bluuebunny/crossref_metadata_2025 huggingface dataset:
P549CIED infection risk score validation using US health claims data
Authors: Ahmed F Z , Blomstrom Lundqvist C , Bloom H , Cooper C , Ellis C , Goette A , Greenspon A , Love C , Johansen J B , Philippon F , Tarakji K , Holbrook R , Sherfesee L , Xia Y , Krahn A
Published: June 2020

Funding Acknowledgements

This work was supported by Medtronic

Background/Introduction: The increasing number of cardiac implantable electronic device (CIED) infections has led to increased interest in the identification of patients who may benefit from additional infection prevention measures.

Purpose

The purpose of this evaluation was to validate the predictive value of the Prevention of Arrhythmia Device Infection Trial (PADIT) risk score to identify patients at increased risk of CIED infection using a U.S. health claims data set.

Methods

A retrospective analysis using the Optum® Clinformatics® claims database was conducted to create a dataset of index procedures which either did or did not result in an infection.  The study population included both commercial and Medicare Advantage patients aged ≥18 years with at least one record of a CIED procedure between January 2011 and September 2014.  Major CIED infections, defined as an infection associated with system removal, invasive procedure without system removal, or death attributable to infection, were identified through diagnosis and procedure codes.  The dataset was randomized (stratified by PADIT score, which included prior procedures, age, depressed renal function, immunocompromised, and procedure type) into a Development Dataset (60%) and a Validation dataset (40%).  A frailty model allowing multiple procedures per patient was fit using the Development Dataset, with PADIT score as the only predictor, excluding patients with prior infection. Prior CIED infection, which was not available in the original PADIT data, was examined for additional predictive value.

Results

The data extraction resulted in a dataset of 53,554 index procedures among 51,583 patients, with 30,950 patients randomized to the Development Dataset.  The distribution of procedures was pacemakers (52%), ICD (20%), CRT (12%), and Revision/Upgrade (16%), while prior procedures were none (62%), 1 (37%), and 2 (1%). Among patients with no history of prior CIED infection, the frailty model showed that a 1 unit increase in the PADIT score predicts higher infection risk (20%) in the U.S. claims data set (Table 1). Prior CIED infection was associated with strong additional predictive value (HR 4.77, p < 0.0001) after adjusting for PADIT score.

Conclusion

In the largest external validation of a CIED risk score, the PADIT risk score predicts increased CIED infection risk, identifying higher risk patients that can benefit from targeted interventions to reduce the risk of CIED infection. Prior CIED infection brings additional predictive value to the PADIT score.
P323Triage-HF Plus: identification of heart failure and non-heart failure events in an ambulatory population using remote monitoring and the triage heart failure risk score Algorithm
Authors: Ahmed F , Taylor J , Green C , Wickwar L , Zaidi A , Cunnington C , Motwani M
Published: June 2020

Background/introduction

Previous studies examining the utility of cardiac implantable electronic devices (CIEDs) to remotely monitor heart failure patients for decompensation have not demonstrated an impact on hard end-points. However, a key limitation of these prior studies (REM-HF and MORE-CARE) has been the failure to stratify patients according to their risk of worsening heart failure (WHF) prior to randomization (usual care vs active monitoring). We examined a different approach, using a single manufacturer’s remote monitoring platform, whereby only patients with CIED-derived data indicating the highest risk of WHF are contacted for assessment. The validated ‘Triage Heart Failure Risk Score’ (Triage-HFRS) is a medical algorithm within Medtronic CIEDs that can risk-stratify patients as low-, medium- or high-risk of WHF in the next 30 days based on integrated monitoring of physiological parameters.

Purpose

 This study is the largest prospective evaluation of the Triage-HFRS, and examines the additional role of contacting those patients with a ‘High-Risk’ Triage-HFRS alert by telephone (Triage-HF Plus pathway).

