bluuebunny/crossref_metadata_2025 huggingface dataset:
Prediction of atrial fibrillation in patients with embolic stroke with undetermined source using electrocardiogram deep learning algorithm and clinical risk factors
Authors: Lee J H , Kwon J , Lee M S , Cho Y , Oh I Y , Park J , Jeon K H
Published: October 2022

Background

Combining the artificial intelligence algorithm with the known clinical risk factors may provide enhanced accuracy for prediction of the hidden atrial fibrillation (AF) in patients with embolic stroke with undetermined source (ESUS).

Purpose

We aimed to develop enhanced prediction models for AF with deep learning algorithm (DLA) and clinical predictors in patients with ESUS. The DLA was created to identify the patients with paroxysmal AF based on their electrocardiograms (ECG) during sinus rhythm.

Methods

We analyzed the 221 patients who underwent insertable cardiac monitor (ICM) for AF detection following ESUS. The DLA was previously developed with sinus rhythm ECGs of 10,605 paroxysmal AF patients and 50,522 non-AF patients. The convolutional neural network was used for the DLA. The primary endpoint was defined as any AF episode lasting over 5 min by ICM. The atrial ectopic burden (AEB) was calculated as the percentage of the number of conducted QRS by atrial ectopy on Holter monitoring.

Results

AF (≥5 min) was detected by ICM in 32 patients (14.5%) during follow-up period of 15.1±8.6 months. AF patients had higher AEB (0.199% vs 0.023%, p<0.001), larger left atrial diameters (LAD, 41.2 mm vs 35.7 mm, p<0.001), and larger left atrial volume index (LAVI, 46.4 ml/m2 vs 32.3 ml/m2, p<0.001) than those without AF. The means of calculated probabilities of AF by DLA were higher in patients with AF than those without AF (63.8% vs 40.2%, p<0.001). In the receiver operating characteristic curve analysis, the areas under the curve (AUC) were the highest in DLA (0.824) followed by AEB (0.784), LAVI (0.780), and LAD (0.768). The multivariable model with AEB, LAVI, and DLA demonstrated excellent prediction accuracy for paroxysmal AF (AUC: 0.902, Figure 1)

Conclusions

In patients with ESUS, the DLA outperformed other clinical risk factors for prediction of AF. Combining DLA with AEB, LAD and LAVI could is a potential useful tool to predict AF in ESUS patients.

Funding Acknowledgement

Type of funding sources: None.
Clinical risk prediction for left atrial appendage thrombus among patients with atrial fibrillation
Authors: Segan L , Nanayakkara S , Spear E , Shirwaiker A , Chieng D , Sugumar H , Ling L H , Prabhu S , Lee G , Morton J , Kalman J , Voskoboinik A , Kistler P
Published: October 2022

Background

Exclusion of left atrial appendage thrombus (LAAT) by transoesophageal echocardiography (TOE) is recommended in patients with inadequate anticoagulation prior to direct cardioversion (DCR) or catheter ablation for atrial fibrillation/flutter (AF/AFL). LAAT risk factors in this population remain poorly defined.

Purpose

Determine LAAT predictors in AF/AFL patients undergoing pre-procedural TOE.

Methods

We evaluated available clinical and transthoracic echocardiographic (TTE) parameters in AF/AFL patients undergoing TOE between 1999–2022 in our institution in Melbourne, Australia. Regression analysis identified predictors of LAAT, which were applied to a weighted score developed in the derivation cohort (70%) and validated in the remaining 30%.

Results

Of 627 patients (age 62±12 years, 27% female, AF 84%,AFL 16%, left ventricular ejection fraction (LVEF) 44±20%), 24% had LAAT and 13.8% dense spontaneous echo contrast precluding DCR. Anticoagulation was NOAC 56.5%, warfarin 32.1% and none in 11.4%. In the LAAT cohort, thrombus resolution occurred in 39% on serial transoesophageal imaging with a median time to resolution of 131 days (IQR 54–398).

Diabetes (p=0.004), prior stroke (p=0.009), coronary disease (p=0.015), renal impairment (p<0.001) and CHADS2VASc >2 (73% vs. 55%, p<0.001) were higher in the LAAT cohort. Age (p=0.093), gender (p=0.689), BMI (p=0.828), anticoagulant type (p=0.316) and diabetes (p=0.107) were not univariate predictors, whereas anticoagulation duration (<30 days), creatinine and TTE markers of remodeling (LVEF, LAVI, RVSP and TAPSE) were independent predictors on univariate and multivariate regression; CHADS2VASc was not significant after adjustment (p=0.090). The weighted risk model included continuous (age, creatinine, LVEF, LAVI, TAPSE and RVSP) and categorical (anticoagulation duration) variables with excellent predictive performance: AUC 0.872 (95% CI 0.798–0.946), PPV 91%, NPV 70% and accuracy 80%.

Conclusion

A novel LAAT risk model comprising clinical and echocardiographic parameters enhances risk prediction over CHADS2VASc in AF/AFL and may guide the need for pre-procedural TOE imaging.

Funding Acknowledgement

Type of funding sources: None.
Risk of stroke and transient ischemic attack after elective cardioversion of atrial fibrillation: a nationwide study in Finland
Authors: Itainen-Stromberg S , Lehto M , Halminen O , Putaala J , Haukka J , Mustonen P , Linna M , Kalatsova K , Aro A , Hartikainen J , Airaksinen K E J
Published: October 2022

Background

Cardioversion is routinely used to restore sinus rhythm in patients with atrial fibrillation (AF). Elective cardioversion (ECV) is associated with an increased risk of thromboembolic complications even during adequate oral anticoagulation (OAC).

