bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of bleeding risk scores in patients with atrial fibrillation and cancer
Authors: Pastori D , Marang A , Bisson A , Herbert J , Lip GYH , Fauchier L
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background. Cancer may increase bleeding risk in atrial fibrillation (AF), but the association between cancer type and specific bleeding events has been scarcely investigated. Furthermore, the performance of bleeding risk scores in this high-risk subgroup of patients is unclear.

Purpose. To describe the incidence rate (IR) of major (MB), gastrointestinal (GI) bleeding and intracranial haemorrhage (ICH) according to cancer types. We also investigated the performance of HAS-BLED, ATRIA and ORBIT scores. 

Methods

Observational retrospective cohort study including 399,344 patients with AF and cancer.

Results. Mean age was 77.9 ± 10.2 years and 63.2% were men. During 2.0 years follow-up, the IR of MB was as high as 8.41%/y, GI bleeding was 3.61%/y and ICH 1.33%/y. MBs were more frequent in liver (12.68%/y), leukaemia (12.39%/y), pancreas (11.71%/y), bladder (11.67%/y) and myeloma (11.64%/y). GI bleedings were highest in liver (7.54%/y), pancreas (7.42%/y) and gastric (5.51%/y). ICH was highest in leukaemia (1.89%/y), myeloma (1.52%/y), lymphoma/liver (1.45%/y) and pancreas (1.41%/y) cancer.

The Table shows the hazard ratio and AUC values for each bleeding score. All the three scores significantly associated with bleeding outcomes, with the HAS-BLED score performing better than others for ICH prediction, and the ORBIT score predicting MB and GI bleedings (p < 0.0001 for all AUC comparisons).

Conclusions. Cancer increases the risk of bleeding in patients with cancer, with specific differences according to each cancer type. HAS-BLED score showed the best predictive value for ICH and the ORBIT score for MB and GI bleeding. MB GI bleeding ICH Hazard Ratio (95%CI) HASBLED score≥3 6.575 (6.390-6.765) 5.735 (5.502-5.978) 5.803 (5.416-6.218) ATRIA score≥5 5.372 (5.241-5.506) 3.617 (3.499-3.739) 1.469 (1.403-1.538) ORBIT score≥4 13.326 (12.977-13.686) 7.453 (7.202-7.712) 2.578 (2.463-2.699) AUC (95%CI) HASBLED score≥3 0.716 (0.714-0.718) 0.702 (0.699-0.704) 0.698 (0.694-0.702) ATRIA score≥5 0.700 (0.698-0.702) 0.662 (0.659-0.665) 0.563 (0.557-0.568) ORBIT score≥4 0.805 (0.804-0.807) 0.756 (0.753-0.758) 0.641 (0.635-0.646) AUC Difference (95% CI) HASBLED≥3 vs ATRIA≥5 0.016 (0.014-0.018) 0.040 (0.037-0.042) 0.136 (0.133-0.138) HASBLED≥3 vs ORBIT≥4 -0.089 (-0.091–0.087) -0.054 (-0.056–0.052) 0.057 (0.055-0.059) ATRIA≥5 vsORBIT≥4 -0.106 (-0.108–0.104) -0.094 (-0.095–0.092) -0.078 (-0.080–0.076)
Cerebral perfusion responses to active standing are attenuated in patients with vasovagal syncope
Authors: Perez-Denia L , Claffey P , O"reilly A , Delgado-Ortet M , Rice C , Kenny RA , Finucane C
Published: May 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Irish Research Council (IRC): Government of Ireland Postgraduate Scholarship Programme 2018, Dublin, Ireland Fundació Universitària Agustí Pedro i Pons, Universitat de Barcelona, Barcelona, Spain

Background

Syncope is a transient loss of consciousness due to cerebral hypoperfusion. While traditionally peripheral haemodynamics are monitored during clinical assessment of syncope, relatively little is known about cerebrovascular haemodynamics during orthostasis in patients with syncope.

Purpose

Here we investigated whether young patients with syncope present an altered cerebral perfusion when compared to healthy controls. Given potential hyper-reactivity of the autonomic nervous system previously reported in these patients, we hypothesise that an overly active cerebral autoregulation will be present in patients with syncope.

Methods

Consecutive patients were prospectively recruited from a National Falls and Syncope Unit, and a convenience sample of young healthy community dwelling adults was recruited from a local university (16-30 years). Participants performed a 3 minute active stand test with continuous measurement of beat-to-beat peripheral haemodynamics (blood pressure (BP), heart rate (HR)) and changes in concentration of oxygenated Δ[O2Hb] and deoxygenated Δ[HHb] haemoglobin were derived from a near-infrared spectroscopy (NIRS) monitor. Baseline, steady state and other time domain features were derived for Δ[O2Hb] (nadir, overshoot, overshoot-to-nadir, overshoot-to-nadir recovery rate) and Δ[HHb] (peak, trough, peak-to-trough, peak-to-trough recovery rate) and multiple linear regression was used to compare differences between the two groups correcting for covariates (p < 0.05 significant).

Results

Patients (n = 40) were younger (20(5.5) vs 23(1) years, p = 0.003) than controls (n = 17) and were well matched in gender, weight, height, BMI and resting haemodynamics. Patients had a smaller Δ[O2Hb] overshoot-to-nadir difference (β: -0.749, CI:(-1.593 0.094), p = 0.08), a slower Δ[O2Hb] recovery rate (β: -0.186, CI:(-0.388 0.016), p = 0.071), and smaller Δ[HHb] peak-to-trough difference (β: -0.530, CI:( -0.921 0.138), p = 0.018) and slower Δ[HHb] recovery rate (β: -0.151, CI: (0.244 0.057), p = 0.008).