Methods

 Prospective, real-world evaluation of the Triage-HF Plus pathway undertaken between June 2016 and September 2019. 326 high-risk Triage-HFRS transmissions were contacted for telephone triage assessment. Screening questions were designed to identify episodes of WHF and non-heart failure events. Interventions were at the discretion of the clinical practitioner and in line with guideline-directed practice. An additional 3-month consecutive sample of low and medium Triage-HFRS transmissions (control group) were also contacted for telephone triage assessment (n= 98).

Results

Successful telephone contact was made following 245 high-risk Triage-HFRS alerts. Following contact, 194 (79.1%) patients reported an acute medical issue: 137 (70.6%) reported symptoms consistent with worsening heart failure (WHF) requiring intervention; and 57 (29.4%) had an alternative acute medical problem. 51 (26.2%) had no apparent reason for the high score. The sensitivity and specificity of CIED-based remote monitoring to identify any HF and non-HF events requiring intervention was 99.5% (97.2-99.9%) and 65.5% (57.3-73.2%) respectively; positive predictive value was 79.2%. The negative predictive value of a non-high risk score to rule out an acute event was 98.9%. Overall accuracy of the pathway to identify an acute issue (HF or non-HF related) was 84.8%.

Conclusion

The Triage-HF Plus clinical pathway is a potentially useful remote monitoring tool for patients with heart failure. The pathway has high diagnostic accuracy to identify patients with WHF and a wide range of non-HF issues which are just as relevant in a population who often have multiple complex co-morbidities and are known for their high health care utilisation.
P1061Incidence and location of PVI gaps identified post-cryoballoon ablation for atrial fibrillation
Authors: Eldadah Z , Jons C , Hollis Z , Dekker L , Mathew S , Schmitt J , Gora P , Porterfield C
Published: June 2020

Background

 Successful delivery of continuous and durable pulmonary vein isolation (PVI) lesion sets is recognized as being critical to long-term clinical outcomes following ablation for atrial fibrillation (AF). Confirmation of PVI following cryoballoon ablation is commonly achieved using a 3.3F circular mapping catheter (CMC) which can be delivered through the central lumen of the cryoballoon, but other diagnostic tools may be used alone or in conjunction with the 3.3F CMC. A high-density, grid-style mapping catheter is now available in multiple geographies; use in cryoballoon ablation procedures and associated outcomes has not been previously reported.

Purpose

 To evaluate diagnostic catheter usage patterns in cryoablation procedures and identify associated trends in procedural characteristics and acute outcomes.

Methods

 Self-reported procedural data was prospectively collected in AF cryoablation cases utilizing various diagnostic catheter tools, including the 3.3F CMC and high-density, grid-style mapping catheter (HD Grid). Procedural characteristics and acute outcomes, including the incidence and location of gaps post-ablation, were recorded and analyzed.

Results

 Data was collected in 23 cryoablation procedures performed in 7 centers across the United States and Europe. De novo and repeat ablations represented 65.2% and 21.7% of cases, respectively (13.0% not reported). 3D mapping was employed in 95.7% of cases. A left common pulmonary vein was present and ablated in 8.7% (2/23). The 28mm cryoballoon was utilized in all cases, with a single case using both a 23mm and 28mm cryoballoon. The 3.3F CMC was used to confirm isolation in all cases using a variety of techniques: voltage mapping (60.9%), exit block (56.5%), entrance block (30.4%), propagation mapping (4.3%), and activation mapping (4.3%); note: total exceeds 100% as more than one technique may be employed in a single case. In 18 cases, PVI was confirmed using a 3.3F CMC followed by secondary confirmation with HD Grid, enabling a direct comparison of the two technologies. The HD Grid identified a total of 12 gaps in 4 (22.2%) patients, which were missed by the 3.3F CMC (Figure 1). No adenosine or isoproterenol use was documented in any case.

Conclusion(s): The 3.3F CMC is routinely used to confirm PVI following cryoballoon ablation for atrial fibrillation, but it may fail to identify gaps in some patients. Subsequent assessment of PVI using the HD Grid identified residual gaps in nearly a quarter of patients, suggesting that sensitivity for gap detection may be improved with this tool. Limitations of this analysis include the small sample size and workflows which consistently assessed PVI with the high-density mapping catheter after confirming isolation with the 3.3F CMC. Despite these limitations, the incidence of residual gaps observed is noteworthy and may warrant additional study.