Purpose

The aim was to analyze the incidence of ischemic stroke and transient ischemic attack (TIA) after first-ever ECV of AF in patients using guideline-recommended OAC.

Methods

This nationwide register-based study includes all (N=9625) AF patients undergoing their first-ever ECV between 2012 and 2018 in Finland. Data was obtained from the Finnish health care registers, including both primary and special health care. The risk of stroke and TIA within 30 days after ECV were estimated in patients using OAC.

Results

The mean age of patients was 68 (±9.9) years, 61.2% were men, and the mean CHA2DS2-VASc score was 2.6 (±1.6, range 0–9). Warfarin was used in 6245 (64.9%) and non-vitamin K oral anticoagulants in 3380 (35.1%) cardioversions, of which 1453 (15.1%) was rivaroxaban, 1246 (12.9%) apixaban, 635 (6.6%) dabigatran, and 46 (0.5%) edoxaban. Twenty-nine (0.3%; 95% confidence interval [CI] 0.2–0.4%) ischemic strokes or TIAs occurred within 30 days after ECV (median 3 days, interquartile range 2.0–8.5) (Figure 1 and Table 1). In warfarin-treated patients experiencing stroke or TIA, the mean INR value before ECV and at the time of stroke or TIA were 2.5 (±0.5) and 2.5 (±0.5), respectively. One of the patients had INR-value <2.0 before ECV and at the time of stroke and one patient had INR value <2.0 before ECV.

Conclusion

In our nationwide study, the rate of stroke and TIA after first-ever ECV was low (0.3%) in all OAC groups.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District
Long-term efficacy and health consumption before and after ablation of AF
Authors: Englund A , Tabrizi F , Scheel S
Published: October 2022

Background

Atrial fibrillation (AF), the most common arrhythmia worldwide, is associated with increased morbidity and mortality. Catheter ablation of AF is the most effective treatment option for symptomatic patients. The long-term efficacy is however not very well studied nor is health consumption before and after an ablation of atrial fibrillation.

Purpose

To study the long-term efficacy and health consumption before and after an ablation of AF in 1453 consecutive patients undergoing ablation in our institution.

Methods

Consecutive patients undergoing radiofrequency ablation for AF were included prospectively. 4 mm irrigated ablation (Biosense Webster) catheters and Carto® were used for all procedures. After a mean period of 4 years a survey measuring arrhythmia symptoms was sent out to all patients who were treated with an ablation of AF between 1st of January 2010 and 31st of December 2016. Data was collected from local registries, the national registry for catheter ablations and the national health registry. Health consumption measured as in-hospital visits two years before and after the procedure was assessed.

Results

877 (72.7%) patients had no further symptomatic arrhythmia four years after the procedure. Among the 329 patients who still reported symptoms 237 (72%) had milder, 65 (20%) had unchanged and 20 (8%, 1.3% of total) had worsened symptoms after e ablation.

The total number of in-hospital visits 2 years before and after the ablation was 4067. There were 2594 in-hospital visits before and 1473 after the ablation, a decrease by 43%. The majority of the these were arrhythmia related, 2264 and 908, respectively, a decrease by 60%. Seven patients had a stroke before the ablation and five after. The median length of stay was 1 day both before and after the ablation.

Conclusion

Health consumption is significantly decreased after an ablation for AF. The long-term effect is good with freedom of symptomatic AF of approximately 70% after four years.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Biosense Webster Inc
Prediction of difficulty in cryoballoon ablation with a 3D deep learning model using polygonal mesh representation
Authors: Nakasone K , Nishimori M , Kiuchi K , Shinohara M , Fukuzawa K , Takami T , Nakamura T , Sonoda Y , Takahara H , Yamamoto K , Suzuki Y , Tani K , Iwai H , Nakanishi Y , Hirata K
Published: October 2022

Background

Cryoballoon ablation (CBA) is a useful treatment for pulmonary vein isolation (PVI). Some cases, however, are difficult to treat and may require multiple freezing procedures and/or touch-up ablation. Although several predictors of CBA difficulty have been reported, no report has been able to assess the spatial location and morphology of the left atrium (LA) and pulmonary veins (PVs). A polygonal mesh is a collection of vertices, edges, and faces that defines the shape of a polyhedral object, and is able to represent a spatial location with a small amount of information. We hypothesized that a deep learning model that learns mesh representation datasets could more accurately detect the CBA difficulty and that we could establish a novel evaluation method in CBA.

Purpose

The aim of this study was to create a model to predict CBA difficulty with a 3D deep learning model using polygonal mesh representation.

Methods and results

All the 140 patients who underwent CBA for drug-resistant atrial fibrillation between January 2015 and January 2022 were included. A 28-mm cryoballoon (Arctic Front Advance, Medtronic) was used in all cases. We defined CBA difficulty as requiring a touch-up ablation procedure to create complete PVI. We converted the volume data in DICOM format of the computed tomography images of PVs and LA to obj file format (shown in Figure 1), which supports the definition of the geometry for object surfaces using polygonal meshes. Next, we developed a deep learning model that could learn polygonal meshes and classify whether the CBA required touch-up ablation or not. Only a training dataset is used to train the deep learning model, and finally, a test dataset is used to evaluate the model metrics. The accuracy, area under the ROC curve, recall, precision, and f1-score of the deep learning model using the test dataset was 86.5%, 87.7%, 66.7%, 75.0%, 70.6%, respectively.

Conclusions

We developed a 3D deep learning model that can detect a difficulty in CBA using polygonal mesh representation. By predicting difficult cases in advance, we will be able to develop strategies to increase the success rate.