Conclusion

Patients with syncope had signs of an attenuated cerebral oxygenation response to an AS when compared to controls. We hypothesise that this is due to hyper-reactive cerebral autoregulation mechanism, which might be related to a hyper-sensitive autonomic system. Furthering our understanding of vasovagal syncope physiology can help inform future interventions and treatments. This study shows the clinical value of measuring cerebral perfusion using NIRS, an easy to use and readily applicable tool, in the assessment of syncope. Abstract Figure. Cerebral oxygenation upon standing
Association of incident fragility fractures in patients hospitalised due to unexplained syncope and orthostatic hypotension
Authors: Johansson M , Rogmark C , Sutton R , Hamrefors V , Fedorowski A
Published: May 2021

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The study was funded by The Swedish Heart-Lung Foundation, The Greta and Johan Kock Foundation, and an Agreement for Medical Education and Research (ALF) grant by Swedish Research Council funding for clinical research in medicine.

Background

Fragility fractures are caused by low-energy insults such as falls from standing height or less and pose a growing health challenge as their incidence rises with increasing age. Impaired orthostatic blood pressure response and a number of cardiovascular biomarkers have been previously identified as risk factors for fractures. It is likely that severe episodes of syncope and orthostatic hypotension increase the risk of subsequent fragility fractures, however this relationship has not been thoroughly examined.

Purpose

To investigate the relationship of hospital admissions due to unexplained syncope and OH with incident fragility fractures in a middle-aged population.

Methods

We analysed a large population-based prospective cohort of 30,446 middle-aged individuals (age, 57.5 ± 7.6; men, 39.8%). We included patients hospitalised due to unexplained syncope and OH. Cox regression analysis adjusted for age, sex, prevalent fractures, body mass index (BMI) were applied to assess the impact of unexplained syncope/OH hospitalisations on subsequent incident fragility fractures. Prevalent fractures occurring before syncope/OH hospitalisation were excluded (n = 39) as well as cases with no follow-up time after the event of syncope/OH (n= 8).

Results

The mean follow-up from baseline to first incident fracture or end of follow-up was 17.8 + 6.5 years, and 8201 (27%) suffered incident fracture. The mean age of patients with unexplained syncope (n = 493) and OH patients (n = 406) at baseline was 61.5 ± 7.1 years (50.1%, male) and 62.6 ± 6.6 years (49.8% male), respectively. The mean time between baseline and first admission for syncope and OH was 12.3 ± 4.5 years, and the mean age at first hospitalisation was 74.4 ± 7.6 years. In the multivariable-adjusted Cox regression, the risk of subsequent incident fractures was increased among patients hospitalised due to unexplained syncope (HR: 1.20; 95% CI 1.03–1.40; p < 0.02) and OH (HR: 1.40; 95% CI 1.20–1.64; p < 0.001), respectively (Kaplan-Meier curves; Figure 1).

Conclusions

Patients hospitalised due to unexplained syncope and OH demonstrate increased risk of subsequent fragility fractures. We suggest that patients who are hospitalised for unexplained syncope and OH should be clinically assessed for true syncope aetiology, systematically treated against fall risk, and evaluated for additional risk factors for fragility fractures. Abstract Figure 1. Kaplan-Meier curves
Ultrasound-guided extra-cardiac vagal stimulation during cardioneuroablationa-a pilot feasibility study
Authors: Piotrowski R , Zuk A , Baran J , Sikorska A , Krynski T , Kulakowski P
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

N/A

Background. Cardioneuroablation (CNA) is a promising method for treatment of vagally-induced vasovagal syncope or functional atrio-ventricular block. Extra-cardiac vagal stimulation (ECVS) from the internal jugular vein is used during CNA to document asystolic response prior to CNA and lack of effects of vagal stimulation on heart rate after CNA.  The recommended technique is placing the pacing catheter under fluoroscopy in the internal right and left jugular vein up to the level of the upper wisdom tooth. However, this technique has several limitations such as increased radiation exposure, unselective cranial nerves stimulation and lack of visualization of vagal nerve. Ultrasound-guided (USG) approach may be an interesting option because it allows visualization of the vagal nerve and enables selective  stimulation under visual control.

Purpose. To assess the utility of USG-guided ECVS during CNA procedures.

Methods. The study group consisted of 6 patients (4 males, mean age 35 ± 12-year-old) underwent CNA.  Firstly, electrode for ECVS was introduced under fluoroscopy into the right and left jugular veins up to the level of the upper wisdom tooth and ECVS was performed. Next, the USG-guided examinations were performed in supine position with head extension. The probe was placed in the transverse plane above the medial edge of the sternocleidomastoid muscle. The course of vagal nerve was identified and place for imaging in the close neighborhood of the jugular vein was chosen. ECVS was performed when the electrode was in good contact with the vein wall and was in the vicinity of the vagal nerve. In both approaches vagal response (asystole and atrio-ventricular block) during ECVS was assessed before and after CNA.

Results. In all patients ECVS was performed from both right and left jugular vein. Localization of vagal nerve using USG was possible in all patients and took less than one minute (see Figure). The effects of ECVS were identical using standard fluoroscopic and USG-guided approach.

Conclusions. USG-guided ECVS during CNA is easy, results are comparable with standard fluoroscopic approach and is probably associated with less fluoroscopy. Since this non-invasive method is the only one which enables vagal nerve visualization, it should become a preferred approach when using ECVS during CNA procedures. Abstract Figure. A electrode position for USG-guided ECVS
Effect of aging on cerebral tissue oxygenation in relation to reflex syncope
Authors: Kharraziha I , Torabi P , Johansson M , Sutton R , Fedorowski A , Hamrefors V
Published: May 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Swedish Heart and Lung Foundation, The Swedish Heart and Lung Association, ALF funds, Skåne University Hospital Funds, The Crafoord Foundation.