Abstract Figure.
P338Dystrophin deficient cardiomyopathy: predictors associated with the cardiac phenotype in a Duchenne registry population - A guide for device therapy
Authors: Carron J , Fitzgerald S J , Costello R , Sheahan R
Published: June 2020

Background

Patients with Duchenne muscular dystrophy (DMD) typically exhibit cardiac dysfunction. With increasing life expectancy due to advances in respiratory support, cardiomyopathy and associated dsyrhythmia are fast becoming the primary cause of morbidity and mortality in this patient group. Despite advances, the correlation between genotype and cardiac phenotype remains poorly understood and individual registries small, with implementation of device therapy often delayed due to poor diagnostic imaging. 

Methods and Aims: A single-center registry for DMD patients was established and data including genotyping, medical therapy and investigations such as cardiac MRI, nt-Pro BNP levels, echocardiogram were analysed. The aim was to potentially identify predictors associated with a more severe cardiac phenotype and thus help to guide provision of device therapy.  

Results

A total of 19 patients (age 17 - 31) with DMD were reviewed (demographics table 1). All patients were evaluated with echocardiography on at least one occasion (mean EF 46.5%). Cardiac MRI was attempted in 6 patients however only completed in 2 due to contractures preventing access to scanning. 11 of 19 patients (58%) demonstrated an impaired left ventricular ejection fraction (EF) <50% (mean EF 42%). Proximal "hot spot" mutations/deletions (exon 2-19) were associated with a more pronounced reduction in EF, all patients with proximal mutations demonstrating an EF < 45% (mean 41%). 5 of 6 (83%) of those with >1 exon deletion mutations demonstrated more severely impaired EF (mean EF 41%) compared to those with single exon deletions (mean EF 52%). Interestingly, one patient with a proximal mutation (exon 3-6 deletion) remains mobilising to distances of 70 meters, however cardiac MRI revealed a moderate degree of fibrosis with an EF of 43%. Correlation between nt-Pro BNP levels with reduced EF was not uniform, however a level < 100 was associated with an EF >55% in 89% of patients studied. of those on steroid regimes, 6 (54%) had impaired LVEF compared to 5 (83%) of those not on steroid therapy. All patients were on at least one class of heart failure modification, with 79% on two and 37% on three agents. Only one patient in the registry has had an ICD implanted. He has had a device for 10 years in and in this time there have been no therapies delivered however runs of non-sustained ventricular tachycardia have been noted. 

Conclusions

Correlation between predictors and cardiac phenotype in a Duchenne population remains unreliable. Location and size of exon alteration appears to be indicative of more markedly impaired LV function, however larger studies are required to characterise this further and challenges remain with regard to accurate assessment of EF. The use of predictors in future may help to guide appropriate provision of device therapy.
1266Novel formin homology 2 domain containing 3 (FHOD3) mutations associated with the pathogenesis of hypertrophic cardiomyopathy (HCM) in an Irish population
Authors: Carron J , O"brien J , Gallagher M , Mcgorrian C , Galvin J
Published: June 2020

Background

The genetic cause of hypertrophic cardiomyopathy (HCM) remains unexplained in a substantial proportion of cases. Recent large sequencing studies suggest that, though not previously implicated, FHOD3 (a Formin protein responsible for sarcomere assembly) may have a role in the pathogenesis of HCM, particularly variants affecting a conserved small coil-coiled domain (amino acids 622 to 655).

Aim

To investigate the relationship between novel FHOD3 mutations, previously classified as variants of uncertain significance (American College of Medical Genetics ACMG Class III), and the development of HCM. 

Methods

A single center review of HCM probands carrying mutations in the FHOD3 gene was conducted. Existing HCM patients from the family heart screening clinic database were retrospectively reviewed. Frequency of FHOD3 mutations, segregation among family members and clinical characteristics of patients were reviewed. All genetic analysis was conducted via the same internationally validated next generation sequencing lab.