Funding Acknowledgement

Type of funding sources: None.
Use of an active esophageal cooling device in zero-fluoroscopy settings without intracardiac echocardiography
Authors: Joseph C , Cooper J , Schricker A , Sala D , Woods C
Published: October 2022

Background

Active esophageal cooling is increasingly being utilized during radiofrequency (RF) ablation to achieve pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF). In addition to data showing decreases in severe esophageal injury with active esophageal cooling, placement of a commercially available cooling device can be identified on intracardiac echocardiography (ICE), allowing implementation in zero-fluoroscopy settings. In the case of procedures that do not have ICE available, an alternative method to determine proper placement of an esophageal cooling device is needed in zero-fluoroscopy settings..

Purpose

To describe a large single-center approach to visualizing an active esophageal cooling device into a 3D mapping system.

Methods

We reviewed data on patients treated with RF ablation for PVI procedures over the time frame 1/1/2020 to 12/31/21. Active esophageal cooling was phased in towards the end of 2020. For all cases, transseptal puncture was performed with the use of transesophageal echocardiography (TEE). After successful transseptal puncture, the TEE probe was removed, and either a single-sensor LET probe or an active esophageal cooling device was placed. For the active cooling device, the distal tip was cut, and an SL-1 (0.032 inch, 150 cm length) guidewire was placed through the central lumen of the cooling device (used for gastric suctioning and enteral feeding). The guidewire was pinned via a pin block to the 3D mapping system (EnSite, Abbott). Unipolar configuration was used to generate a 3D map, which was then visualized during device placement. Placement was confirmed after visualizing the guidewire tip on the 3D map passing below the coronary sinus (Figure 1).

Results

A total of 417 cases were performed over the study timeframe. The mean age of patients was 65±10 years, and 40% were female. A total of 5 complications were recorded (3 pericardial effusions, 1 pseudoaneurysm, and 1 air embolism). A total of 156 patients received LET monitoring, and 261 received active esophageal cooling. The mean procedure length was 109±24 minutes for cases utilizing LET monitoring, and 93±11 minutes for cases utilizing active esophageal cooling. Visualization of the active esophageal cooling device on the cardiac mapping system was possible in all cases.

Conclusions

We describe here the largest series to date utilizing active esophageal cooling in a zero-fluoroscopy, zero-ICE setting. With increasing efforts to reduce fluoroscopy, this approach allows pursuit of zero-fluoroscopy even in systems without the availability of ICE, while maintaining procedural speed and safety.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Attune Medical
Heart failure and the risk of left atrial thrombus formation in patients with atrial fibrillation and atrial flutter: insights from the LATTEE registry
Authors: Wybraniec M , Mizia-Szubryt M , Gawalko M , Uzieblo-Zyczkowska B , Gorczyca-Glowacka I , Kaufmann D , Wojcik M , Hiczkiewicz J , Fijalkowski M , Szymanska A , Haberka M , Michalski B , Tomaszuk-Kazberuk A , Kozinski M , Mizia-Stec K
Published: October 2022

Background

The aim of the study was to evaluate the prevalence of left atrial thrombus (LAT) on transesophageal echocardiography (TEE) in patients with atrial fibrillation and atrial flutter (AF/AFl) with reference to the presence of heart failure (HF) and its subtypes.

Methods

The research is a substudy of multicenter, prospective, observational Left Atrial Thrombus on Transesopahgeal Echocardiography (LATTEE) registry, which comprised 3109 consecutive patients with AF/AFl undergoing TEE prior to direct current cardioversion or catheter ablation. TEE parameters, including presence of LAT, were compared between patients with and without HF, as well as different subtypes of HF, including HF with preserved (HFpEF), mid-range (HFmrEF) and reduced ejection fraction (HFrEF).

Results

HF was diagnosed in 1336 patients (43%). HF patients had higher prevalence of LAT than non-HF patients (12.8% vs. 4.4%, P<0.001). The rate of LAT increased with the more advanced type of systolic dysfunction (HFrEF vs. HFmrEF vs. HFpEF: 20.3% vs. 10.5% vs. 7.4%, P<0.001; Figure 1). Univariate analysis revealed that HFrEF (OR 4.13, 95% CI: 3.13–5.46) but not HFmrEF or HFpEF predicted the presence of LAT. Multivariable logistic regression indicated that left ventricular ejection fraction (unit OR=0.94 per 1%, 95% CI: 0.93–0.95) was an independent predictor of LAT formation. Receiver operator characteristic analysis showed LVEF ≤48% predicted presence of LAT (AUC=0.74, P<0.0001).

Conclusion

The diagnosis of HFrEF, but not HFpEF, confers a considerable risk of LAT presence despite widespread utilization of adequate anticoagulation in the assessed population. TEE should be considered in these patients prior to cardioversion or catheter ablation despite adequate oral anticoagulation.

Funding Acknowledgement

Type of funding sources: None.
Body mass index from the RE-LY trial: further evidence of the obesity paradox
Authors: Jacobs M , Ezekowitz M , Nagarakanti R , Eikelboom J , Khan O , Reiss J , Liu H , McAndrew T , Francese D , Arce J , Brueckmann M , Connolly S , Yusuf S
Published: October 2022

Background

The obesity paradox has been reported in 3 post-hoc analyses evaluating the direct oral anticoagulants (DOAC) against warfarin (W): apixaban (ARISTOTLE), rivaroxaban (ROCKET), and edoxaban (ENGAGE-AF).

Purpose

To evaluate the obesity paradox in a post-hoc analysis of the RE-LY trial, comparing dabigatran 110 mg BID (D110), 150 mg BID (D150), and W by body mass index (BMI).