Background

There is an increased susceptibility to syncope with aging attributed to age-related physiological impairments. Cerebral oximetry non-invasively measures cerebral tissue oxygenation (SctO2) and has been shown to be valuable in syncope evaluation. SctO2 has been found to decrease with aging but it is unknown whether the decrease in SctO2 is related to increased susceptibility to syncope during orthostatic provocation. By measuring SctO2 during head up tilt test (HUT) we can study age-related differences in SctO2 and their impact on developing reflex syncope.

Purpose

To investigate the effect of age on the cerebral tissue oxygenation threshold for syncope and presyncope among patients with vasovagal syncope.

Methods

Non-invasive haemodynamic monitoring and near-infrared spectroscopy (NIRS) were applied during head-up tilt (HUT) in 139 vasovagal syncope patients (mean [SD] 45[17] years, 60% female), and 82 control patients with a normal response to HUT (45[18] years, 61% female). Group differences in SctO2 and systolic blood pressure (SBP) during HUT in supine position, after 3 and 10 min of HUT, 30 seconds prior to syncope ("presyncopal phase") and during syncope in different age groups (<30, 30-60 and  >60 years) were compared using one-way ANOVA and Tukey"s multiple comparison test. Associations between age and SctO2 were studied using linear regression models adjusted for sex and concurrent SBP.

Results

Lower SctO2 in supine position was associated with increasing age among controls (B=-0.085, p = 0.010) but not among VVS patients (B=-0.036, p = 0.114). No age-related differences in SctO2 were found after 3 and 10 minutes of HUT and during syncope.  Mean SctO2 (%) during the presyncopal phase decreased over the advancing age groups (<30: 66.9 ± 6.2, 30-60: 64.5 ± 6.1, >60: 62.2 ± 5.8; p = 0.009 for inter-group comparison). In contrast, mean SBP during the presyncopal phase did not differ by age groups (<30: 85.6 ± 21.8, 30-60: 77.6 ± 19.7, >60: 77.6 ± 20.8 mmHg, p = 0.133). Age was associated with lower SctO2 during the presyncopal phase after adjusting for sex and SBP (B = 0.096, p = 0.001).

Conclusion

Older VVS patients have lower cerebral tissue oxygenation in the presyncopal phase compared with younger patients independently of systolic blood pressure. These results suggest either that with imminent reflex syncope cerebral tissue oxygenation diminishes more with advancing age or that cerebral deoxygenation is better tolerated by older reflex syncope patients. Abstract Figure.
Myocardial fibrosis as a predictor of sudden death in patients with coronary artery disease
Authors: Zegard A , Okafor O , Debono J , Kalla M , Lencioni M , Marshall H , Hudsmith L , Qiu T , Steeds R , Stegemann B , Leyva F
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND The ‘grayzone’ of myocardial fibrosis (GZF) on cardiovascular magnetic resonance may be a substrate for ventricular arrhythmias (VAs).

OBJECTIVES To determine whether GZF predicts SCD and VAs (ventricular fibrillation or sustained ventricular tachycardia) in patients with coronary artery disease (CAD) and a wide range of LVEFs.

METHODS In this retrospective study of CAD patients, myocardial fibrosis presence on visual assessment (MFVA) and GZF mass in patients with MFVA was assessed in relation to SCD and the composite, arrhythmic endpoint of SCD or VAs.

RESULTS Among 979 patients (age: 65.8 ± 12.3 yrs [mean ± SD]), 29(2.96%) suffered a SCD and 80(8.17%) met the arrhythmic endpoint over 5.82 years (median; interquartile range: 4.1-7.3). In the whole cohort, MFVA was strongly associated with SCD (hazard ratio [HR]:10.1, 95% CI 1.42-1278.9) and the arrhythmic endpoint (HR:28.0, 95% CI 4.07-3525.4). In competing risks analyses, associations between LVEF < 35% and SCD (subdistribution HR [sHR]:2.99, 95% CI 1.42-6.31) and the arrhythmic endpoint (sHR:4.71, 95% CI 2.97-7.47) were weaker. In competing risks analyses of the MFVA subcohort (n = 832), GZF using the 3SD method (GZF3SD) > 5.0 g was strongly associated with SCD (sHR:10.8, 95% CI 3.74-30.9) and the arrhythmic endpoint (sHR:7.40, 95% CI 4.29-12.8). Associations between LVEF < 35% and SCD (sHR:2.62, 95% CI 1.24-5.52) and the arrhythmic endpoint (sHR:4.14, 95% CI 2.61-6.57) were weaker.

CONCLUSIONS In CAD patients, MFVA plus quantified GZF3SD mass was more strongly associated with SCD and VAs than LVEF. In selecting patients for implantable cardioverter defibrillators, assessment of MFVA followed by quantification of GZF3SD mass may be preferable to LVEF. Abstract Figure.
Accuracy of electroanatomical mapping guided cardiac radiotherapy for ventricular arrhytmias: pitfalls and solutions
Authors: Abdel-Kafi S , Sramko M , Omara S , De Riva M , Cvek IJ , Peichl P , Kautzner J , Zeppenfeld K
Published: May 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was partially supported by the grant AZV NU20-02-00244 from the Ministry of Health of the Czech Republic

OnBehalf

WECAM

Background

One of the main limitations of Radiofrequency catheter ablation (RFCA) is the difficulty in targeting specific VT substrate locations when they are deep intramural, covered by epicardial fat or in the proximity of a coronary artery. Stereotactic body radiotherapy (SBRT) has emerged as an alternative treatment for VT after RFCA failure. However, the accuracy of substrate volume delineation, the gross target volume (GTV), based on electroanatomical mapping (EAM) and interobserver agreement are still unknown.