Results

Of 367 HCM probands identified in our center, 9 (2.45%) were found to have ACMG Class III mutations affecting the FHOD3 gene. Five of these 9 probands (56%) displayed the same p.Arg637Gln mutation, while the remaining 4 (44%) carry the same p.Ile648Thr residue alteration. Both of these are rare mutations, found to be present in <1% of controls in previous large sequencing studies and not previously reported. Among probands with the p.Ile648Thr mutation, co-segregation was confirmed in one family, another first-degree relative in the same family having suffered a sudden cardiac death (HCM confirmed on autopsy). In those with the p.Arg367Gln mutation, a strong family history was observed in two separate families, 4 first-degree members having a confirmed HCM diagnosis. Carriers of both mutation types displayed varying degrees of disease severity with rates of non-sustained ventricular tachycardia and device implantation similar to other HCM cohorts (∼40%).

Conclusions

FHOD3 is a novel gene, recently implicated in the pathogenesis of HCM, though not previously well described in the literature. Carrier frequency of FHOD3 mutations in the HCM population in our center is similar to that described in recent publication (1-2%), and all carry variants affecting the suspected small coil-coiled domain (amino-acids 622-625).

Abstract Figure.
P505Short and long-term outcomes of medical management of patients with a first episode of arrhythmic storm
Authors: Acosta Martinez J , Caballero Valderrama M , Dominguez Cano J L , Campos Pareja A , Frutos Lopez M , Garcia Riesco L , Arana Rueda E , Pedrote Martinez A
Published: June 2020

INTRODUCTION

There is few data about long-term outcomes of conservative management (without catheter ablation) of patients with a first episode of arrhythmic storm (AS) in the current context. This study analyzes the short and long-term outcomes of implantable cardioverter defibrillator (ICD) patients with a first episode of AS receiving non-interventional management. 

METHODS

Consecutive patients admitted with a first episode of AS between January 2008 and June 2019 receiving medical management without catheter ablation were included. AS was defined as ≥ 3 appropriate ICD therapies occurring during a 24h span. Medical management included: correction of triggers, sedation/mechanical ventilation, antiarrhythmic drugs, ICD reprogramming and neuraxial modulation. Baseline clinical characteristics and follow-up data were recorded. All patients were followed every 6 months at the ICD office. The primary end-point was all-cause mortality.

RESULTS

60 patients (81% male, 62.8 ± 16.2 years, 43% ischaemic, LVEF 35.4 ± 14%) with a first episode of AS treated conservatively were included. Thirty-day survival was 96.5% and 1-year survival was 82%. During a median (interquartilic range) follow-up of 31 (6-69) months 31 (51.7%) patients died (51.6% due to cardiovascular aetiology) and 35 (58.3%) patients were readmitted  (48.5% due to recurrent arrhythmic events and 45.7% due to heart failure). Age [HR 1.05 (95% confidence interval: 1.01-1.08)] and end-diastolic diameter [HR 1.05 (95% confidence interval: 1-2)] were the strongest independent predictors of all-cause mortality.

CONCLUSION

Despite the severity of this entity, medical management (without catheter ablation) of a first episode of AS is reasonable given its good 30-day and 1-year survival. However, a high rate of AS recurrence and readmissions are observed during long-term follow-up. Efforts are needed in order to identify those patients with a first episode of AS that could benefit from an early catheter ablation strategy.
P490Time boundaries of three-phase time-sensitive model for ventricular fibrillation cardiac arrest
Authors: Goto Y , Funada A , Maeda T , Okada F , Goto Y
Published: June 2020

Funding Acknowledgements

Japan Society for the Promotion of Science (KAKENHI Grant No. 18K09999)

Background

Recent clinical evidence has suggested that the pathophysiology of ventricular fibrillation (VF) cardiac arrest may consist of three time-sensitive phases, namely electrical, circulatory, and metabolic. According to this model of cardiopulmonary resuscitation (CPR), the optimal treatment of cardiac arrest is phase-specific. The potential survival benefit of bystander cardiopulmonary resuscitation (BCPR) depends in part on ischemic time (i.e., the collapse-to-shock interval), with the greatest benefit occurring during the circulatory (second) phase. However, the time boundaries between phases are not precisely defined in the current literature.

