concordance. If all of the chest leads V1-6 are positive or they’re all negative, that’s “powerful information” indicating VT, according to Dr. Asirvatham.

• Time from onset of R wave to S wave nadir. Even if chest concordance isn’t present, VT can be diagnosed with near-absolute certainty simply by measuring the time from onset of the R wave to the lowest point on the S wave. If it’s longer than 100 milliseconds, that finding strongly favors VT.

“Remember these ECG features and 99% of the time you will correctly diagnose VT,” the cardiologist said.

Dr. Asirvatham reported serving as a consultant to a dozen medical device companies.

[email protected]

SNOWMASS, COLO. – For all the talk of embracing the heart team approach to coronary revascularization as the new standard, emphasizing interdisciplinary collaboration between cardiologists and surgeons, hybrid coronary revascularization remains a rarely employed strategy.

Hybrid coronary revascularization (HCR) is performed at one-third of U.S. centers providing coronary artery bypass graft (CABG) surgery, but that’s a misleading statistic. A mere handful of the centers have extensive experience with this strategy, according to the first nationwide assessment of HCR in patients with multivessel coronary artery disease.

“Only a very few centers – maybe 5 or 10 – do hybrid procedures as 8%-10% of their volume,” Dr. Vinod H. Thourani* said at the Annual Cardiovascular Conference at Snowmass.

He was a coinvestigator in the analysis of nearly 200,000 CABG procedures in the Society of Thoracic Surgeons (STS) national database for 2011-2013. Hybrid coronary revascularization – a combination of surgical and percutaneous techniques coupling minimally invasive bypass of the left anterior descending (LAD) coronary artery using an internal mammary artery graft along with drug-eluting stents for non-LAD lesions – accounted for just 0.48% of total CABG volume. And no trend for growth in the HCR approach was evident during the study period.

Moreover, even in the one-third of U.S. CABG centers that performed hybrid coronary revascularization, the strategy was used on average in less than 1% of all CABG procedures (Circulation 2014;130:872-9), noted Dr. Thourani, professor of cardiothoracic surgery and codirector of the Structural Heart and Valve Center at Emory University, Atlanta.

In contrast, he and his Emory colleagues have fully embraced HCR. At Emory, even as the annual number of primary isolated CABG procedures with sternotomy fell by 44% from 2005 to 2012, there was a compensatory increase in the number of HCRs.

“We’ve actually maintained our coronary bypass volume based on introducing HCR, unlike a lot of programs,” according to the surgeon.

The appeal of HCR is that it combines the durability of the internal mammary artery-to-LAD graft – long recognized as the main source of the survival advantage CABG holds over percutaneous interventions – with drug-eluting stents as a less invasive alternative to often-unreliable vein grafts in non-LAD target vessels.

The current American College of Cardiology/American Heart Association guidelines on coronary revascularization give HCR a favorable class IIa recommendation. However, since there are few data on clinical outcomes with HCR versus conventional CABG, Dr. Thourani and his coinvestigators compared in-hospital outcomes in the STS database. They found that after adjustment for the higher cardiovascular risk profiles present in patients undergoing HCR, the rates of in-hospital mortality and major morbidity in the two groups were similar, suggesting HCR may offer an equally safe alternative to CABG in selected patients.

Patients want less invasive alternatives to CABG with sternotomy. The three most common minimally invasive, sternal-sparing approaches are minimally invasive direct coronary artery bypass, or MIDCAB; robotic-assisted totally endoscopic coronary artery bypass, or TECAB; and robotic-assisted coronary artery bypass, a favored approach at Emory. In robotic-assisted coronary artery bypass, the harvest of the left internal mammary artery, pericardiotomy, and targeting of the LAD are accomplished with robotic assistance, but the anastomosis is hand sewn under direct vision, off pump, via a non–rib-spreading 3- to 4-cm minithoracotomy.

In a report on 307 consecutive patients who underwent robotic-assisted CABG at the university, including 159 who had HCR for multivessel disease, short-term clinical and angiographic outcomes were excellent (J. Thorac. Cardiovasc. Surg. 2014;147:179-85). Particularly striking, in Dr. Thourani’s view, was that only one postoperative stroke occurred, for a 0.3% incidence. That’s a far lower rate than typical with CABG with vein grafts.

In a more recent, as-yet-unpublished update including 477 consecutive HCR patients at Emory, the stroke rate remained extraordinarily low at 0.2%, he said.

“You can almost eliminate stroke with this procedure,” according to Dr. Thourani.

Thirty-day mortality was 0.8%, with an MI rate of 1.0%, a 3.8% incidence of conversion to sternotomy, and a 1.9% repeat revascularization rate. The rate of Fitzgibbon A patency was 96.2%, he noted.

“Return to work is really at the patient’s discretion. We tell them, ‘when you don’t hurt, you can go back.’ Some people go back 4-5 days after surgery. And there are really zero limitations for the patient – none whatsoever,” the surgeon said.

The HCR approach to multivessel revascularization appears to be particularly advantageous in diabetic patients and in older individuals. In a retrospective, nonrandomized single-center comparison of 143 HCR recipients who were propensity score matched to 572 patients who underwent multivessel CABG (Am. J. Cardiol. 2014;114:224-9), the HCR recipients had significantly fewer procedural complications, faster recovery, and similar 3-year mortality (see graphic).

Dr. Thourani said that because of the dirth of randomized trials data, it must be conceded that there is equipoise at present regarding the most effective treatment strategy in patients with multivessel coronary disease. The options are CABG with left internal mammary artery and vein grafts, HCR, medical management, multivessel percutaneous coronary intervention (PCI), and multiarterial CABG. But he added that the available evidence, while not definitive, does point the way forward.

