Introduction: Risk models are greatly needed to target appropriate patients for implantable cardioverter defibrillators (ICDs) in clinical practice for primary prevention of sudden death. Hypothesis: We hypothesized that the Seattle Heart Failure Model (SHFM) for overall survival and the Seattle Proportional Risk Model (SPRM) for proportional risk of arrhythmic death (AD) would identify National Cardiovascular Data Registry (NCDR) ICD Registry patients most likely to have improved survival with versus without an ICD. Methods: SHFM and SPRM scores were determined for patients with and without ICDs (ICD Registry versus a control group derived from the University of Washington Registry, Italian Heart Failure Registry, Swedish Heart Failure Registry, COMET, Val-HeFT, and PRAISE trials). Multivariable Cox proportional hazards regression was used to evaluate adjusted associations of SPRM and SHFM with survival over 5 years from the Social Security Death Index. Results: Among 98,846 patients (87,914 with ICDs and 10,932 without ICDs), increasing SFHM risk was strongly associated with decreased survival (P<0.0001). Compared with patients having a lower SPRM-predicted proportional risk of AD, patients with a higher predicted proportional AD risk had approximately twice the ICD survival benefit (HR 0.602 [95% CI 0.537-0.675] for SPRM quintile 5 versus HR 0.793 [0.736-0.855] for SPRM quintile 1). The ICD-SPRM interaction was highly significant (Figure). The ICD did not improve adjusted survival versus controls in the 25% of patients with higher predicted survival (SHFM < mean) but a lower proportional AD risk (SPRM < mean) (HR 0.921, 95% CI 0.787-1.08, P=0.31); however, survival in patients with opposite findings (SHFM > mean, SPRM > mean) was greatly improved versus controls (HR 0.599, 95% CI 0.530-0.677, P<0.0001). Conclusions: The SHFM and SPRM scores together identify real-world patients most likely to benefit from primary prevention ICD implantation.
Introduction: Among patients with stable coronary artery disease (CAD), the primary goal of percutaneous coronary intervention (PCI) is to improve symptoms and quality of life. It is not known, how...
Abstract Purpose: Percutaneous left atrial appendage (LAA) occlusion is increasingly performed in patients with atrial fibrillation and long-term contraindications for anticoagulation. Our aim was to evaluate the effects of LAA occlusion with the Watchman device on the geometry of the LAA orifice and assess its impact on the adjacent left upper pulmonary vein (LUPV) hemodynamics. Methods: We included 50 consecutive patients who underwent percutaneous LAA occlusion with the Watchman device. Three-dimensional images of LAA pre- and post-device placement were analyzed offline. We measured the LAA orifice diameters in the long axis, and the minimum and maximum diameters, circumference, and area in the short axis view. Eccentricity index was calculated as maximum/minimum diameter ratio. The LUPV peak S and D velocities pre- and post-procedure were also measured. Results: Patients were elderly (mean age 76±8 years years), 30 (60%) were men. There was a significant increase of all LAA orifice dimensions following LAA occlusion: diameter 1 (pre-device 18.1±3.2 vs. post-device 21.5±3.4 mm, p<0.001), diameter 2 (20.6±3.9 vs. 22.1±3.6 mm, p<0.001), minimum diameter (17.6±3.1 vs. 21.3±3.4 mm, p<0.001), maximum diameter (21.5±3.9 vs. 22.4±3.6 mm, p=0.022), circumference (63.6±10.7 vs. 69.6±10.5 mm, p<0.001), and area (3.1±1.1 vs. 3.9±1.2 cm 2 , p<0.001). Eccentricity index decreased after procedure (1.23±0.16 vs. 1.06±0.06, p<0.001). LUPV peak S and D velocities did not show a significant difference (0.29±0.15 vs. 0.30±0.14 cm/s, p=0.637; and 0.47±0.19 vs. 0.48±0.20 cm/s, p=0.549; respectively). Conclusion: LAA orifice stretches significantly and it becomes more circular following LAA occlusion without causing a significant impact on the LUPV hemodynamics.
