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    • Cardiovascular magnetic resonance imaging CMR is recognized

    2019-04-29

    Cardiovascular magnetic resonance imaging (CMR) is recognized as a versatile, safe, and reproducible technique, allowing for accurate structural and functional assessment of the heart. CMR is the gold standard for ejection fraction measurement [15–17]. Considering the technical limitations of other imaging modalities such as 2D echocardiography, this method is particularly useful to measure RVEF [13,16,17].
    Materials and methods
    Results
    Discussion Since the largest ICD clinical trials included patients with a moderately to severely reduced LVEF [2,4,6–8,20], this is also the main criterion in current evidence-based guidelines for ICD implantation [2,4,6,7,21]. However, there is increasing evidence of substantial variability and underutilization of ICD, as well as inappropriate shocks and implant complications [22]. Therefore, there is a need for more accurate risk stratification that enhances the selection of patients who will derive the greatest benefit from ICD therapy, with the ultimate goal to improve patient care and health outcomes in a cost-effective manner. RVSD is as an independent predictor of mortality in patients with rock pathway failure and adverse outcomes after myocardial infarction [10,12,23]. In patients with idiopathic dilated cardiomyopathy, RVEF has also been shown to be an independent predictor of survival [12,24,25], and biventricular involvement represents a typical feature of this disease. In a case control study of 57 ICD patients, Malasana and colleagues identified a higher prevalence of RVSD in the group with ICD shocks than in those who did not have ICD shocks. However, this study included only a small number of patients, and the relationship between the LV and RV was not analyzed [13]. Our study, building on previous work, is the first to analyze the relationship between the LVEF and RVEF in a cohort with a wider range of LVEF values who were considered for ICD implantation. Tabereaux and colleagues demonstrated that RVSD represents a strong predictor of lack of clinical response to cardiac resynchronization therapy (CRT) in patients with heart failure due to left ventricular dysfunction, and should be considered when prescribing CRT [26]. However, this remains unexplored in the ICD population. In arrhythmogenic right ventricular dysplasia [22], RVSD is a major diagnostic criterion, and ICD is an important therapeutic option; however, current guidelines do not contemplate the inclusion of morphologic or functional RV parameters in the decision of ICD implantation [14,27]. A multicenter study of patients with tetralogy of Fallot [23,27] suggested the importance of ICD therapy in preventing sudden death in high-risk patients. In these patients, RV deterioration is an important prognostic indicator. Although in these specific diseases, the RV may be the origin of life-threatening arrhythmia, it is not known whether RV structural and functional parameters may afford additional guidance for ICD placement in the majority of patients who have LV dysfunction. Our study follows previous efforts to investigate the use of CMR in patients considered for ICD implantation. Joshi and colleagues demonstrated the contribution of CMR in the risk stratification of patients receiving an ICD [28]. About 20% of patients considered for ICD implantation were reclassified when studied by CMR as compared with echocardiography. More recently, the extent and heterogeneity of the scar in late gadolinium CMR imaging may predict the outcome [29,30], and have been proposed as additional promising markers to stratify risk in ICD patients [31]. CMR provides more accurate and reproducible measurements of RV volumes and function as compared with 2D echo or nuclear imaging. Our study suggests that RVEF assessment might be another useful parameter in assessing risk stratification of ICD candidates.
    Conclusion
    Disclosures
    Funding
    Conflict of interest
    Introduction The development of a fully automatic pacing system [1,2] is becoming increasingly important in today׳s remote-control era and is driven by the need to both improve patient safety and ensure pacing therapy. Device-based capture detection enables stimulation parameters to be continually adjusted in the ambulatory setting. This allows narrower safety margins to be used and prolongs the life of the device. Many of the follow-up tasks of the pacemaker and implantable cardioverter defibrillator (ICD) are performed routinely and reported automatically by the device itself on the first programmer screen (fast-path). These tasks include measuring battery voltage, lead impedance, and sensed electrogram amplitude. Automatic programming adjustments for rate response, mode switching, and atrial–ventricular (AV) interval adaptation are commonplace [3–6]. These data are useful for both in-clinical and remote follow up. This capability was first described by Funke [7] in 1972. Currently, various pacemakers are able to detect ventricular capture automatically, a feature that has yielded benefits [8,9].