“As we move into 2015 and the future, I think we should be doing less of the left intermal mammary artery with vein grafts, potentially less of the medical therapy, and I think we need to do a lot more multiarterial grafts if we think patients need to be opened up with a sternotomy. And if we don’t think they need to be opened up, we need to think very strongly about hybrid revascularization instead of multivessel PCI, especially in patients who are diabetic or old,” according to the surgeon.

Dr. Thourani reported serving as a consultant to Edwards Lifesciences and St. Jude Medical and receiving research grants from Abbott, Boston Scientific, Medtronic, and Sorin.

[email protected]

*Clarification, 4/20/2015: Dr. Vinod H. Thourani wishes to clarify that,  as he stated in his presentation, the current work he reported on from Emory University was performed by Dr. Michael Halkos, who is the leader of hybrid revascularization at Emory, and that Dr. Halkos was lead author and researcher in several of the other studies reported upon.

SNOWMASS, COLO. – For all the talk of embracing the heart team approach to coronary revascularization as the new standard, emphasizing interdisciplinary collaboration between cardiologists and surgeons, hybrid coronary revascularization remains a rarely employed strategy.

Hybrid coronary revascularization (HCR) is performed at one-third of U.S. centers providing coronary artery bypass graft (CABG) surgery, but that’s a misleading statistic. A mere handful of the centers have extensive experience with this strategy, according to the first nationwide assessment of HCR in patients with multivessel coronary artery disease.

“Only a very few centers – maybe 5 or 10 – do hybrid procedures as 8%-10% of their volume,” Dr. Vinod H. Thourani* said at the Annual Cardiovascular Conference at Snowmass.

He was a coinvestigator in the analysis of nearly 200,000 CABG procedures in the Society of Thoracic Surgeons (STS) national database for 2011-2013. Hybrid coronary revascularization – a combination of surgical and percutaneous techniques coupling minimally invasive bypass of the left anterior descending (LAD) coronary artery using an internal mammary artery graft along with drug-eluting stents for non-LAD lesions – accounted for just 0.48% of total CABG volume. And no trend for growth in the HCR approach was evident during the study period.

Moreover, even in the one-third of U.S. CABG centers that performed hybrid coronary revascularization, the strategy was used on average in less than 1% of all CABG procedures (Circulation 2014;130:872-9), noted Dr. Thourani, professor of cardiothoracic surgery and codirector of the Structural Heart and Valve Center at Emory University, Atlanta.

In contrast, he and his Emory colleagues have fully embraced HCR. At Emory, even as the annual number of primary isolated CABG procedures with sternotomy fell by 44% from 2005 to 2012, there was a compensatory increase in the number of HCRs.

“We’ve actually maintained our coronary bypass volume based on introducing HCR, unlike a lot of programs,” according to the surgeon.

The appeal of HCR is that it combines the durability of the internal mammary artery-to-LAD graft – long recognized as the main source of the survival advantage CABG holds over percutaneous interventions – with drug-eluting stents as a less invasive alternative to often-unreliable vein grafts in non-LAD target vessels.

The current American College of Cardiology/American Heart Association guidelines on coronary revascularization give HCR a favorable class IIa recommendation. However, since there are few data on clinical outcomes with HCR versus conventional CABG, Dr. Thourani and his coinvestigators compared in-hospital outcomes in the STS database. They found that after adjustment for the higher cardiovascular risk profiles present in patients undergoing HCR, the rates of in-hospital mortality and major morbidity in the two groups were similar, suggesting HCR may offer an equally safe alternative to CABG in selected patients.

Patients want less invasive alternatives to CABG with sternotomy. The three most common minimally invasive, sternal-sparing approaches are minimally invasive direct coronary artery bypass, or MIDCAB; robotic-assisted totally endoscopic coronary artery bypass, or TECAB; and robotic-assisted coronary artery bypass, a favored approach at Emory. In robotic-assisted coronary artery bypass, the harvest of the left internal mammary artery, pericardiotomy, and targeting of the LAD are accomplished with robotic assistance, but the anastomosis is hand sewn under direct vision, off pump, via a non–rib-spreading 3- to 4-cm minithoracotomy.

In a report on 307 consecutive patients who underwent robotic-assisted CABG at the university, including 159 who had HCR for multivessel disease, short-term clinical and angiographic outcomes were excellent (J. Thorac. Cardiovasc. Surg. 2014;147:179-85). Particularly striking, in Dr. Thourani’s view, was that only one postoperative stroke occurred, for a 0.3% incidence. That’s a far lower rate than typical with CABG with vein grafts.

In a more recent, as-yet-unpublished update including 477 consecutive HCR patients at Emory, the stroke rate remained extraordinarily low at 0.2%, he said.

“You can almost eliminate stroke with this procedure,” according to Dr. Thourani.

Thirty-day mortality was 0.8%, with an MI rate of 1.0%, a 3.8% incidence of conversion to sternotomy, and a 1.9% repeat revascularization rate. The rate of Fitzgibbon A patency was 96.2%, he noted.

“Return to work is really at the patient’s discretion. We tell them, ‘when you don’t hurt, you can go back.’ Some people go back 4-5 days after surgery. And there are really zero limitations for the patient – none whatsoever,” the surgeon said.

The HCR approach to multivessel revascularization appears to be particularly advantageous in diabetic patients and in older individuals. In a retrospective, nonrandomized single-center comparison of 143 HCR recipients who were propensity score matched to 572 patients who underwent multivessel CABG (Am. J. Cardiol. 2014;114:224-9), the HCR recipients had significantly fewer procedural complications, faster recovery, and similar 3-year mortality (see graphic).

