ESC TV 2015 – Best of ESC Congress 2015 – Chapter 5: Heart Failure – Arrhythmias

ESC TV 2015 – Best of ESC Congress 2015 – Chapter 5: Heart Failure – Arrhythmias

January 4, 2020 0 By Bertrand Dibbert


In SERVE-HF, 1 325 systolic heart failure patients presenting central
sleep apnea were randomised to receive either adaptive servo-ventilation or
medical management alone median follow-up was 31 months We found actually there was no difference in outcome at all, and, surprisingly, which is taking
both respiratory physicians and cardiologists completely by surprise, we found an increase in mortality and if you look at cardiovascular mortality it was up 34 % so not only does it not make any difference to the patients with systolic heart failure, but it actually increases the risk of them dying, so this is a real game-changer trial, really important 3D printing is entering the area of
valvular imaging and repair as illustrated by the first 3D printed
tricuspid using transthoracic echocardiography We hope that it will facilitate the communication with the surgeons, with the relatives and it also
will hopefully provide us with more insights on the tricuspid valve
pathologies and the hope is that after advancing our understanding, we’ll also be able to project much easier the future percutaneous intervention dedicated for a tricuspid valve
that now are emerging in the field A leadless single pacing pacemaker has
been evaluated in the LEADLESS II study, a non randomised trial in which
300 patients from 56 North American centres has the device transfemorally implanted in the right ventricle Vivek Reddy summarises the key findings 6 months after implantation Number 1, the device can be implanted in 96 % of the patients number 2, there is about a 6.5% rate
of major complications and we expect this to decrease over time, but remember
that 99% of the operators had never performed device implantation before, number 3, the vast majority of patients, once the device is successfully implanted had adequate sensing and pacing over the long term and number 4, the expected longevity of this device is out to 15
plus years MANTRA-PAF study is a randomized comparison of catheter ablation and antiarrhythmic drug therapy as first-line treatment for
paroxysmal atrial fibrillation and 5 years follow-up results were reported in London After 5 years, there was a significantly lower burden of atrial fibrillation in the catheter ablation group than in the drug therapy group, significantly more patients were free from any and symptomatic atrial
fibrillation in the catheter ablation group than in the drug group, and only 3 % in the ablation group and 5% in the drug group had developed persistent
atrial fibrillation, that is very few At 2 years, the patient’s quality of life
scores were significantly better than at baseline in both treatment groups and
with no difference between groups and now after 5 years, still quality of
life is significantly better than at baseline with both treatments and
without any difference from 2 years Well John, were you surprised by the
results of SERVE-HF? How can you explain this increase in mortality? Ok, well the first question is the easy one to answer, yes I was very surprised as I think everybody
was as you know this was a trial of a certain type of assisted ventilation in
central sleep apnea and there is a 30% increase in mortality, can I explain it?
It is very difficult, there are lots of theories, some people believe for example the haemodynamic effects of this ventilation could be detrimental in
patients with severe heart failure that is a possibility, but there is a very
interesting counter theory which is actually central sleep apnea may be a
protective adaption in heart failure and that by countermanding that you make
patients worse, I think we’ll be able to tease this out in heart failure because there is another type of treatment for central sleep apnea which is phrenic nerve
stimulation that is being studied at the moment, that has no haemodynamic effect, so it will sort of tease out whether this was a harmful effect of the ventilation
or whether it was a harmful effect of actually affecting the central nervous
system abnormality I think the messages for physicians here are that you shouldn’t use assisted non-invasive ventilation in patients with central
sleep apnea, but it has still got a very important role to play in the relief of
obstructive sleep apnea and of course we all use CPAP and other forms of assisted ventilation in patients with acute heart failure where we know it is safe from
a large trial called 3CPO and it is effective in relieving symptoms It comes up with a new topic or so, we have been aware or we have concerns about drugs which are lowering in our patients with heart failure and diabetics the glucose level, so did we
get any new information from the studies? being presented at the ESC Congress this year? You are absolutely right, we were very concerned last year following the SAVOR-TIMI 53
results showing that a DPP-4 inhibitor might increase the risk of heart failure,
because of course heart failure is the most diabetogenic state that
there is and anywhere between 30 and 50 percent patients with heart failure,
diagnosed and undiagnosed diabetes, and we need new treatments and this looked like
a promising type of glucose lowering therapy, but then there is this safety
concern, at this meeting, I think those safety concerns were put to rest because a much larger trial called TECOS showed that another DPP-4 inhibitor actually
did not increase the risk of heart failure and there was an additional