Methods

Baseline characteristics were evaluated using World Health Organization (WHO) criteria of overweight and obese (BMI ≥25 kg/m2) and under and normal weight (BMI <25 kg/m2). Stroke and systemic embolism, ischemic stroke, major bleeding, mortality, and intracranial hemorrhage were evaluated using BMI as a continuous variable and by the WHO criteria using a cox proportional hazard model.

Results

BMI was available in 99.9% of patients randomized; 74% had a BMI ≥25. At baseline, patients with a BMI ≥25 were younger (70.9 vs 73.1, p<0.001) and had fewer prior strokes (11.5% vs 15.6%, p<0.001), but higher mean creatinine clearance (78.3 vs 57.0, p<0.001) and rates of diabetes (25.8% vs 16.1%, p<0.001) (Table 1). Independent of drug assignment, patients with a BMI ≥25 had lower rates of stroke and systemic embolism (HR 0.65 [95% CI 0.54–0.79], p<0.001), ischemic stroke (0.75 [95% CI 0.60, 0.94], p=0.01), major bleeding (HR 0.79 [95% CI 0.69,0.89], p<0.001), mortality (HR 0.60 [95% CI 0.53, 0.67], p<0.001) and intracranial hemorrhage (HR 0.53 [95% CI 0.38, 0.73], p<0.001) compared to those with a BMI <25. Using BMI as a continuous variable combining all outcomes at 3 years, endpoint rates declined as BMI approached 25 in all 3 treatment groups. The exceptions were intracranial hemorrhage for D110 and D150 and stroke in D150 patients, where rates were low independent of BMI. No significant interaction between BMI and treatment was observed in individual outcomes except for the D110 vs. D150 comparison for major bleeding, in favor of D110 for patients with BMI ≥25 (HR 0.77 [95% CI 0.65, 0.91] and HR 1.12 [95% CI 0.86, 1.47], interaction p=0.0190).

Conclusions

In RE-LY, independent of drug assignment, patients with a higher BMI had improved outcomes, demonstrating the obesity paradox. As BMI increased towards 25, outcome rates improved except for intracranial hemorrhage rates for both D110 and D150 and ischemic stroke rates for D150, which were low independent of BMI. Patients treated with D110 with a BMI ≥25 kg/m2 had significantly lower rates of bleeding compared to D150.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Sharpe Strumia Foundation
Watchman device migration and embolization: a report from the NCDR LAAO registry
Authors: Friedman D , Zimmerman S , Tan Z , Freeman J , Curtis J
Published: October 2022

Background

Incomplete anchoring of the Watchman left atrial appendage closure (LAAO) device can result in substantial device migration or device embolization requiring percutaneous or surgical retrieval.

Purpose

To report rates and characteristics of in-hospital and post-discharge Watchman device migration and embolization events in the United States.

Methods

We performed a retrospective analysis of Watchman procedures (January 2016 through March 2021) reported to the National Cardiovascular Data Registry LAAO Registry. We excluded patients with prior LAAO interventions, no device released, and missing device information. In-hospital events were assessed among all patients and post-discharge events were assessed among patients with 45-day follow-up.

Results

Of 120,278 Watchman procedures, device migration or embolization occurred in 0.07% of patients (n=84) during the index hospitalization and surgery was performed in 39 patients. The in-hospital mortality rate was 14% among patients with device migration or embolization and 20.5% among patients who underwent surgery. In-hospital migration or embolization was more common: at hospitals with a lower median annual procedure volume (24 vs. 41 procedures, p<0.0001), with first-generation Watchman versus next-generation Watchman FLX devices (0.08% vs. 0.04%, p=0.0048), with larger LAA ostia (median 23 mm vs. 21 mm, p=0.004), and with a smaller difference between device and LAA ostial size (median difference 4 mm vs. 5 mm, p=0.04). There were no differences by age, sex, hospital type, hospital size, or teaching versus non-teaching status. Of 98,147 patients with 45-day follow-up, device migration or embolization after discharge occurred in 0.06% (n=54) patients and cardiac surgery was performed in 7.4% (n=4) of cases. The 45-day mortality rate was 3.7% (n=2) among patients with post-discharge device migration or embolization. Post-discharge migration or embolization was more common among men (79.7% of events but 58.9% of all procedures, p=0.0019), taller patients (177.9 cm vs. 172 cm, p=0.0005), and those with greater body mass (99.9 kg vs. 85.5 kg, p=0.0055); in contrast to in-hospital events, there were no differences in hospital volume, device characteristics, or LAA characteristics.

Conclusions

Watchman device migration or embolization is rare but associated with high mortality (Figure 1) and frequently requires surgical retrieval. A substantial proportion of all device migration or embolization cases occur after discharge and different patient and procedure characteristics are associated with in-hospital versus post-discharge cases. Given the morbidity and mortality associated with device migration or embolization, risk mitigation strategies and on-site cardiac surgical back-up are of paramount importance.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health
Importance of bilateral vagus nerve stimulation for effective atrioventricular node denervation during cardioneuroablation
Authors: Stiavnicky P , Wichterle D , Jansova H , Stojadinovic P , Haskova J , Peichl P , Cihak R , Kautzner J
Published: October 2022

Background

The progression of parasympathetic denervation of the atrioventricular node (AVN) during cardioneuroablation (CNA) can be evaluated by extracardiac vagal stimulation (ECVS). The right vagus nerve is usually used for stimulation (R-ECVS) because the right jugular vein is easily accessible. However, the AVN node is predominantly under the control of the left vagus nerve.

Purpose

To highlight the importance of left vagus stimulation (L-ECVS) for effective AVN denervation.