Dr. Thourani said that because of the dirth of randomized trials data, it must be conceded that there is equipoise at present regarding the most effective treatment strategy in patients with multivessel coronary disease. The options are CABG with left internal mammary artery and vein grafts, HCR, medical management, multivessel percutaneous coronary intervention (PCI), and multiarterial CABG. But he added that the available evidence, while not definitive, does point the way forward.

“As we move into 2015 and the future, I think we should be doing less of the left intermal mammary artery with vein grafts, potentially less of the medical therapy, and I think we need to do a lot more multiarterial grafts if we think patients need to be opened up with a sternotomy. And if we don’t think they need to be opened up, we need to think very strongly about hybrid revascularization instead of multivessel PCI, especially in patients who are diabetic or old,” according to the surgeon.

Dr. Thourani reported serving as a consultant to Edwards Lifesciences and St. Jude Medical and receiving research grants from Abbott, Boston Scientific, Medtronic, and Sorin.

[email protected]

*Clarification, 4/20/2015: Dr. Vinod H. Thourani wishes to clarify that,  as he stated in his presentation, the current work he reported on from Emory University was performed by Dr. Michael Halkos, who is the leader of hybrid revascularization at Emory, and that Dr. Halkos was lead author and researcher in several of the other studies reported upon.

SNOWMASS, COLO. – For all the talk of embracing the heart team approach to coronary revascularization as the new standard, emphasizing interdisciplinary collaboration between cardiologists and surgeons, hybrid coronary revascularization remains a rarely employed strategy.

Hybrid coronary revascularization (HCR) is performed at one-third of U.S. centers providing coronary artery bypass graft (CABG) surgery, but that’s a misleading statistic. A mere handful of the centers have extensive experience with this strategy, according to the first nationwide assessment of HCR in patients with multivessel coronary artery disease.

“Only a very few centers – maybe 5 or 10 – do hybrid procedures as 8%-10% of their volume,” Dr. Vinod H. Thourani* said at the Annual Cardiovascular Conference at Snowmass.

He was a coinvestigator in the analysis of nearly 200,000 CABG procedures in the Society of Thoracic Surgeons (STS) national database for 2011-2013. Hybrid coronary revascularization – a combination of surgical and percutaneous techniques coupling minimally invasive bypass of the left anterior descending (LAD) coronary artery using an internal mammary artery graft along with drug-eluting stents for non-LAD lesions – accounted for just 0.48% of total CABG volume. And no trend for growth in the HCR approach was evident during the study period.

Moreover, even in the one-third of U.S. CABG centers that performed hybrid coronary revascularization, the strategy was used on average in less than 1% of all CABG procedures (Circulation 2014;130:872-9), noted Dr. Thourani, professor of cardiothoracic surgery and codirector of the Structural Heart and Valve Center at Emory University, Atlanta.

In contrast, he and his Emory colleagues have fully embraced HCR. At Emory, even as the annual number of primary isolated CABG procedures with sternotomy fell by 44% from 2005 to 2012, there was a compensatory increase in the number of HCRs.

“We’ve actually maintained our coronary bypass volume based on introducing HCR, unlike a lot of programs,” according to the surgeon.

The appeal of HCR is that it combines the durability of the internal mammary artery-to-LAD graft – long recognized as the main source of the survival advantage CABG holds over percutaneous interventions – with drug-eluting stents as a less invasive alternative to often-unreliable vein grafts in non-LAD target vessels.

The current American College of Cardiology/American Heart Association guidelines on coronary revascularization give HCR a favorable class IIa recommendation. However, since there are few data on clinical outcomes with HCR versus conventional CABG, Dr. Thourani and his coinvestigators compared in-hospital outcomes in the STS database. They found that after adjustment for the higher cardiovascular risk profiles present in patients undergoing HCR, the rates of in-hospital mortality and major morbidity in the two groups were similar, suggesting HCR may offer an equally safe alternative to CABG in selected patients.

Patients want less invasive alternatives to CABG with sternotomy. The three most common minimally invasive, sternal-sparing approaches are minimally invasive direct coronary artery bypass, or MIDCAB; robotic-assisted totally endoscopic coronary artery bypass, or TECAB; and robotic-assisted coronary artery bypass, a favored approach at Emory. In robotic-assisted coronary artery bypass, the harvest of the left internal mammary artery, pericardiotomy, and targeting of the LAD are accomplished with robotic assistance, but the anastomosis is hand sewn under direct vision, off pump, via a non–rib-spreading 3- to 4-cm minithoracotomy.

In a report on 307 consecutive patients who underwent robotic-assisted CABG at the university, including 159 who had HCR for multivessel disease, short-term clinical and angiographic outcomes were excellent (J. Thorac. Cardiovasc. Surg. 2014;147:179-85). Particularly striking, in Dr. Thourani’s view, was that only one postoperative stroke occurred, for a 0.3% incidence. That’s a far lower rate than typical with CABG with vein grafts.

In a more recent, as-yet-unpublished update including 477 consecutive HCR patients at Emory, the stroke rate remained extraordinarily low at 0.2%, he said.

“You can almost eliminate stroke with this procedure,” according to Dr. Thourani.

Thirty-day mortality was 0.8%, with an MI rate of 1.0%, a 3.8% incidence of conversion to sternotomy, and a 1.9% repeat revascularization rate. The rate of Fitzgibbon A patency was 96.2%, he noted.

“Return to work is really at the patient’s discretion. We tell them, ‘when you don’t hurt, you can go back.’ Some people go back 4-5 days after surgery. And there are really zero limitations for the patient – none whatsoever,” the surgeon said.