Aim

To analyze and optimize the interobserver agreement for GTV delineation on cardiac CT (CCT) based on EAM data acquired to guide radiotherapy for ventricular arrhythmias.

Method

Available EAM data was exported and merged with the segmented CCT using manual registration by two observers. A GTV was created by the observers for predefined left ventricular (LV) areas based on preselected endocardial EAM points, indicating the 2D-surface area of interest. The interobserver (non)overlapping GTV volumes were analyzed. The influence of (interobserver) registration accuracy and availability of EAM data on the final GTV and 2D-surface location within each LV area was evaluated.

Results

The median distance between the CCT and EAM after registration was 2.7 mm, 95%th percentile 6.2 mm for observer #1 and 3.0 mm, 95%th percentile 7.6 mm for observer #2 (p = 0.9). Created GTVs were significantly different (8 vs 19 ml) with lowest GTV overlap (35%) for lateral wall target areas. Similar, the highest shift between 2D-surfaces was observed for the lateral LV (6.4mm (3.0-9.9)). The same trend is seen in the (non) overlapping volume for lateral area (P = 0.004). The optimal surface registration accuracy (2.6 mm) and interobserver agreement (Δ interobserver EAM surface registration accuracy 1.32 mm) on final GTVs could be achieved if at least three cardiac chambers were mapped, including high-density LV EAM.

Conclusion

Detailed EAM of at least three chambers allows for accurate co-registration of EAM data with CCT and high interobserver agreement on GTVs to guide radiotherapy of ventricular arrythmias. However, the substrate location should be taken in consideration when creating a treatment volume margin. Gross target volume (GTV) and InterobserGTV volume Observer #1 (cc)GTV volume Observer #2 (cc)Surface shift (mm)Basal anterior, (IQR)7.6 (6.2-11.5)9.3 (5.3-10)3.8 (2.2-4.5)Lateral, (IQR)8.0 (6.9-12.7)19.1 (15.7-21.4)6.2 (5.3-6.4)Septal, (IQR)10.1 (6.2-12.8)13.9 (7.7-14.6)6.4 (3.0-9.9)Abstract Figure. Graphical abstract
A novel ventricular map of electrograms duration as a method to identify areas of slow conduction during ablation of ventricular tachycardia
Authors: Rossi P , Cauti FM , Polselli M , Iaia L , Fanti V , Niscola M , Andreoli C , Calore F , Bianchi S
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background – Wave front inhomogeneous propagation is crucial for reentry circuit generation. Bipolar EGM duration is indicative of local conduction delay and may identify areas of low conduction as a functional substrate. This study aimed to create a map of EGM duration during the VT (VEDUM Map) to identify the area of the slowest conduction and to verify if RF delivery at this area allows to rapidly interrupt the VT.

Methods – 24 high-density VTs maps (21 patients) were analyzed. Activation maps and voltage maps during SR were performed. An offline remap confirmed with MathLab software was customized to visualize the longest duration electrogram during VT.

Results – All of the VTs were interrupted during the first RF delivery (mean time 7,3 ± 5,4 sec (range 3-25 sec)) at the area with the longest EGM duration (212 ± 47 ms (range 113-330 ms)). . In 9 pts (37,5%) the longest EGM was located at the entrance or exit area of the activation maps while in 5 pts (21%) the EGM covered the full diastolic phase. Finally, in 10 pts the longest EGM occurred in the mid-exit-diastolic phase.

Conclusions - A novel Ventricular map of Electrograms DUration (VEDUM Map) is highly accurate in defining a conductive vulnerable zone of the VT circuit. The longest EGM duration within the isthmus is highly predictive of rapid VT termination. Quantitative variablesQualitative variablesMeanMedianStandard DeviationAge71738.40BMI26.624.54.02LV EDV16315442.7LV EDD61.2629.9LV EF38.7369.74VT cycle lenght (TCL)35537556.4EGM max. duration in VT21220847EGM max dur / TCL58.260.512Maximum EGM duration localization in CLProto = 12.5%Meso = 33.3%Tele = 25%Full = 20.8%Myocardium voltage characteristics in VEDUM EGMHealthy = 25%Transition = 20.8%Scar = 41.7%Critical Isthmus area12.3107.3VT Interruption during RFYes = 79.2%No = 20.8%Time (seconds) to interruption765Access typeEndo = 58.3%Epi = 29.2%Clinical and procedural dataAbstract Figure.
Impact of age on catheter ablation of premature ventricular contractions
Authors: Badertscher P , John L , Payne J , Bainey A , Ishida Y , Field M , Winterfield J , Gold MR
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Catheter ablation (CA) of frequent premature ventricular contractions (PVC) is increasingly performed in older patients as the population ages.

Purpose

The purpose of this study was to assess the impact of age on procedural characteristics, safety and efficacy on PVC ablations.

Methods

Consecutive patients with symptomatic PVCs undergoing CA between 2015 and 2020 were evaluated. Acute ablation success was defined as the elimination of PVCs at the end of the procedure. Sustained success was defined as an elimination of symptoms, and  ≥80% reduction of PVC burden determined by Holter-ECG during long-term follow. Patients were sub-grouped based on age (< 65 years vs. ≥ 65 years).

Results

A total of 114 patients were enrolled (median age 64 years, 71% males) and followed up for a median duration of 228 days. Baseline and procedural data were similar in both age groups. A left-sided origin of PVCs was more frequently observed in the elderly patient group compared to younger patients (83% vs. 67%, p = 0.04, Figure 1). The median procedure time was significantly shorter in elderly patients (160 min vs. 193 min, p = 0.02). The rates of both acute (86% vs. 92%, p = 0.32) and sustained success (70% vs. 71%, p = 0.90) were similar between groups. Complications rates (3.7%) did not differ between the two groups.