Methods

Both R-ECVS and L-ECVS (frequency: 50 Hz; pulse width: 0.05 ms; output 1 V / 1 kg; max. 70 V, duration 5 s) was attempted in 80 patients (age: 41±12 years, 45% men) undergoing CNA with stepwise strategy consisting of ablation of right anterior ganglionated plexus (RAGP) followed by ablation of posteromedial left ganglionated plexus (PMLGP). The study objective was the AVN response to L-ECVS (evaluated as the max. R-R interval during stimulation train) at the point when AVN non-reactivity to R-ECVS was achieved.

Results

A total of 59 patients were suitable for the analysis. Of the remaining 21 patients, left (n=14) or right (n=2) jugular veins were not accessible, AVN non-reactivity to L-ECVS was achieved before non-reactivity to R-ECVS (n=4), or AVN denervation was not achieved at all (n=1). At baseline, the AVN response was identical for R-ECVS (max. R-R median: 6.9 s, interquartile range [IQR]: 5.7–8.2 s) and L-ECVS (median: 7.1 s, IQR: 6.0–8.3 s), P=0.44. AVN non-reactivity to R-ECVS was present already at baseline (n=2); was achieved after ablation of RAGP (n=14), after ablation PMLGP (n=38), or after extensive ablation (n=5). At the point of AVN non-reactivity to R-ECVS, the response of AVN to L-ECVS was as follows: none (n=25), 2: 1 AV block (n=13) or complete AV block (n=21). The corresponding median of max. R-R interval was: 1.2 s, IQR: 0.6–4.8 s distributed as shown in Figure 1.

Conclusions

In 34/59 (58%) patients, significant AVN response to L-ECVS persists after reaching AVN non-reactivity to R-ECVS. Stimulation of both vagal nerves tightens the procedural endpoint and may increase the clinical efficacy of CNA, especially in patients with dominant AVN disorder.

Funding Acknowledgement

Type of funding sources: None.
Clinical factors affecting survival in patients with D-transposition of the great arteries after atrial switch repair: a meta-analysis
Authors: Nartowicz S , Jakielska E , Cieplucha A , Ratajczak P , Grajek S N , Lesiak M , Trojnarska O
Published: October 2022

Background

Atrial switch repair (AtrSR) was the initial method of operation in patients with D-transposition of the great arteries (D-TGA) constituting the right ventricle as a systemic one. Currently, it has been replaced with arterial switch operation (ASO), but the cohort of adults after AtrSR is still large and requires strict cardiological management of late complications. For this reason, we aimed to evaluate potential long-term mortality risk factors in patients with D-TGA after AtrSR (either Mustard or Senning procedure)

Method

We searched MEDLINE database for suitable trials. We included 22 retrospective and prospective cohort studies of patients with D-TGA with at least 5 years mean/median follow-up time after Mustard or Senning procedure, with an end-point of non-sudden cardiac death (n-SCD) and sudden cardiac death (SCD) after at least 30 days after surgery.

Results

A total of 2912 patients were enrolled, of which 351 met the combined endpoint of n-SCD/SCD. The long-term mortality risk factors were: NYHA>II/heart failure hospitalization (OR=7.25; p=0.0001), tricuspid valve regurgitation (OR=4.64; p=0.0005), Mustard procedure (OR=2.15; p=0.0008), complex D-TGA (OR=2.41; p=0.005), right ventricle dysfunction (OR=1.94; p=0.05). Supraventricular arrhythmia (SVT; OR=2.07; p=0.09) and pacemaker implantation (OR=2.37; p=0.29) did not affect long-term survival in this group of patients. In an additional analysis, SVT showed a statistically significant impact on SCD (OR=2.74; p=0.005) but not on n-SCD (OR=1.5; p=0.57).

Conclusions

This meta-analysis identified that at least moderate tricuspid valve regurgitation, NYHA class > II/heart failure hospitalization, right ventricle dysfunction, complex D-TGA and Mustard procedure as risk factors of long-term mortality in patients after AtrSR.

Funding Acknowledgement

Type of funding sources: None.
Fibrosis inhibits ablation lesion formation in muscle tissue
Authors: Mayr M , Lewalter T , Keil A , Kaufmann Y , Tiemann K , Jilek C
Published: October 2022

Introduction

Myocardial fibrosis is a trigger for both atrial and ventricular arrhythmia. Ventricular fibrosis correlates with ventricular tachycardia, ventricular fibrillation, and sudden death. Besides medical therapy, radiofrequency (RF) ablation is an important therapeutical option to treat ventricular arrhythmia. Our study gains insights into effectivity of RF ablation depending on the degree of fibrosis.

Methods

Using a wet lab, we created with radiofrequency (RF) ablation lesions in parts of restructured beef with a defined, homogenous content of 0, 10, 20 and 50% fiber. We calculated the volume of ablation zones (called lesion volume below). Both common ablation modes low-power long-duration (LPLD: 30 W, 30 s) and high-power short-duration (HPSD: 70 W, 10 s) were tested. Lesion volumes of fibrotic beef were compared to lesion volumes of fibrotic-free beef using an ordinary ANOVA. The effect and interaction of fibrosis and ablation mode to the lesion volume was tested by a two-way ANOVA.