The HCR approach to multivessel revascularization appears to be particularly advantageous in diabetic patients and in older individuals. In a retrospective, nonrandomized single-center comparison of 143 HCR recipients who were propensity score matched to 572 patients who underwent multivessel CABG (Am. J. Cardiol. 2014;114:224-9), the HCR recipients had significantly fewer procedural complications, faster recovery, and similar 3-year mortality (see graphic).

Dr. Thourani said that because of the dirth of randomized trials data, it must be conceded that there is equipoise at present regarding the most effective treatment strategy in patients with multivessel coronary disease. The options are CABG with left internal mammary artery and vein grafts, HCR, medical management, multivessel percutaneous coronary intervention (PCI), and multiarterial CABG. But he added that the available evidence, while not definitive, does point the way forward.

“As we move into 2015 and the future, I think we should be doing less of the left intermal mammary artery with vein grafts, potentially less of the medical therapy, and I think we need to do a lot more multiarterial grafts if we think patients need to be opened up with a sternotomy. And if we don’t think they need to be opened up, we need to think very strongly about hybrid revascularization instead of multivessel PCI, especially in patients who are diabetic or old,” according to the surgeon.

Dr. Thourani reported serving as a consultant to Edwards Lifesciences and St. Jude Medical and receiving research grants from Abbott, Boston Scientific, Medtronic, and Sorin.

[email protected]

*Clarification, 4/20/2015: Dr. Vinod H. Thourani wishes to clarify that,  as he stated in his presentation, the current work he reported on from Emory University was performed by Dr. Michael Halkos, who is the leader of hybrid revascularization at Emory, and that Dr. Halkos was lead author and researcher in several of the other studies reported upon.

SNOWMASS, COLO. – Under intense fiscal pressure to curb early hospital readmissions for heart failure, cardiologists and hospital administrators are taking a hard look at the traditional role of the emergency department as the point of triage for patients with decompensated heart failure.

“Alternatives to the emergency department for ambulatory triage and intervention are essential,” Dr. Akshay Desai said at the Annual Cardiovascular Conference at Snowmass.

“Traditionally, when our patients become decompensated, we send them from our office or clinic to the ED. And 80%-90% of those who present to the ED with the diagnosis of heart failure are admitted to the hospital. So this means that the ED is a pretty ineffective triage point for heart failure patients. Most ED staff are concerned about ambulatory follow-up and feel it’s safer to follow patients in the hospital. The message here is we need a more robust ambulatory framework to manage patients with milder decompensation so they don’t all need to come into the hospital,” said Dr. Desai of Brigham and Women’s Hospital and Harvard Medical School, Boston.

Hospital admission is of questionable value for a large fraction of decompensating heart failure patients. After all, not that much happens to them in the hospital that couldn’t take place in a less costly setting.

“For the most part, our patients in the hospital for decompensated heart failure get IV diuretics, with an average weight loss of about 4 kg. Surveillance is typically once- or twice-daily laboratory tests and a bedside clinical visit by a physician at 7:30 in the morning. Few patients get much else. There’s little diagnostic testing, few other therapies that require intensive monitoring, and most patients feel a little better by their first day in the hospital,” he said.

This suggests the need for what he called “an evolved model of heart failure care” in which the ED is replaced as the point of service by some form of ambulatory center that can serve as a buffer limiting the number of patients who need to come into the hospital.

“It could be a home-based strategy of IV diuretic administration, a clinic-based strategy of outpatient diuretic administration, or an observation unit based in the ED. All of these are now being tested in various models across the country as alternatives to help manage the readmission problem, and also to make life better for our patients, who’d prefer not to be in the hospital if they could be managed in other ways,” Dr. Desai continued.

Reducing 30-day readmission rates after a hospitalization for heart failure is seen by health policy makers as an opportunity to simultaneously improve care and reduce costs. But studies show only about half of readmissions in patients with heart failure are cardiovascular related, just half of those cardiovascular readmissions are heart failure related, and only about 30% of heart failure readmissions are truly preventable. However, wide variation exists across the country in risk-adjusted 30-day readmission rates, suggesting there is an opportunity for improvement in outlier hospitals.

Numerous factors have been linked to high heart failure readmission rates, including patient sociodemographic characteristics, comorbid conditions, and serum markers of heart failure severity. One underappreciated factor, in Dr. Desai’s view, is that readmission rates are significantly higher in hospitals that are financially and clinically resource poor, as shown in a Harvard School of Public Health analysis of Medicare claims data for more than 900,000 heart failure discharges. These resource-poor hospitals provide care for underserved populations, and they are experiencing a disproportionate burden of the financial penalties imposed for early readmission.

“As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care,” according to the Harvard investigators (Circ. Cardiovasc. Qual. Outcomes 2011;4:53-9).

Dr. Desai reported serving as a consultant to 5AM Ventures, AtCor Medical, Novartis, and St. Jude Medical.

[email protected]

SNOWMASS, COLO. – Under intense fiscal pressure to curb early hospital readmissions for heart failure, cardiologists and hospital administrators are taking a hard look at the traditional role of the emergency department as the point of triage for patients with decompensated heart failure.

“Alternatives to the emergency department for ambulatory triage and intervention are essential,” Dr. Akshay Desai said at the Annual Cardiovascular Conference at Snowmass.

“Traditionally, when our patients become decompensated, we send them from our office or clinic to the ED. And 80%-90% of those who present to the ED with the diagnosis of heart failure are admitted to the hospital. So this means that the ED is a pretty ineffective triage point for heart failure patients. Most ED staff are concerned about ambulatory follow-up and feel it’s safer to follow patients in the hospital. The message here is we need a more robust ambulatory framework to manage patients with milder decompensation so they don’t all need to come into the hospital,” said Dr. Desai of Brigham and Women’s Hospital and Harvard Medical School, Boston.