study with a different type of increasing based therapy, a GLP-1
analogue, a trial called ELIXA, in acute MI patients, also did not show any concern
about increased risk of heart failure, so I think those concerns have been put to rest Do you want to make any additional comments on this Sanjay? Well, I do yes, it was a non inferior trial, but we should still be punching our arms in the air about this because the situation is that although glycemic control has a very modest effect on the
actual heart, it has got a very significant effect on microvascular complications,
notably retinopathy, nephropathy and of course blindness due to diabetes is the
commonest cause of blindness in the western world and so, in this particular
situation normally people with heart failure have only got insulin or metformin, but only
in a very small number of cases because many of these people have also got
impaired creatinine clearance and therefore metformin is prohibited, so I think the fact that we can now use another oral hypoglycemic agent to prevent
microvascular complications is a very big deal Great, let’s move on to another topic because we had this fantastic new 3D printing of a tricuspid valve, first of all, do we really need it? That will come probably in the future if we really need it, there are already
some experience, for example with congenital heart disease, using CT or CMR, that have much higher spacial resolution to create models where the surgeons can tailor which is the best approach for each patient, and this
is for the first time from transthoracic echocardiography, 3D transthoracic
echocardiography, getting the model of a tricuspid valve Do we need it? We do not know, there is the growing field of transcatheter interventions where we
do not see their structure directly it is different from the surgeons, and where we need, really, a detail anatomical evaluation of the patients, the tricuspid valve is a sort of the forgotten valve sometimes and we have this growing population that has been operated in the past from the left side, from the mitral valve from the aortic valve, that come back again with tricuspid regurgitation and they have a very high risk for surgery and they may be admitted recurrently because of heart failure and now there are evolving new techniques on transcatheter tricuspid repair where this technology of 3D
printing maybe can help us to tailor the treatment of the patient Do you think that it might also apply to the other valves such as the mitral valve because it may help in discussing
with the surgeon having such a tool? There are already some experiences on the communication between the surgeons and the cardiologist on how to treat a patient for example with mitral valve with 3D transaesophageal echocardiography,
that technique already give us a very good information, anatomical information, of the mitral valve, but if, in addition to that, you can print it, you can have it in your hand, you can even imagine that you can print similar tissue characteristics of the mitral valve you can see what happens if you apply certain rings or if you apply certain techniques of application so you
can, for each patient, personalise the treatment that you want So we saw some interesting information at this congress about leadless pacing and, Cecilia my
question to you Leadless, but perhaps needless? Good start, well as a pacemaker doctor I would d like to get rid of leads and the pacemaker pocket because they release complications now we have hopes for the future because there are now two types of leadless pacemaker they are being studied in observational
trials and this is one such of these, LEADLESS II in which 300 patients who were indicated for a VVI device, a very unusual indication in cardiac pacing they were implanted with a 4 cms 5 mm device into the right ventricle and they achieve their goals, they had a high successful
implantation rate in inexperienced implanters who have no previous experience of leadless implantations, they had good pacemaker function, but there were some complications and that is, in my opinion related to the 18 French
introductory sheet that is involved in the placement of this device and we
should may potentially also damage the tricuspid valve, I do not know, but they
report the complication rate which they said was comparable to pacemaker
registry, if you go to the Danish pacemaker registry which is ongoing, the
complications that were serious, such as cardiac perforation and tamponade, are
actually higher in this study than reported in this registry, so it is not free
from complications So an innovation that is on the way, but not quite ready yet and you know the place for single chamber pacing these days is maybe quite limited I would say about 10 % About 10 %, ok, now there has also been
interesting data on the follow-up of AF ablation and the impact, tell us about that? I think most of us when we consider RF ablation in atrial fibrillation patients, we go for trying a
drug first, an antiarrhythmic drug and that goes pretty much with the guidelines, but the MANTRA-PAF trial was interesting in that this
challenged this approach and tried RF ablation versus antiarrhythmic drug as the first line therapy and what they showed over the
5 years is that 15 % more patients in the RF ablation group
were free for any atrial fibrillation and 10 % more were free from symptom related to atrial
fibrillation compared to antiarrhythmic drug arm so I believe it really emphasises that we should perhaps consider RF ablation a little bit earlier than we are currently