Results

Higher degrees of fibrosis create smaller lesion volumes (M = mean volume ablation zone): M (0%) = 322 mm3 (SD 187 mm3), M (10%) = 226 mm3 (SD 94.8), M (20%) = 217 mm3 (SD 103 mm3) and M (50%) = 186 mm3 (SD 92.7 mm2). Lesion volumes in fibrotic tissue differ significantly from lesion volumes in fibrotic-free tissue (F(3,124) = 6.94, p<0.001). There is a significant difference in lesion volumes for all degrees of fibrosis compared to fibrosis-free tissue (MD = mean difference of ablation zone volumes between 0% fibrosis and 10, 20 and 50% fibrosis): MD (0, 10%) = 95.6 mm3 (95% confidence interval (20.8–170), p=0.008), MD (0, 20%) = 105 mm3 (95% confidence interval (30.4–180), p=0.003) and MD (0, 50%) = 135 mm3 (95% confidence interval (60.7–210), p<0.001). We also found a significant difference in lesion volumes related to the content of fiber in a comparison of all groups (F(3,120) = 7,49, p≪0.001). There is no significant difference in lesion volumes related to the used ablation mode (F(1,120) = 2.89, p=0.09). There is also no significant difference in lesion volumes related to the interaction between the content of fiber and the ablation mode (F(3,120) = 1.23, p=0.3).

Conclusion

Lesions created by RF ablation are influenced by fibrosis. A higher content of fibrosis is associated with smaller lesion volumes. Neither LPLD nor HPSD ablation mode shows an advantage in fibrotic tissue.

Funding Acknowledgement

Type of funding sources: None.
Comparison of septal vs hisian ventricular synchrony in paediatric patients
Authors: Chavez Gutierrez C , Pasarin Tapia M M , Pacheco Lopez S L , Mariona Montero V A
Published: October 2022

Background

Long-term right ventricular stimulation is associated with left ventricular dysfunction and cardiomyopathy, particularly in pediatrics and congenital heart diseases. Research has shown that pacemaker-induced cardiomyopathy can be reversed with stimulation of the Bundle of His in-adult's, however the available information on it's use in pediatrics is scarce. In this study, pacemaker carriers were analyzed over a period of 26 months to set up a protocol for improving the quality of life of patients undergoing this type of procedure.

Introduction

Cardiac stimulation initially arose with the aim of correcting the hemodynamic instability caused by the low cardiac output resulting from complete atrioventricular block, the next objective sought was to obtain atrioventricular synchrony and with it a more physiological functioning. Stimulation in the Bundle of His and the hisian zone induces a physiologically normal sequence of activation and thus prevents damage associated with the asynchronous pattern.

Material and methods

We reviewed 21 pediatric patients with pacemakers of stimulation in the Bundle of His and right septal stimulation that had echocardiographic assessment of ventricular function, as well as the assessment of ventricular synchrony. The study period included was from June 2019 to August 2021.

Results

The total number of patients was 21 of whom 52.4% (11) were carriers of Hisiana stimulation pacemakers, 47.6% (10) with septal pacemakers. Ventricular function was correlated between both groups without obtaining significant relevance. We obtained significant relevance in the evaluation of atrioventricular asynchrony obtaining a P<0.05 (P=0.01), as well as intraventricular synchrony with a P<0. 05 (p=0. 07).

Conclusions

The site of ventricular stimulation is the major determinant of the presentation or deterioration of asynchrony and ventricular function in the pediatric population. With this study we can conclude that the pacemakers of hisian stimulation are the ones that are closest to cardiac physiological activation and maintain ventricular and intraventricular atrio synchrony for a better ventricular function.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Instituto Mexicano del Seguro Social- Centro Medico Nacional de Occidente - UMAE Pediatria.
Conventional single-chamber pacemakers versus transcatheter pacing systems at long-term follow-up
Authors: Gonzalez-Melchor L , Martinez-Sande J L , Garcia-Seara J , Rodriguez-Manero M , Fernandez-Lopez X A , Minguito-Carazo C , Gonzalez T , Gonzalez Juanatey J R
Published: October 2022

Background

Leadless pacemakers systems (LPM), have demonstrated safety and efficacy at mid-long term follow-up. There are still issues that cannot be completely avoided with conventional transvenous pacemaker (VVI) such as infectious or pocket related complications in which LPM are clearly superior.

Purpose

The aim of the study was to compare the clinical and device performance between LPM and VVI in a one-center long-term follow-up.

Methods

This was a prospective, observational, one-center study. We include all patients with a single chamber pacemaker implantation from June 1 2015 to March 1 2022 to complete a long-term follow-up. All clinical, electrical and echocardiographic characteristics, including electrical parameters, complications and mortality, were described.

Results

We included 245 patients with VVI pacemakers and 315 LPM. Mean age was 79.6±6.6 in LPM and 83.5±8.9 y/o in VVI pacemakers. All clinical, electrical and echocardiographic characteristics are described in Table 1. Electrical parameters of LPM were stable at long-term follow-up. There were a total of 7 complications in LPM and 17 in VVI pacemakers (p=0.006). There were no significant differences between major complications but there were in minor complications as shown in Table 2. There were no significant differences in mortality between both groups, but there was one death related to endocarditis in a VVI pacemaker patient during the follow-up (40,3±10 months).

Conclusions

In our study, there were no significant differences in terms of mortality and major complications between LMP and VVI at long-term follow-up. We consider our study supports the results in favor of the safety and effectiveness of LPM in the long-term.

Funding Acknowledgement

Type of funding sources: None.
Rates of implantable cardioverter defibrillator implantation and outcomes in octogenarians or older compared to non-octogenarians in a statewide cohort from 2009 to 2018
Authors: Vijayarajan V , Hsu A , Cheng Y Y , Wei M S S , Sy R , Chow V , Hyun K , Brieger D , Kritharides L , Ng A C C
Published: October 2022

Background

Octogenarians are underrepresented or excluded in major implantable cardioverter defibrillator (ICD) trials. The deployment of ICDs and their real-world outcomes in octogenarians is unclear.