Hospital admission is of questionable value for a large fraction of decompensating heart failure patients. After all, not that much happens to them in the hospital that couldn’t take place in a less costly setting.

“For the most part, our patients in the hospital for decompensated heart failure get IV diuretics, with an average weight loss of about 4 kg. Surveillance is typically once- or twice-daily laboratory tests and a bedside clinical visit by a physician at 7:30 in the morning. Few patients get much else. There’s little diagnostic testing, few other therapies that require intensive monitoring, and most patients feel a little better by their first day in the hospital,” he said.

This suggests the need for what he called “an evolved model of heart failure care” in which the ED is replaced as the point of service by some form of ambulatory center that can serve as a buffer limiting the number of patients who need to come into the hospital.

“It could be a home-based strategy of IV diuretic administration, a clinic-based strategy of outpatient diuretic administration, or an observation unit based in the ED. All of these are now being tested in various models across the country as alternatives to help manage the readmission problem, and also to make life better for our patients, who’d prefer not to be in the hospital if they could be managed in other ways,” Dr. Desai continued.

Reducing 30-day readmission rates after a hospitalization for heart failure is seen by health policy makers as an opportunity to simultaneously improve care and reduce costs. But studies show only about half of readmissions in patients with heart failure are cardiovascular related, just half of those cardiovascular readmissions are heart failure related, and only about 30% of heart failure readmissions are truly preventable. However, wide variation exists across the country in risk-adjusted 30-day readmission rates, suggesting there is an opportunity for improvement in outlier hospitals.

Numerous factors have been linked to high heart failure readmission rates, including patient sociodemographic characteristics, comorbid conditions, and serum markers of heart failure severity. One underappreciated factor, in Dr. Desai’s view, is that readmission rates are significantly higher in hospitals that are financially and clinically resource poor, as shown in a Harvard School of Public Health analysis of Medicare claims data for more than 900,000 heart failure discharges. These resource-poor hospitals provide care for underserved populations, and they are experiencing a disproportionate burden of the financial penalties imposed for early readmission.

“As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care,” according to the Harvard investigators (Circ. Cardiovasc. Qual. Outcomes 2011;4:53-9).

Dr. Desai reported serving as a consultant to 5AM Ventures, AtCor Medical, Novartis, and St. Jude Medical.

[email protected]

SNOWMASS, COLO. – Under intense fiscal pressure to curb early hospital readmissions for heart failure, cardiologists and hospital administrators are taking a hard look at the traditional role of the emergency department as the point of triage for patients with decompensated heart failure.

“Alternatives to the emergency department for ambulatory triage and intervention are essential,” Dr. Akshay Desai said at the Annual Cardiovascular Conference at Snowmass.

“Traditionally, when our patients become decompensated, we send them from our office or clinic to the ED. And 80%-90% of those who present to the ED with the diagnosis of heart failure are admitted to the hospital. So this means that the ED is a pretty ineffective triage point for heart failure patients. Most ED staff are concerned about ambulatory follow-up and feel it’s safer to follow patients in the hospital. The message here is we need a more robust ambulatory framework to manage patients with milder decompensation so they don’t all need to come into the hospital,” said Dr. Desai of Brigham and Women’s Hospital and Harvard Medical School, Boston.

Hospital admission is of questionable value for a large fraction of decompensating heart failure patients. After all, not that much happens to them in the hospital that couldn’t take place in a less costly setting.

“For the most part, our patients in the hospital for decompensated heart failure get IV diuretics, with an average weight loss of about 4 kg. Surveillance is typically once- or twice-daily laboratory tests and a bedside clinical visit by a physician at 7:30 in the morning. Few patients get much else. There’s little diagnostic testing, few other therapies that require intensive monitoring, and most patients feel a little better by their first day in the hospital,” he said.

This suggests the need for what he called “an evolved model of heart failure care” in which the ED is replaced as the point of service by some form of ambulatory center that can serve as a buffer limiting the number of patients who need to come into the hospital.

“It could be a home-based strategy of IV diuretic administration, a clinic-based strategy of outpatient diuretic administration, or an observation unit based in the ED. All of these are now being tested in various models across the country as alternatives to help manage the readmission problem, and also to make life better for our patients, who’d prefer not to be in the hospital if they could be managed in other ways,” Dr. Desai continued.

Reducing 30-day readmission rates after a hospitalization for heart failure is seen by health policy makers as an opportunity to simultaneously improve care and reduce costs. But studies show only about half of readmissions in patients with heart failure are cardiovascular related, just half of those cardiovascular readmissions are heart failure related, and only about 30% of heart failure readmissions are truly preventable. However, wide variation exists across the country in risk-adjusted 30-day readmission rates, suggesting there is an opportunity for improvement in outlier hospitals.

Numerous factors have been linked to high heart failure readmission rates, including patient sociodemographic characteristics, comorbid conditions, and serum markers of heart failure severity. One underappreciated factor, in Dr. Desai’s view, is that readmission rates are significantly higher in hospitals that are financially and clinically resource poor, as shown in a Harvard School of Public Health analysis of Medicare claims data for more than 900,000 heart failure discharges. These resource-poor hospitals provide care for underserved populations, and they are experiencing a disproportionate burden of the financial penalties imposed for early readmission.

“As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care,” according to the Harvard investigators (Circ. Cardiovasc. Qual. Outcomes 2011;4:53-9).

Dr. Desai reported serving as a consultant to 5AM Ventures, AtCor Medical, Novartis, and St. Jude Medical.

[email protected]

SNOWMASS, COLO. – The 12-lead Holter monitor is an invaluable and underutilized tool for turning cardiac resynchronization therapy nonresponders into responders, according to Dr. N.A. Mark Estes III.

