49 A case report of cardiac contractility modulation therapy for heart failure treatment in patient with amyloidosis: is to be considered a valid therapeutic option?

Aims Cardiac amyloidosis (CA) is primarily associated with fibril deposits in many cardiac structures, causing biventricular wall thickness and stiffness. CA may result in arrhythmias and particularly in an aggressive form of heart failure (HF). Cardiac contractility modulation (CCM) showed to be a concrete therapeutic option in patients with symptomatic HF despite optimal medical therapy (OMT), with Left Ventricular Ejection Fraction (LVEF) between 25% and 45%, with narrow QRS complex (<130 ms). This case aims to further explore the effectiveness of CCM therapy in a patient affected by concomitant ischaemic cardiomyopathy and CA. Methods and results A 42-year-old man with Chronic HF secondary to both post-ischaemic due to spontaneous coronary artery dissection (SCAD) and post alcoholic dilated cardiomyopathy was hospitalized at our department in February 2020 due to worsening HF (3rd HF hospitalization in the same year). The patient was a NYHA class III, with chronic kidney failure, a narrow QRS complex (100 ms) and a LVEF of 27% with familiar history of sudden death, already implanted with ICD. The patient resulted untreatable with sacubitril/valsartan, as it elicited strong hypotension. During current hospitalization the BNP value was 942.60 pg/ml, and the Quality of Life (QoL) evaluated from Minnesota Living with Heart Failure Questionnaire (MLHFQ) score was 72 points. Moreover, the patient underwent umbilical biopsy that confirmed the presence of amyloidosis. Thus, the CCM therapy device (Optimizer® Smart, Impulse Dynamics) was implanted to try to reduce HF symptoms and hospitalizations. The therapy was programmed for 10 h per day, with delivery of CCM from both septal leads with amplitude of 6.5 V at 20.56 ms pulses duration. Figure 1A and B shows the septal position of leads and a surface ECG with the CCM therapy spike after QRS. The patient significantly improved as early as the first period after implantation. The 10-month in-office FU performed on December 2020 revealed in addition to the absence of new HF hospitalizations, a significant improvement in QoL and HF-symptoms, with a MLWHFQ score of 42, an enhancement to NHYA class II, and even a slight decrease of BNP of 767 pg/ml. The echo exam revealed no significant changes in the EF, with an improvement of global longitudinal strain and no worsening of other haemodynamic parameters. A further FU performed in June 2021 showed continuous improvement of QoL with a MLWHFQ score of 25 e no HF hospitalizations. Conclusions In this patient affected by multiple cardiomyopathies, including CA, CCM therapy proved to improve its QoL with no HF hospital admissions since the implantation. The absence of significant echocardiographic worsening is a positive aspect, considering the patient’s status, the concomitant aetiologies, and the presence of amyloidosis, given its progressive and infiltrative nature.

Occurrence and Persistency of Conduction Disturbances during Transcatheter Aortic Valve Implantation

Background and Objectives: Conduction disturbances such as left bundle branch block (LBBB) and complete atrio-ventricular block (cAVB) are relatively frequent complications following trans-catheter aortic valve implantation (TAVI). We investigated the dynamics of these conduction blocks to further understand luxating factors and predictors for their persistency. Materials and Methods: We prospectively included 157 consecutive patients who underwent a TAVI procedure. Electrocardiograms (ECGs) were obtained at specific time points during the TAVI procedure and at follow-up until at least six months post-procedure. Results: Of the 106 patients with a narrow QRS complex (nQRS) before TAVI, ~70% developed LBBB; 28 (26.4%) being classified as super-transient (ST-LBBB), 20 (18.9%) as transient (T-LBBB) and 24 (22.6%) as persistent (P-LBBB). Risk of LBBB was higher for self-expandable (SE) than for balloon-expandable (BE) prostheses and increased with larger implant depth. During the TAVI procedure conduction disturbances showed a dynamic behavior, as illustrated by alternating kinds of blocks in 18 cases. Most LBBBs developed during balloon aortic valvuloplasty (BAV) and at positioning and deployment of the TAVI prosthesis. The incidence of LBBB was not significantly different between patients who did and did not undergo BAV prior to TAVI implantation (65.3% and 74.2%, respectively (p = 0.494)). Progression to cAVB was most frequent for patients with preexisting conduction abnormalities (5/34) patients) and in patients showing ST-LBBB (6/28). Conclusions: During the TAVI procedure, conduction disturbances showed a dynamic behavior with alternating types of block in 18 cases. After a dynamic period of often alternating types of block, most BBBs are reversible while one third persist. Patients with ST-LBBB are most prone to progressing into cAVB. The observation that the incidence of developing LBBB after TAVI is similar with and without BAV suggests that a subgroup of patients has a substrate to develop LBBB regardless of the procedure.

Efficacy of Cardiac Resynchronization Therapy in Patients with a Narrow QRS Complex

Aims. In the guidelines for cardiac resynchronization therapy (CRT), there is a gap between the Japanese Circulation Society (JCS) criteria, which specify a QRS duration of ≥120 ms, and other countries, with a QRS ≥ 130 ms. The efficacy of CRT remains controversial in patients with a narrow QRS <130 ms. The aims of this study are to evaluate the response to CRT in patients with a narrow QRS and to identify predictors of mortality. Methods. We retrospectively studied 212 patients who received CRT. They were divided into narrow QRS (<130 ms) and wide QRS (≥130 ms) groups. We compared CRT response rates and investigated whether age, gender, baseline New York Heart Association (NYHA) class, ischemic etiology, atrial fibrillation, and ventricular arrhythmias are associated with response and also predictive of mortality. Results. The CRT response rate was not significantly different between the wide QRS group and the narrow QRS group (74.6% versus 77.2%, p = 0.6876), and the response rate in the narrow QRS group was as good as that reported worldwide. NYHA class IV was shown to be a predictor of mortality (HR 9.38, 95% CI 5.35–16.3, p < 0.0001). Conclusions. The present study demonstrated that patients with a narrow QRS complex responded well to CRT. Even with QRS <130 ms, CRT should be tried if no other effective treatment is available.

Reversibility of a High-Grade Atrioventricular Block Treated Homeopathically

Background A 61-year-old female patient requested a homeopathic therapy as an alternative to a pacemaker for a non-acute myocardial infarction, high-grade atrioventricular node block (HG-AVNB) with a narrow QRS complex. Methods Homeopathic Digitalis purpurea (Digitalis) was employed to accelerate the patient's heart rate. Results Digitalis caused within 3 days a pulse rate of about 90 beats per minute (bpm) which is represented on the electrocardiogram (ECG) by an accelerated junctional rhythm (AJR).The AJR compelled seeking a medicine to reduce its rate. Homeopathic Arsenicum album (Arsenicum) reduced its rate and also seemed to have assisted in the unanticipated recovery of the atrioventricular node (AVN). Conclusions This case report represents, an ECG documented case of a medical treatment modality which could be an alternative to pacemakers for patients with a HG-AVNB with a narrow QRS complex. Digitalis has been safe and effective during its 3 and a half year employment.