Conclusion

In a large series of patients with a variety of underlying arrhythmia substrates, similar rates of acute procedural success, complications, and ventricular arrhythmia-free-survival were observed after CA of PVCs. Older age alone should not be a reason to withhold CA of PVCs. Abstract Figure 1
Ventricular tachycardia ablation in nonischemic cardiomyopathy
Authors: Nascimento Matos D , Cavaco D , Carmo P , Carvalho MS , Rodrigues G , Carmo J , Galvao Santos P , Moscoso Costa F , Mendes M , Morgado F , Adragao P
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

Catheter ablation outcomes for drug-resistant ventricular tachycardia (VT) in nonischemic cardiomyopathy (NICM) are suboptimal when compared to ischemic cardiomyopathy. We aimed to analyse the long-term efficacy and safety of percutaneous catheter ablation in this subset of patients.

METHODS

Single-center observational retrospective registry including consecutive NICM patients who underwent catheter ablation for drug-resistant VT during a 10-year period. The efficacy endpoint was defined as VT-free survival after catheter ablation, while safety outcomes were defined by 30-days mortality and procedure-related complications. Independent predictors of VT recurrence were assessed by Cox regression.

RESULTS

In a population of 68 patients, most were male (85%), mean left ventricular ejection fraction (LVEF) was 34 ± 12%, and mean age was 58 ± 15 years. All patients had an implantable cardioverter-defibrillator. Twenty-six (38%) patients underwent epicardial ablation (table 1). Over a median follow-up of 3 years (IQR 1-8), 41% (n = 31) patients had VT recurrence and 28% died (n = 19). Multivariate survival analysis identified LVEF (HR= 0.98; 95%CI 0.92-0.99, p = 0.046) and VT storm at presentation (HR = 2.38; 95%CI 1.04-5.46, p = 0.041) as independent predictors of VT recurrence. The yearly rates of VT recurrence and overall mortality were 21%/year and 10%/year, respectively. No patients died at 30-days post-procedure, and mean hospital length of stay was 5 ± 6 days. The complication rate was 7% (n = 5, table 1), mostly in patients undergoing epicardial ablation (4 vs 1 in endocardial ablation, P = 0.046).

CONCLUSION

LVEF and VT storm at presentation were independent predictors of VT recurrence in NICM patients after catheter ablation. While clinical outcomes can be improved with further technical and scientific development, a tailored endocardial/epicardial approach was safe, with low overall number of complications and no 30-days mortality. Abstract Figure.
Grayzone myocardial fibrosis and ventricular arrhythmias in patients with a left ventricular ejection fraction greater than 35%
Authors: Zegard A , Okafor O , Debono J , Kalla M , Lencioni M , Marshall H , Hudsmith L , Qiu T , Steeds R , Stegemann B , Leyva F
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND Clinical guidelines adopt LVEF cut-offs <30 or <35% as an indication for implantable cardioverter defibrillator (ICD) therapy. Most patients succumbing to sudden cardiac death (SCD), however, have a LVEF≥35%.

OBJECTIVES To determine whether myocardial fibrosis (MF) and grayzone fibrosis (GZF) on cardiovascular magnetic resonance (CMR) is associated with ventricular arrhythmias in patients with coronary artery disease (CAD) and a LVEF≥35%.

METHODS In this retrospective study of CAD patients, GZF mass using the 3SD method (GZF3SD) and total fibrosis mass using the 2SD method (TF2SD) on CMR were assessed in relation to the primary, combined endpoint of SCD, ventricular tachycardia, ventricular fibrillation or resuscitated cardiac arrest.

RESULTS Among 701 patients (age: 65.8 ± 12.3 yrs [mean ± SD]), 28 (3.99%) patients met the primary endpoint over 5.91 years (median; interquartile range 4.42-7.64). In competing risks analysis, a GZF3SD mass ≥ 5.0 g was strongly associated with the primary endpoint (subdistribution hazard ratio [sHR]: 17.4 [95% CI 6.64-45.5]); area under receiver operator characteristic curve [AUC]: 0.85, p < 0.001). A weaker association was observed for TF2SD mass ≥ 23 g (HR: 10.4 [95% CI 4.22-25.8]; AUC: 0.80, p < 0.001). The range of sHRs for GZF3SD mass (1 to 526.6) was wider than for TF2SD mass (1 to 37.6).

CONCLUSIONS In CAD patients with a LVEF≥35%, GZF3SD mass was strongly associated with the arrhythmic endpoint. These findings hold promise for its use in identifying patients with CAD and a LVEF≥35% at risk of arrhythmic events. Abstract Figure.
Short-term variability of repolarization is equally modulated by atrial and (bi)ventricular high rate pacing in patients with an indication for an implantable cardioverter defibrillator
Authors: Smoczynska A , Sprenkeler DJ , Jalink H , Ritsema Van Eck HJ , Meine M , Vos MA
Published: May 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Dutch Heart Foundation

Background

 An increase in temporal dispersion of repolarization, quantified as short-term variability of the QT-interval (STV-QT), precedes ventricular arrhythmias and has therefore been proposed as a marker for monitoring of imminent arrhythmic risk. A reversal of an increased STV by high rate pacing at 100 bpm was anti-arrhythmic in the chronic atrioventricular block dog model susceptible to Torsade de Pointes arrhythmias upon challenge with an IKr-blocker. The objective of the current study was to investigate the physiological modulation of STV by pacing in patients with an indication for an implantable cardioverter defibrillator (ICD), and to compare atrial and ventricular pacing.