“The Achilles heel of CRT right now is the failure to respond that occurs in one-quarter to one-third of patients who receive the device. And I think it’s less and less due to a problem of poor patient selection or technical failure, but instead due to common mistakes made in patients who’ve been properly selected and in whom a CRT device has been placed appropriately. I think there’s a lot of room for improvement here,” said Dr. Estes, director of the cardiac arrhythmia center and professor of medicine at Tufts University in Boston.

One common mistake is to accept at face value the CRT device counter when it shows a high percentage of ventricular pacing that’s supposed to be indicative of adequate biventricular pacing in patients. That’s not reliable in patients with coexisting heart failure and atrial fibrillation. In fact, the device pacing counter can markedly overestimate the degree of effective biventricular pacing in patients with permanent atrial fibrillation undergoing CRT. That’s because it may incorrectly count fusion and pseudofusion beats as paced events, even though ventricular capture and atrioventricular resynchronization fail to occur during such beats. The 12-lead Holter monitor will tell the real story regarding ventricular rate control and the percentage of fully paced beats, Dr. Estes said at the Annual Cardiovascular Conference at Snowmass.

“In patients with atrial fibrillation, you can’t just do an EKG, and you can’t just do an interrogation of the device and see that they have 90% or 95% biventricular pacing, which is the sweet spot you need to be North of to make sure they’re having benefit. You really need to do the 24-hour Holter monitor,” the cardiologist emphasized.

“It happens all the time,” he continued. “It happens in my own institution, where we have people come in with heart failure who are being evaluated for an LVAD [left ventricular assist device] because when their CRT device is interrogated, it shows 95% pacing. Everyone’s getting ready to put in the LVAD, and we put them on a Holter monitor and guess what? They’re 60% paced. And sometimes you can have dramatic – really dramatic – improvements by just slowing the ventricular response.”

Increasingly, however, he and his fellow electrophysiologists are alternatively turning to atrioventricular junction ablation in suitable candidates for the catheter-based procedure in order to improve their clinical response to CRT.

Dr. Estes cited a study by Columbia University cardiologists as being highly influential in shaping the new understanding of how to use 12-lead Holter monitoring to identify patients with atrial fibrillation who aren’t responding to CRT. They studied 19 patients with permanent atrial fibrillation who were on CRT, all of whom were on beta-blockers, amiodarone, and digoxin for rate control. Although device interrogation showed all 19 patients had in excess of 90% biventricular pacing 12 months after CRT implantation, only 9 patients were actually clinical responders to CRT as defined by at least a 1-grade improvement in New York Heart Association functional class.

Upon wearing an ambulatory 12-lead Holter monitor for 24 hours, only the nine patients with clinical improvement in response to CRT actually had effective pacing; 94% of their heart beats over the course of 24 hours were fully paced, with a mere 2% fusion beats and less than 4% pseudofusion beats. The other 10 patients had an average of only 60% fully paced beats, along with 16% fusion and 24% pseudofusion beats.

The CRT clinical responders also showed evidence of reverse remodeling, with significantly greater improvements in left ventricular ejection fraction, end-systolic dimension, end-diastolic diameter, and end-systolic and end-diastolic volume, compared with nonresponders.

The lesson, according to the investigators, is that the percentage of biventricular pacing, as obtained from CRT device interrogation, is an unreliable indicator of effective pacing in patients with permanent atrial fibrillation. The goal of CRT programming in this population is to try to achieve 100% biventricular capture on the 12-lead Holter monitor (J. Am. Coll. Cardiol. 2009;53:1050-5).

A series of landmark randomized trials has established that in suitable candidates for CRT with NYHA class I through ambulatory class IV heart failure with reduced ejection fraction, the device therapy provides on average about a 17% reduction in all-cause mortality and a 29% decrease in hospitalizations for heart failure above and beyond the benefits obtained through guideline-directed medical therapy. However, the improvements seen in patients with NYHA class I symptoms are less impressive than in those with NYHA class II-IV disease. And it’s possible that the randomized controlled trials overestimate the true benefit from CRT.

“This is a group of extremely experienced investigators who know the literature well. They’re typically quite savvy with patient selection, and they’re vested in getting the right patients into these trials. Unfortunately, there’s not a registry of all eligible patients, so we can’t tell exactly how those patients were selected. It would have been helpful,” Dr. Estes said.

It’s clear from the randomized trials that the ideal patient for CRT is a woman under age 65 with nonischemic cardiomyopathy with a left bundle branch block, normal sinus rhythm, and a QRS duration of 150 milliseconds or more. That’s who’s most likely to obtain clinical benefit from the therapy. The flip side of that is that an older male patient with ischemia, atrial fibrillation, a QRS of 120-150 milliseconds, and non–left bundle branch block is less likely to respond.

“We’ve figured this out. I think we’ve gotten pretty good at giving patients an honest estimate of their probability of responding independent of our ability to get a lead into a good spot in the coronary sinus,” Dr. Estes said. “More than 95% of patients can be adequately resynchronized currently with the tools we have, so it’s not the barrier that it once represented. We have many different techniques available.”

Despite intensive efforts by investigators using sophisticated nuclear studies, echocardiography, and MRI, however, nothing to date has been able to predict who’s going to respond to CRT as well as a simple electrical parameter: the QRS duration.

“It remains really the gold standard. It’s an electrical marker for what is a mechanical event,” Dr. Estes said.

He reported serving as a consultant to Medtronic, St. Jude Medical, and Boston Scientific and receiving research support from Boston Scientific and St. Jude Medical.

[email protected]

SNOWMASS, COLO. – The 12-lead Holter monitor is an invaluable and underutilized tool for turning cardiac resynchronization therapy nonresponders into responders, according to Dr. N.A. Mark Estes III.