Purpose

The purpose of the present study was to determine the time boundaries of the three-phase time-sensitive model for VF cardiac arrest.

Methods

We reviewed 20,741 adult patients with initial VF after witnessed out-of-hospital cardiac arrest from a presumed cardiac origin who were included in the All-Japan Utstein-style registry from 2013 to 2017. We excluded patients who underwent bystander defibrillation prior to arrival of emergency medical services personnel. The study end point was 1-month neurologically intact survival (Cerebral Performance Category scale 1 or 2). Collapse-to-shock interval was defined as the time from collapse to first shock delivery by emergency medical services personnel. Patients were divided into two groups, BCPR (n = 11,606, 56.0%) and non-BCPR (n = 9135, 44.0%), according to whether they had received BCPR or not.

Results

The rate of 1-month neurologically intact survival in the BCPR group was significantly higher than that in the non-BCPR group (27.9% [3237/11,606] vs 17.9% [1632/9135], P < 0.0001; adjusted odds ratio [OR], 1.90; 95% confidence interval [CI], 1.75–2.07; P < 0.0001). Overall, increased collapse-to-shock interval was associated with significantly decreased adjusted odds of 1-month neurologically intact survival (adjusted OR for each 1-minute increase, 0.94; 95% CI, 0.93–0.95; P < 0.0001). In the BCPR group, the ranges of collapse-to-shock interval that were associated with increased adjusted 1-month neurologically intact survival were from 7 minutes (adjusted OR, 1.95; 95% CI, 1.44–2.63; P < 0.0001) to 17 minutes (adjusted OR, 2.82; 95% CI, 1.62–4.91; P = 0.0002) as compared with those in the non-BCPR group. However, the increase in neurologically intact survival of the BCPR group became statistically insignificant as compared with that of the non-BCPR group when the collapse-to-shock interval was outside these ranges.

Conclusions

The above-mentioned findings suggest that the time boundaries of the three-phase time-sensitive model for VF cardiac arrest may be as follows: electrical phase, from collapse to <7 minutes; circulatory phase, from 7 to 17 minutes; and metabolic phase, >17 minutes onward from collapse.
P1353Echocardiographic predictor of sick sinus syndrome following catheter ablation of persistent atrial fibrillation
Authors: Yoshie K , Okada A , Seki S , Tabata H , Shoin W , Kobayashi H , Okano T , Motoki H , Shoda M , Kuwahara K
Published: June 2020

Funding Acknowledgements

Abbott Medical Japan, Medtronic Japan, Boston Scientific Japan, Biotronic Japan, Japan Life Line

Background / Introduction

Although sick sinus syndrome(SSS) can be associated with atrial fibrillation(AF), predictive factors of SSS following catheter ablation(CA) of persistent atrial fibrillation(perAF) are not well known.

Purpose

We investigated echocardiographic parameters to predict occurrence of SSS after restoration of sinus rhythm by CA for perAF patients.

Methods

Ninety-eight consecutive perAF patients from June 2014 to May 2018 treated with CA were retrospectively reviewed. Twelve patients(12%, SSS group) developed SSS after successful CA and 86 patients(88%, non-SSS group) did not. Baseline characteristics, blood exam, and echocardiographic findings(RA area size, LA area size, EF, etc) before AF CA were analyzed using Student’s t test, Mann-Whitney test, Chi-square test and Univariate analysis. Multivariate logistic analysis was then performed using those parameters. The atrial area size was calculated from 4 chamber view at the atrial end- systole.