Methods

 ECG recordings were obtained with a sampling frequency of 1200 Hz in 10 dual chamber ICD patients and 10 patients with cardiac resynchronization therapy with defibrillation function (CRT-D) during the implantation or replacement. One-minute recordings were made during sinus rhythm (SR), and during pacing at 80 and 100 beats per minute (bpm) from the atrium (AAI), atrium and right ventricle (DDD RVp), and during atrio-biventricular pacing (DDD BiVp). The QT-interval was determined offline with fiducial segment averaging at one minute of each pacing rate, and 31 consecutive beats were used to calculate STV-QT with the following formula: ∑|D(n + 1)-Dn |/(N×√2), where D represents the determinant of repolarization (in this case the QT interval), and N represents the number of beats taken into account minus 1.

Results

 In the patients overall, STV-QT decreased from 1.27 ± 0.38 ms in SR (±58 bpm) to 0.86 ± 0.26 ms* during AAI80, and to 0.68 ± 0.22 ms*† during AAI100 (*p < 0.05 compared to SR, †p < 0.05 compared to 80 bpm). The same decrease was seen during DDD80 RVp (0.81 ± 0.28 ms*) and during DDD100 RVp (0.66 ± 0.22 ms*†) (fig. 1). Additionally, DDD BiVp decreased STV-QT to 0.78 ± 0.20 ms* at 80 bpm and to 0.62 ± 0.19 ms* at 100 bpm in CRT-D patients (fig. 2).

Conclusion

 Pacing at 80 and 100 bpm decreases STV-QT compared to sinus rhythm both in dual chamber ICD patients and CRT-D patients. The modulation of STV-QT is similar during atrial, and atrio- right ventricular and atrio-biventricular pacing. Abstract Figure. Modulation of STV-QT by AAI and DDD RVp
Leadless pacemakers: where is the device?
Authors: Elrefai M , Menexi C , Roberts P
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Leadless pacemakers (LPs) were designed to avoid lead-related complications associated with transvenous pacing. To minimise the risk of complications, there is preference towards implanting LPs into the septal aspect of the right ventricle rather than the apex or free wall. The Transcatheter Pacing Study (TPS) and the international post-approval registry demonstrated the safety and reliability of the LP systems in real-world settings. The registry demonstrated that more than half of the LPs were implanted into the septum and most required <2 attempts at deployment. We report a radiological method of defining LP position.

Methods

We reviewed the first 100 LPs implanted at our centre. Two independent observers who didn’t implant LPs reviewed the patients’ post-implant fluoroscopy images and/or post-implant CXRs when available. The reviewers assessed the devices’ positions in postero-anterior (PA) and/or right anterior oblique (RAO) views based on conventional fluoroscopic criteria for lead position. We used the proposed criteria interchangeably on fluoroscopic images and post implant CXRs (Figure). Differences in classification of device position were resolved by consensus.

Results

Three experienced operators implanted 100 LPs at our centre. Patients (61% male) 56.6 ± 22.2 years had normal hearts (74%), ischaemic cardiomyopathies (12%), congenital heart diseases (6%), valvular pathologies (5%) and dilated cardiomyopathies (3%). Indications for pacing were symptomatic sinus node dysfunction (36%), followed by high grade atrio-ventricular block (33%), bradyarrhythmia associated with atrial tachyarrhythmias (27%) and other indications for pacing (4%). We had a 100% successful implant rate, 88% required ≤2 attempts and 70% required one attempt. There were no major complications.

We were able to classify the site of the LPs implants in a total of 90 patients who had fluoroscopic projections or chest x-rays that would allow us to classify the implant sites. A total of 32 implants were in the apex (35.6%). 28 were in mid-septum (31.1 %), 15 in the apical septum (16.7%), 14 on the septal aspect of the right ventricular inflow (15.5%) and 1 implant (1.1%) in the septum of the RV outflow tract.

Conclusion

Our proposed method of defining LP position demonstrated that the rate of implants into the true apex at our centre was highly comparable to that of the international registry. It also showed that we had lower rates of implants into the mid-septum in favour of apical septum. There were no pericardial effusions or cardiac perforations resulting from our implant procedures regardless of the site of the implant. We utilised widely used fluoroscopic and chest x-ray criteria for categorisation of the LPs implantation sites. However, a recognised limitation to our analysis is that our findings were not validated using other imaging modalities such as echocardiogram or cardiac computerised tomography (CT). Abstract Figure. Criteria to classify device position
His pacing program: a 2-year single-centre experience
Authors: Pasara V , Brestovac M , Matasic R , Prepolec I , Radic D , Pezo-Nikolic B , Krpan M , Puljevic M , Puljevic D , Lovric Bencic M , Milicic D , Velagic V
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

His bundle pacing (HBP) physiologically activates the ventricles by a direct stimulation of the His-Purkinje cardiac conduction system. It was first described in the 1970s, and the initial feasibility studies were reported in the early 2000s. Later on, technological advances led to its widespread adoption and growing evidence base. 

Purpose

This retrospective study aimed to assess implant success rate, feasibility and safety of the His-bundle lead implantation program in our centre.

Methods

All patients who underwent His-bundle lead implantation in our centre from the start of the HBP program in November 2018 until November 2020 were analyzed. Data were collected from existing hospital electronic medical records.

Results

A total of 125 patients (64.8 % male, 65.1 ± 13.9 years) were included in the study. Nearly half of patients (47.2 %) had chronic heart failure and 39.2 % had atrial fibrillation. Indications for pacing included antibradycardia pacing (68.8 %) and cardiac resynchronization therapy (31.2 %). His-bundle lead was successfully implanted in 114 patients (91.2 % acute success), while the rest of the procedures were converted into right ventricle lead placement. 32.8 % of all patients had native narrow QRS complexes. Among patients who received HBP for cardiac resynchronization therapy, QRS duration was reduced from 177.5 ± 26.4 at baseline to 145.8 ± 23.9 after HBP (p < 0.001). However, QRS duration slightly prolonged in the antibradycardia group from 118.8 ± 31.9 at baseline to 130.4 ± 25.3 after HBP (p = 0.011). Seven (8.6 %) patients in the antibradycardia group had late lead disfunction/dislodgement and therefore underwent reoperation with the conventional right ventricle lead placement. Two patients (4.7 %) from the resynchronization group had inappropriate resynchronization response and underwent the conventional coronary sinus lead implantation. Only one patient (0.8 %) had a device-associated infection. 