Purpose

To investigate the prevalence and outcomes of ICD implantation in octogenarian or older vs non-octogenarian.

Methods

We extracted details of all ICD implanted statewide from 2009–2018 including patient's characteristics, in-hospital complications and mortality using the Centre-for-Health-Record-Linkage administrative datasets. Implantation rates were adjusted for the population size by sex, age-groups in decade and calendar-year. Analysis was stratified by age <80 vs ≥80yo.

Results

There were 9304 admissions (12.1% ≥80yo) for de novo ICD implantation (mean±SD implantation: 1163±122 cases per-annum). The mean age for ≥80 vs <80yo groups was 83.5±2.9yo vs 66.2±12.1yo respectively (overall cohort mean age 66.1±13.1yo). Total ICD implantations increased by 8.4±12.4% vs 1.8±8.4% per-annum for ≥80 vs <80yo groups. The mean implantation rates were 52.7±10.8 vs 22.0±2.8 per-100,000-persons in ≥80yo compared to <80yo, respectively, with rates increasing at 7.7±18.3% per-100,000-persons-per-annum in ≥80yo. In contrast, implantation rates declined slightly by 0.2±12.4% per-100,000-persons-per-annum in <80yo groups. There was a non-significant trend towards more in-hospital non-fatal complications in ≥80yo compared to <80yo (10.8% vs 9.0% respectively, p=0.054), with no difference in in-hospital mortality (0.6% vs 0.4% respectively, p=0.32). The 1-year mortality was 10.7% in ≥80yo compared to 4.7% in <80yo (p<0.001), and 2-year mortality was 20.2% vs 8.8% respectively (p<0.001). The 1-yr and 2-yr mortality hazard ratio for ≥80yo was 2.0 (95% confidence interval [CI] 1.6–2.5, p<0.001) and 2.2 (95% CI 1.8–2.5, p<0.001) respectively after adjusting for sex, year of implantation, referral source, indications for ICD, and comorbidities. Overall, the annual rates of total in-hospital non-fatal complications and mortality did not alter significantly during the study period.

Conclusion

Despite limited clinical trials data on efficacy of ICD use in octogenarians or older, implantation rate was more than double that of <80yo age-groups, with the implantation rate observed to be increasing in ≥80yo. There was no significant difference in in-hospital mortality between the two age-groups, however the 1-year and 2-year mortality rates were significantly higher in the ≥80yo.

Funding Acknowledgement

Type of funding sources: None.
The role of trigger factors in the occurrence of appropriate ICD shocks and their prognostic implications
Authors: Kleemann T , Lampropoulou E , Kouraki K , Strauss M , Fendt A , Mohammad O , Zahn R
Published: October 2022

Background

The role of triggers in the occurrence of appropriate ICD shocks due to ventricular tachyarrhythmias is not well known. The aim of the study was to assess the prevalence of trigger factors in appropriate ICD shocks and to analyze their prognostic impact on clinical outcome.

Methods

A total of 710 consecutive patients of a prospective single-centre ICD-registry who received a first appropriate ICD shock between 2000 and 9/2021 were analyzed.

Results

In 35% of ICD patients with first ICD shock, at least one of the following triggers was found: Ischemia (22%), Compliance (9%), Decompensation (38%), Stress (12%), Technical (5%), Electrolyte/endocrinological disorder (22%) and Medication intoxication (4%) (Table 1). The trigger factors can be summarized under the acronym ICD-STEMi. Patients with trigger associated ICD shocks had a more depressed ejection fraction and presented more often with ventricular fibrillation or electrical storm. The therapy after VT/VF shock in the trigger group comprised trigger optimization in 100% and heart failure optimization in 21% as compared to 0% respectively 10% in the no-trigger group (p<0.001). The ventricular arrhythmia therapy (antiarrhythmics or VT ablation) was not different between both groups (35% in each group). Patients with triggered first ICD shock had an increased 5-year mortality rate (50% versus 38%, p<0.001) (Figure 1).

Conclusions

In one third of ICD patients with first appropriate ICD shock, at least one trigger can be identified. Finding a trigger strongly influenced therapy after VT/VF shock. Patients with triggered ICD shock have a higher 5-year mortality rate. The evaluation of trigger factors after the occurrence of ICD shocks is mandatory and can be systematically evaluated using the acronym ICD-STEMi.

Funding Acknowledgement

Type of funding sources: None.
Predictors of all-cause mortality for patients undergoing transvenous lead extraction
Authors: Azari A , Kristjansdottir I , Gatti P , Gadler F
Published: October 2022

Background

Risk assessment of TLE patients may be challenging due to incomplete knowledge about possible risk factors for post-TLE outcomes. The aim of this study was to identify predictors of 30-days and 1-year all-cause mortality including the novel parameter frailty in a large retrospective series of patients undergoing TLE at a high-volume centre.

Methods

Medical journals of 893 consecutive patients undergoing TLE between January 1, 2010 and December 31, 2018 were retrogradely analysed. Univariate logistic regression and multivariate analyses were performed to identify risk factors.