Results

The multivariate analysis for predictive factors of SSS is shown in the table. Right atrium(RA) area could predict SSS(17.3 ± 4.8cm2 vs. 14.7 ± 3.6cm2, odds ratio 1.468; 95% confidence interval 1.088 to 1.981, p = 0.012). Gender (female) was also an independent predictor(4/12 (33%) vs. 8/86 (9%), odds ratio 39.832; 95% confidence interval 2.589 to 612.938, p = 0.008). The other echocardiographical findings(LA area size, EF, etc), baseline characteristics and blood exam results were not related to SSS after successful CA of perAF patients.

Conclusions

The large RA area size and gender (female) could predict SSS in perAF patients after restoration of sinus rhythm by successful CA. We may need to inform possible SSS after CA to female patients with a large RA before CA.

Multivariate Logistic analysis Total(N = 98) SSS group (N = 12) Non SSS group (N = 86) Odds ratio 95% CI P-value Age 64(58-69) 68(60-72) 63(57-69) 1.032 0.929-1.145 0.560 Gender/Female 12(12%) 4(33%) 8(9%) 39.832 2.589-612.938 0.008 CKD 27(28%) 6(50%) 21(24%) 1.264 0.179-8.945 0.814 BNP 91(53-180) 206(167-304) 82(48-169) 1.003 0.993-1.012 0.609 RDW 45.1 ± 3.9 46.4 ± 4.8 44.9 ± 3.8 1.242 0.971-1.588 0.085 RA area 15.1 ± 3.8 17.3 ± 4.8 14.7 ± 3.6 1.468 1.088-1.981 0.012 LA area 24.2(17.0-24.9) 24.4(17.7-26.3) 24.1(16.8-24.4) 0.967 0.803-1.165 0.726 Right atrium area and gender were the independent predictor of SSS in persistent atrial fibrillation patients after restoration of sinus rhythm
P1417Short and long term efficiency of different therapeutic approaches to perimitral atrial flutter
Authors: Kupo P , Pap R , Bencsik G , Saghy L
Published: June 2020

Introduction

Catheter ablation of perimitral flutter can be challenging, owing to difficult anatomy. The most commonly applied procedure is the creation of a mitral isthmus line (between the lower left pulmonary vein and the mitral anulus) or an anteroseptal line (between the upper right pulmonary vein and the anterior mitral anulus).

Purpose

Our study aimed to compare the short and long term efficacy of two different ablation methods.

Methods

In our retrospective study 45 consecutive patients diagnosed with perimitral flutter were included between 2009 and 2018.

Results

Radiofrequency ablation was performed in 48 cases in 31 patients (mitral isthmus line (n = 25, 52.1%); anteroseptal line (n = 23, 47.9%)). Arrhythmia-termination and sinus rhythm restoration could be achieved in 64.6% of the cases (mitral isthmus line: 16/25 (64.0%), anteroseptal line: 15/23 (65.2%). Comparing two different techniques, there was no significant difference (p = 0.85) in acute success rates. During 24.3 months of follow-up period, in 60.0% of the patients no recurrence occurred. The arrhythmia recurred in 6 cases (40.0%) after anteroseptal line ablation, and in 8 cases (53.3%) after mitral isthmus line ablation. No difference was found in the long term efficiency of two  different ablation techniques (p = 0.211).

Conclusion

In our retrospective study we found no significant difference in the short and long term efficiency of two different therapeutic approaches to perimitral atrial flutter.
P1431Radiofrequency ablation of left atrium in patients with mitral valve replacement. The future of surgical treatment for atrial fibrillation in mitral valve disease?
Authors: Utyasheva A , Abdulyanov I V , Sungatullin M A , Vagizov I I
Published: June 2020

Aims

  The evaluation of sinus rhythm preservation after surgical treatment of atrial fibrillation by left-atrial RFA in patients with mitral valve prosthetics.

Materials and methods

 A prospective, randomized study was performed in the interregional clinical and diagnostic center of Kazan in 2011-2018 which were included 136 patients with mitral valve pathology and persistent AF. The average age of patients was 57 ± 5, the gender division was dominated by female patients  and made up 97 (58.4%).