Conclusion

Our data suggest that HBP is a feasible strategy of physiological pacing and resynchronization with an acceptable success and low complication rates. Our His-bundle implantation program results are similar to data available in the current literature.
Septal vs apical defibrillator electrode placement a systematic review
Authors: Santos H , Almeida I , Santos M , Paula S , Miranda H , Figueiredo M , Neto M , Sousa C , Sa C , Chin J , Almeida S , Almeida L
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

The optimal right ventricular defibrillator lead placement is still a debatable matter. We attempt to performed a systemic review to evaluate whether septal and apical placement had significant differences in the follow-up with an indication for implantation of these devices.

Objective

Review the evidence regarding the efficacy and safety of right ventricular apical and septal defibrillator lead placement.

Methods

A systemic research on MEDLINE and PUBMED with the term "septal pacing", "apical pacing" "septal defibrillation" or "apical defibrillation". 309 results were identified, however, after a serious analysis, several articles were excluded. Comparisons between apical and septal placement were performed regarding R wave amplitude, pacing threshold at 0.5 ms, lead impedance, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD) and lead complication that produced lead re-placement. Mean differences (MD) and confidence interval (CI) was used as a measurement of treatment.

Results

Six studies were selected, including a total of 2180 patients. The studies were performed with different techniques, analyses and goals. The studies presented heterogeneous and diverse results, with a varied follow-up period, that resulted in the exclusion of one of the studies. Mean age 64.51 years old, 76.86% male, a median ejection fraction of 27.84%, NYHA class of 2.65, ischemic etiologic in 51.10% and a follow-up period of 26.49 months. Septal defibrillator lead placement was established in 772 patients, while the apical defibrillator lead placement was performed in 1399 patients. No differences regarding the lead performance on apical and septal placement were detected regarding the R-wave (MD -0.36, CI -0.75 - +0.03, p = 0.68, I2 = 0%) (reported in 3 studies) and lead impedance (MD -23.83, CI -51.36 - +3.69, p = 0.003, I2 = 82%) (reported in 3 studies). Pacing threshold seems to be favor a septal defibrillator lead implantation (MD -0.05, CI -0.09 - -0.02, p = 0.12, I2 = 53%) (reported in 3 studies). Concerning echocardiography parameters during the follow up period, LVEF (MD -0.83, CI -3.05 - +1.38, p = 0.10, I2 = 57%) (reported in 3 studies) and LVEDD (MD -0.51, CI -2.13 - +1.10, p = 0.20, I2 = 38%) (reported in 3 studies) were not significant influenced for the defibrillator lead placement. Lead complications that provoke a lead replacement was not significant between the lead placement (MD 1.25, CI 0.53 – 2.94, p = 0.71, I2 = 0%) (reported in 3 studies).

Conclusions

Just pacing threshold proved to improve the septal defibrillator lead placement. Neither the other lead parameters or the echocardiography results during the follow-up were influenced by the lead placement. For a definitive conclusion is important to further investigation.
Mortality, appropriate and inappropriate shocks - observations from an institutional implantable cardioverter defibrillator registry
Authors: Prepolec I , Pasara V , Ciglenecki E , Bogdanic JE , Putric Posavec J , Pezo-Nikolic B , Matasic R , Krpan M , Lovric-Bencic M , Puljevic M , Puljevic D , Milicic D , Velagic V
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Implantable cardioverter defibrillator (ICD) is an effective therapy for primary (PP) and secondary prevention (SP) of sudden cardiac death (SCD). ICD adverse events include inappropriate shocks (IS), device infection and failure. 

Methods

We analysed the data concerning all newly implanted ICDs in our institution from 2011 to 2017. Follow-up data was collected until the end of 2019.

Results

In total, 507 ICDs were implanted (85.4% male, 57.6 ± 14.0 years-old), 375 (74.0%) for PP and 132 (26.0%) for SP. The mean follow-up was 34.3 ± 23.8 months. ICD delivered therapy in 42.4% of SP and in 28.8% of PP patients (p = 0.15). In PP, shocks were delivered in 25.7% of non-ischaemic heart disease (NIHD) and in 17.6% ischaemic heart disease (IHD) patients (p = 0.81). IS were significantly more common in NIHD patients (13.8% vs 2.4% in IHD group, p < 0.0001). PP patients with NIHD also had a higher shock burden (average of 8.0 ± 17.4 shocks compared to 2.7 ± 3.0 in the IHD group). However, it failed to reach the level of statistical significance (p = 0.052). In SP, the rate of ICD activation and that of IS were similar in both groups (IHD and NIHD). In total, 32.6% of SP patients received appropriate shock (AS) and 5.3% of them received at least one IS (average number of AS and IS being 8.7 ± 11.5 and 1.1 ± 0.4 respectively). Mortality was significantly higher in SP than in PP (34.8% vs 13.9%, p < 0.001). In PP, significantly more deaths occurred among IHD than NIHD patients (18.8% vs 10.0%, p < 0.001). 