“The Achilles heel of CRT right now is the failure to respond that occurs in one-quarter to one-third of patients who receive the device. And I think it’s less and less due to a problem of poor patient selection or technical failure, but instead due to common mistakes made in patients who’ve been properly selected and in whom a CRT device has been placed appropriately. I think there’s a lot of room for improvement here,” said Dr. Estes, director of the cardiac arrhythmia center and professor of medicine at Tufts University in Boston.

One common mistake is to accept at face value the CRT device counter when it shows a high percentage of ventricular pacing that’s supposed to be indicative of adequate biventricular pacing in patients. That’s not reliable in patients with coexisting heart failure and atrial fibrillation. In fact, the device pacing counter can markedly overestimate the degree of effective biventricular pacing in patients with permanent atrial fibrillation undergoing CRT. That’s because it may incorrectly count fusion and pseudofusion beats as paced events, even though ventricular capture and atrioventricular resynchronization fail to occur during such beats. The 12-lead Holter monitor will tell the real story regarding ventricular rate control and the percentage of fully paced beats, Dr. Estes said at the Annual Cardiovascular Conference at Snowmass.

“In patients with atrial fibrillation, you can’t just do an EKG, and you can’t just do an interrogation of the device and see that they have 90% or 95% biventricular pacing, which is the sweet spot you need to be North of to make sure they’re having benefit. You really need to do the 24-hour Holter monitor,” the cardiologist emphasized.

“It happens all the time,” he continued. “It happens in my own institution, where we have people come in with heart failure who are being evaluated for an LVAD [left ventricular assist device] because when their CRT device is interrogated, it shows 95% pacing. Everyone’s getting ready to put in the LVAD, and we put them on a Holter monitor and guess what? They’re 60% paced. And sometimes you can have dramatic – really dramatic – improvements by just slowing the ventricular response.”

Increasingly, however, he and his fellow electrophysiologists are alternatively turning to atrioventricular junction ablation in suitable candidates for the catheter-based procedure in order to improve their clinical response to CRT.

Dr. Estes cited a study by Columbia University cardiologists as being highly influential in shaping the new understanding of how to use 12-lead Holter monitoring to identify patients with atrial fibrillation who aren’t responding to CRT. They studied 19 patients with permanent atrial fibrillation who were on CRT, all of whom were on beta-blockers, amiodarone, and digoxin for rate control. Although device interrogation showed all 19 patients had in excess of 90% biventricular pacing 12 months after CRT implantation, only 9 patients were actually clinical responders to CRT as defined by at least a 1-grade improvement in New York Heart Association functional class.

Upon wearing an ambulatory 12-lead Holter monitor for 24 hours, only the nine patients with clinical improvement in response to CRT actually had effective pacing; 94% of their heart beats over the course of 24 hours were fully paced, with a mere 2% fusion beats and less than 4% pseudofusion beats. The other 10 patients had an average of only 60% fully paced beats, along with 16% fusion and 24% pseudofusion beats.

The CRT clinical responders also showed evidence of reverse remodeling, with significantly greater improvements in left ventricular ejection fraction, end-systolic dimension, end-diastolic diameter, and end-systolic and end-diastolic volume, compared with nonresponders.

The lesson, according to the investigators, is that the percentage of biventricular pacing, as obtained from CRT device interrogation, is an unreliable indicator of effective pacing in patients with permanent atrial fibrillation. The goal of CRT programming in this population is to try to achieve 100% biventricular capture on the 12-lead Holter monitor (J. Am. Coll. Cardiol. 2009;53:1050-5).

A series of landmark randomized trials has established that in suitable candidates for CRT with NYHA class I through ambulatory class IV heart failure with reduced ejection fraction, the device therapy provides on average about a 17% reduction in all-cause mortality and a 29% decrease in hospitalizations for heart failure above and beyond the benefits obtained through guideline-directed medical therapy. However, the improvements seen in patients with NYHA class I symptoms are less impressive than in those with NYHA class II-IV disease. And it’s possible that the randomized controlled trials overestimate the true benefit from CRT.

“This is a group of extremely experienced investigators who know the literature well. They’re typically quite savvy with patient selection, and they’re vested in getting the right patients into these trials. Unfortunately, there’s not a registry of all eligible patients, so we can’t tell exactly how those patients were selected. It would have been helpful,” Dr. Estes said.

It’s clear from the randomized trials that the ideal patient for CRT is a woman under age 65 with nonischemic cardiomyopathy with a left bundle branch block, normal sinus rhythm, and a QRS duration of 150 milliseconds or more. That’s who’s most likely to obtain clinical benefit from the therapy. The flip side of that is that an older male patient with ischemia, atrial fibrillation, a QRS of 120-150 milliseconds, and non–left bundle branch block is less likely to respond.

“We’ve figured this out. I think we’ve gotten pretty good at giving patients an honest estimate of their probability of responding independent of our ability to get a lead into a good spot in the coronary sinus,” Dr. Estes said. “More than 95% of patients can be adequately resynchronized currently with the tools we have, so it’s not the barrier that it once represented. We have many different techniques available.”

Despite intensive efforts by investigators using sophisticated nuclear studies, echocardiography, and MRI, however, nothing to date has been able to predict who’s going to respond to CRT as well as a simple electrical parameter: the QRS duration.

“It remains really the gold standard. It’s an electrical marker for what is a mechanical event,” Dr. Estes said.

He reported serving as a consultant to Medtronic, St. Jude Medical, and Boston Scientific and receiving research support from Boston Scientific and St. Jude Medical.