Results

A total of 893 patients were identified. Local infection was the dominant indication (41.1%) and pacemaker was the most common device (49.4%). Mean age was 65±16 years and 73.0% were males. The median follow up was 3.9 years (IQR, 4.5 years). Within the systemic infection group, Staphylococcus aureus was the main microorganism in the positive blood cultures (44.4%) and 69.4% of the patients had vegetations. The 30-days and 1 year mortality rates were 2.5% and 9.7%, respectively. Per-procedural mortality occurred in 1 patient. Significant risk factors for 30-days all-cause mortality at univariate analysis were anaemia, systemic infection, clinical frailty scales (CFS) 5–7 and stage 5 chronic kidney disease (CKD). Age, CRT-P/D (vs ICD), reduced ejection fraction, anaemia, BMI <25 kg/m2, CFS 4–7 and CKD stages 3–5 were identified as significant predictors of 1-year all-cause mortality. Within the systemic infection subgroup, leucocytosis and white blood cell count (WBC) 8.8–15x109/L were associated with significant 30-days and 1-year all-cause mortality and CRP 200–300 mg/L and low WBC count correlated with 1-year all-cause mortality. Local infection patients with CRP 100–150 mg/L had an elevated risk for 1-year all-cause mortality. Multivariate analysis identified CKD 5, CFS 5–7 and systemic infection for 30-days all-cause mortality and age, CKD 5, CFS 5–7, systemic infection and BMI <25 kg/m2 for 1-year all-cause mortality as independent risk factors.

Conclusions

Patient-related characteristics, comorbidities and systemic infection independently predicted worse post-TLE prognosis. Several parameters need to be considered when assessing patients for TLE in order to risk stratify the patients and optimize the post-TLE care. Frailty is a novel parameter with significant influence on short and long-term outcome.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Internal funding
Effect of proton radiation therapy on cardiovascular implantable electronic devices [CIED]
Authors: Gumuser E , Sharif Z , Ho R , Allison J , Aitelli A , Bussiere M , Shih H , Mela T
Published: October 2022

Background

The number of cancer patients with CIED receiving radiotherapy has increased dramatically with improving life expectancy in both patients with cardiovascular disease and cancer. The advent of proton therapy adds new concern for potential malfunction in CIED devices, both due to significant neutron scatter and its use of strong magnets to focus radiation beams. Therefore, we aimed to assess the incidence of CIED malfunction secondary to proton therapy in this patient cohort.

Methods

We retrospectively analyzed patients with CIED undergoing proton therapy at our institute between 2011–2021. Each device was programmed pre-treatment and monitored post-treatment according to a special protocol developed in our centre. Treatments were prescribed to doses up to 70 Gy (RBE) and delivered using either passive-scattering or pencil beam techniques. Distances between the CIED and treated volumes ranged from 10–50 cm. We analyzed baseline patient demographics, CIED demographics, CIED outcomes pre-proton therapy as well as post-proton therapy including device reset and requirement for replacement, analyzing up to most recent check.

Results

Fifty-one patients with CIED underwent proton therapy during the study period. Estimated neutron dose ranged from 0.05–2.0 mSv/GyRBE for this patient cohort. Baseline demographics outlines in table 1. Of note 26/51 patients underwent proton therapy for ophthalmic malignancies, 6/51 for brain/skull malignancies. CIED comprised of 39 pacemakers and 12 implantable cardioverter defibrillators. Fourteen patients were pacemaker-dependent. Using 95% Confidence Interval, ventricular threshold, impedance, and amplitude, as well as atrial threshold and amplitude were unchanged, whereas atrial impedance measurements had a change pre- and post-proton therapy (Table 2). No patients had a device reset. One patient had a premature battery depletion three months post-radiotherapy for pancreatic cancer.

Conclusions

Our findings suggest that proton therapy does not significantly impact CIED function. Whilst caution remains as further data is accrued, close monitoring, particularly with the advent of remote monitoring, of these patients should be recommended.

Funding Acknowledgement

Type of funding sources: None.
Cardiac sodium/hydrogen exchanger (NHE11) as a novel potential target for SGLT2i in heart failure
Authors: Perez-Carrillo L , Gimenez-Escamilla I , Feijoo-Bandin S , Lago F , Gonzalez-Juanatey J R , Martinez-Dolz L , Portoles M , Tarazon E , Rosello-Lleti E
Published: October 2022

Background

Despite the cardiac benefits of sodium/glucose cotransporter 2 inhibitors (SGLT2i), their basic of action remains unclear. Sodium/hydrogen exchanger (NHE) has been proposed as mechanism of action of SGLT2i, but there are controversies related to its function and expression in heart failure (HF).

Purpose

We hypothesized that sodium transported-related molecules could be altered in human HF and they could be modulated through SGLT2i.

Methods

Transcriptome-level differences in genes involved in sodium transport between HF and control (CNT) were investigated in 36 heart samples with RNA-sequencing technology (HF, n=26; CNT, n=10). In addition, NHE11 and NHE1 protein levels were determined in 80 heart samples (HF, n=70; CNT, n=10) by ELISA assay. Furthermore, the effect of empagliflozin on NHE11 mRNA levels in rat left ventricular tissue (n=22) was studied through RT-qPCR.

Results

We observed alterations in several genes involved in sodium transport. Among them the overexpression in SLC9C2 (p=0.005) and SCL9A1 (p=0.020) genes, which encode the NHE11 and NHE1 proteins, respectively. In addition, cardiac protein levels of these molecules were determined. We found a significant increase in the concentration of NHE11 (p=0.042) and NHE1 (p=0.018) in HF. Moreover, NHE11 levels were correlated with left ventricular diameters. Due to the relevance of NHE11 changes observed, we studied the effect of SGLTi on its expression. NHE11 mRNA levels were reduced in rats treated with empagliflozin (p=0.010).

Conclusions

Our findings show alterations in several sodium transport, reinforce the importance of these channels in HF progression. We described upregulation in NHE11 and NHE1 in HF patients, but only NHE11 correlated with cardiac dysfunction. In addition, the most relevant finding is the change observed in the expression of the unknown NHE11 after treatment with empagliflozin. These results propose NHE11 as a potential target of SGLT2i in cardiac tissue.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Carlos III European Regional Development Fund (ERDF)