Conclusion

The prevalence of AS and IS was relatively higher than reported elsewhere. Same was true for mortality. Interestingly, the rate of IS was somewhat higher in NIHD than in IHD, which was unexpected. ICD outcomes Primary prevention Secondary prevention Total IHD NIHD Total IHD NIHD Patients, n 375 165 210 132 88 44 Patients with ICD activation, n (%) 108 (28.8) 46 (27.9) 62 (29.5) 56 (42.4) 33 (37.5) 22 (50.0) Patientns with AS, n (%) 60 (16.0) 27 (16.4) 33 (15.7) 43 (32.6) 29 (33.0) 14 (31.8) Patientns with IS, n (%) 33 (8.8) 4 (2.4) 29 (13.8) 7 (5.3) 5 (5.7) 2 (4.5) AS delivered (mean ± SD) 5.6 ± 13.3 2.7 ± 3.0 8.0 ± 17.4 8.7 ± 11.5 9.9 ± 12.2 9.7 ± 17.6 IS delivered (mean ± SD) 3.2 ± 5.1 1.2 ± 0.5 3.5 ± 5.4 1.1 ± 0.4 1.0 ± 0 3.2 ± 5.2 Deaths, n (%) 52 (13.9) 31 (18.8) 21 (10.0) 46 (34.8) 32 (36.4) 14 (31.8) Time to death (months, mean ± SD) 20.3 ± 13.9 19.9 ± 12.6 21.1 ± 16.5 27.1 ± 25.7 28.9 ± 24.9 22.6 ± 28.1 ICD, implantable cardioverter defibrillator; IHD, ischemic heart disease; NIHD, non-ischemic heart disease; AS, appropriate shock; IS, inappropriate shock
Cardiac operations and interventions during the COVID-19 pandemic: a nationwide perspective
Authors: Leyva F , Zegard A , Okafor O , Stegemann B , Ludman P , Qiu T
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Aims

The COVID-19 pandemic has led to a decline in hospitalizations for non-COVID-19 related conditions. We explored the impact of the COVID-19 pandemic on cardiac operations and interventions undertaken in England.

Methods

An administrative database covering hospital activity for England, the Health Episodes Statistics, was used to assess a total of 286,697 hospitalizations for cardiac operations and interventions, as well as 227,257 hospitalizations for myocardial infarction (MI) and 453,799 for heart failure (HF) from 7th January 2019 to 26th July 2020.

Results

Over the 3 months of ‘lockdown’, total numbers and mean reductions in weekly rates (n [-%]), compared with the same time period in 2019, were: coronary artery bypass grafting (-2507 [-64%]); percutaneous coronary intervention (-5245 [-28%]; surgical (-1324 [-41%]) and transcatheter (-284 [-21%]) aortic valve replacement; mitral valve replacement; implantation of pacemakers (-6450 [-44%]), cardiac resynchronization therapy with (-356 [-42%]) or without (-491 [-46%] defibrillation devices, and implantable cardioverter defibrillators (-501 [-45%]); atrial fibrillation ablation (-1902 [-83%]), and other ablations (-1712 [-64%]) (all p < 0.001). Over this period, there were 21,038 fewer procedures than in the reference period in 2019 (p < 0.001). These changes paralleled reductions in hospitalizations for MI (-10,794 [-27%]) and HF (-63,058 [-28%]) (both p < 0.001).

Conclusions

The COVID-19 pandemic has led to substantial reductions in the number of cardiac operations and interventions undertaken. An alternative strategy for healthcare delivery to patients with cardiac conditions during the COVID-19 pandemic is urgently needed. Abstract Figure.
Chronic electrical performance of a new ultra-thin left ventricular quadripolar pacing lead
Authors: Anselme F , Ziglio F , Shan N , Heckman LIB , Kuiper M , Prinzen FW
Published: May 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): H2020-FTI [Fast Track to Innovation] Pilot-2016 and MicroPort CRM

Background

Left ventricular (LV) lead positioning is an important contributor to cardiac resynchronization therapy (CRT) response. Multiple additional LV sites could be stimulated by passing a new ultra-thin (1.2 Fr, 0.4 mm) quadripolar microlead from one LV vein into another via venous collaterals.

Purpose

Study the acute and chronic stability and electrical pacing performance of a novel 1.2 Fr quadripolar microlead ("Axone 4LV").

Methods

Seven healthy adult dogs underwent CRT defibrillator implantation, including a right ventricular lead and the microlead. The microlead was advanced into the coronary sinus network using a dedicated microguide catheter. The animals were followed up at 1, 15, 30 and 90 days post-implant to evaluate chronic stability and electrical pacing performance.

Results

Successful uncomplicated implantation was achieved in all cases. Despite the small diameter of the distal veins and collaterals, placement of the pacing electrodes in two different LV veins was feasible via available collateral passages. Lead position was stable in all cases and over the entire study period. Capture threshold and pacing impedance at 90 days post-implant were 1.7 ± 0.5 V with 1323 ± 245 Ω, respectively, at 0.5 ms pulse width. The mean pacing energy to get capture was 1.1 ± 0.5 µJ and less than 2 µJ in all cases (2 µJ ≈ 1.4 V @500 Ω, 0.5 ms). No phrenic nerve stimulation was observed during pacing.

Conclusions

The novel 1.2 Fr quadripolar microlead demonstrated adequate stability and good electrical performance allied to low energy consumption. This quadripolar microlead may extend pacing options while increasing device longevity in CRT. Changes in pacing parameters over time Post-implant Follow-up Pacing Threshold Pacing Impedance Pacing Energy 1 day 1.4 ± 0.7 V 1294 ± 270 Ω 0.8 ± 0.7 µJ 15 days 1.9 ± 0.9 V 1336 ± 274 Ω 1.8 ± 1.8 µJ 30 days 1.8 ± 0.7 V 1187 ± 303 Ω 1.5 ± 1.2 µJ 90 days 1.7 ± 0.5 V 1323 ± 245 Ω 1.1 ± 0.5 µJ