[email protected]

SNOWMASS, COLO. – The 12-lead Holter monitor is an invaluable and underutilized tool for turning cardiac resynchronization therapy nonresponders into responders, according to Dr. N.A. Mark Estes III.

“The Achilles heel of CRT right now is the failure to respond that occurs in one-quarter to one-third of patients who receive the device. And I think it’s less and less due to a problem of poor patient selection or technical failure, but instead due to common mistakes made in patients who’ve been properly selected and in whom a CRT device has been placed appropriately. I think there’s a lot of room for improvement here,” said Dr. Estes, director of the cardiac arrhythmia center and professor of medicine at Tufts University in Boston.

One common mistake is to accept at face value the CRT device counter when it shows a high percentage of ventricular pacing that’s supposed to be indicative of adequate biventricular pacing in patients. That’s not reliable in patients with coexisting heart failure and atrial fibrillation. In fact, the device pacing counter can markedly overestimate the degree of effective biventricular pacing in patients with permanent atrial fibrillation undergoing CRT. That’s because it may incorrectly count fusion and pseudofusion beats as paced events, even though ventricular capture and atrioventricular resynchronization fail to occur during such beats. The 12-lead Holter monitor will tell the real story regarding ventricular rate control and the percentage of fully paced beats, Dr. Estes said at the Annual Cardiovascular Conference at Snowmass.

“In patients with atrial fibrillation, you can’t just do an EKG, and you can’t just do an interrogation of the device and see that they have 90% or 95% biventricular pacing, which is the sweet spot you need to be North of to make sure they’re having benefit. You really need to do the 24-hour Holter monitor,” the cardiologist emphasized.

“It happens all the time,” he continued. “It happens in my own institution, where we have people come in with heart failure who are being evaluated for an LVAD [left ventricular assist device] because when their CRT device is interrogated, it shows 95% pacing. Everyone’s getting ready to put in the LVAD, and we put them on a Holter monitor and guess what? They’re 60% paced. And sometimes you can have dramatic – really dramatic – improvements by just slowing the ventricular response.”

Increasingly, however, he and his fellow electrophysiologists are alternatively turning to atrioventricular junction ablation in suitable candidates for the catheter-based procedure in order to improve their clinical response to CRT.

Dr. Estes cited a study by Columbia University cardiologists as being highly influential in shaping the new understanding of how to use 12-lead Holter monitoring to identify patients with atrial fibrillation who aren’t responding to CRT. They studied 19 patients with permanent atrial fibrillation who were on CRT, all of whom were on beta-blockers, amiodarone, and digoxin for rate control. Although device interrogation showed all 19 patients had in excess of 90% biventricular pacing 12 months after CRT implantation, only 9 patients were actually clinical responders to CRT as defined by at least a 1-grade improvement in New York Heart Association functional class.

Upon wearing an ambulatory 12-lead Holter monitor for 24 hours, only the nine patients with clinical improvement in response to CRT actually had effective pacing; 94% of their heart beats over the course of 24 hours were fully paced, with a mere 2% fusion beats and less than 4% pseudofusion beats. The other 10 patients had an average of only 60% fully paced beats, along with 16% fusion and 24% pseudofusion beats.

The CRT clinical responders also showed evidence of reverse remodeling, with significantly greater improvements in left ventricular ejection fraction, end-systolic dimension, end-diastolic diameter, and end-systolic and end-diastolic volume, compared with nonresponders.

The lesson, according to the investigators, is that the percentage of biventricular pacing, as obtained from CRT device interrogation, is an unreliable indicator of effective pacing in patients with permanent atrial fibrillation. The goal of CRT programming in this population is to try to achieve 100% biventricular capture on the 12-lead Holter monitor (J. Am. Coll. Cardiol. 2009;53:1050-5).

A series of landmark randomized trials has established that in suitable candidates for CRT with NYHA class I through ambulatory class IV heart failure with reduced ejection fraction, the device therapy provides on average about a 17% reduction in all-cause mortality and a 29% decrease in hospitalizations for heart failure above and beyond the benefits obtained through guideline-directed medical therapy. However, the improvements seen in patients with NYHA class I symptoms are less impressive than in those with NYHA class II-IV disease. And it’s possible that the randomized controlled trials overestimate the true benefit from CRT.

“This is a group of extremely experienced investigators who know the literature well. They’re typically quite savvy with patient selection, and they’re vested in getting the right patients into these trials. Unfortunately, there’s not a registry of all eligible patients, so we can’t tell exactly how those patients were selected. It would have been helpful,” Dr. Estes said.

It’s clear from the randomized trials that the ideal patient for CRT is a woman under age 65 with nonischemic cardiomyopathy with a left bundle branch block, normal sinus rhythm, and a QRS duration of 150 milliseconds or more. That’s who’s most likely to obtain clinical benefit from the therapy. The flip side of that is that an older male patient with ischemia, atrial fibrillation, a QRS of 120-150 milliseconds, and non–left bundle branch block is less likely to respond.

“We’ve figured this out. I think we’ve gotten pretty good at giving patients an honest estimate of their probability of responding independent of our ability to get a lead into a good spot in the coronary sinus,” Dr. Estes said. “More than 95% of patients can be adequately resynchronized currently with the tools we have, so it’s not the barrier that it once represented. We have many different techniques available.”

Despite intensive efforts by investigators using sophisticated nuclear studies, echocardiography, and MRI, however, nothing to date has been able to predict who’s going to respond to CRT as well as a simple electrical parameter: the QRS duration.

“It remains really the gold standard. It’s an electrical marker for what is a mechanical event,” Dr. Estes said.

He reported serving as a consultant to Medtronic, St. Jude Medical, and Boston Scientific and receiving research support from Boston Scientific and St. Jude Medical.

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