All patients underwent either mitral valve prosthesis with mechanical prosthesis Meding-2 which made up 96 (70.5%) or biological prosthesis Carpantier-Edwards which made up 40 (29.4%).

Radiofrequency isolation of the left atrium and pulmonary veins was performed by standard procedure by Cox-IV which doesn’t include the right atrium tissue.

Results and discussion: In the early post surgical period, recovery of sinus rhythm was observed in 111 (81.6%) patients. Cardiac Pacemaker Implantation was performed in 1 (0.73%) case.  The results of the study were assessed after surgical treatment in 22 ± 5 months, the sinus rhythm was preserved in 99 patients from the study group and made up 72.7%.

Conclusion

Radiofrequency ablation  the left atrium provides long-term preservation of sinus rhythm in the treatment of patients with atrial fibrillation and mitral valve pathology.
P472Cerebral thromboembolic risk in atrial fibrillation ablation: a direct comparison of vitamin K antagonists versus non-vitamin K-dependent oral anticoagulants
Authors: Petzl A M , Derndorfer M , Kollias G , Moroka K , Aichinger J , Martinek M , Puererfellner H
Published: June 2020

Aims

Cerebral thromboembolic events are well-known complications of pulmonary vein isolation (PVI) and can manifest as stroke or silent cerebral embolic lesions. Over the last years, the preferred oral anticoagulation in atrial fibrillation (AF) shifted from vitamin K antagonists (VKA) to non-vitamin K-dependent oral anticoagulants (NOAC). The aim of this study was to compare the incidence of cerebral embolic lesions after AF ablation in patients on VKA versus patients on NOAC, and to identify corresponding clinical and procedural risk factors.

Methods

A total of 421 patients undergoing PVI (by radiofrequency catheter or cryoballoon) were prospectively included into the study. Of these, 43.7% were on VKA and 56.3% on NOAC treatment. In the NOAC group 38% of patients had an interruption of anticoagulation for 24-36 hours. All patients underwent pre- and postprocedural cerebral magnetic resonance imaging.

Results

Periprocedural cerebral lesions occurred in 13.1% overall. Of these, three (0.7%) resulted in symptomatic cerebrovascular accidents. Incidence of cerebral lesions was significantly higher in patients on NOAC compared to VKA (16% vs. 9.2% respectively, p = 0.04), as well as in patients that had intraprocedural cardioversions compared to no cardivoersions (19.5% vs. 10.4% respectively, p = 0.03). In multivariate analysis both parameters were found to be independent risk factors for cerebral embolism. No significant difference between interrupted and uninterrupted NOAC administration could be detected.

Conclusions

In patients undergoing AF ablation, we identified the use of NOAC and intraprocedural cardioversion as independent risk factors for the occurrence of periprocedural cerebral embolic lesions.

Abstract Figure. Incidence of cerebral embolic lesions
P521Conversion test during Subcutaneous Implantable Cardioverter-Defibrillator Implantation in clinical practice: in-hospital and mid-term outcome
Authors: Bianchi V , Diemberger I , Tavoletta V , Perrotta L , Ottaviano L , Migliore F , Francia P , Ammendola E , De Bonis S , Ferrari P , Dello Russo A , Palmisano P , Salzano G , Lovecchio M , Viani S
Published: June 2020

Funding Acknowledgements

No funding

OnBehalf

RHYTHM DETECT Registry

Background

With subcutaneous implantable cardioverter–defibrillators (S-ICD), conversion test (CT) is still recommended at implantation. However, prior works found that adherence to this recommendation is declining in clinical practice.

Purpose

To describe current practice regarding CT at S-ICD implantation, and also measure in-hospital outcome of patients who underwent CT and mid-term outcome of patients without CT.

Methods

We analyzed 1652 consecutive patients (49 ± 15 years old, 80% male, 51% with ischemic or non-ischemic dilated cardiomyopathy, 45% with ejection fraction ≤35%) who underwent S-ICD implantation in 60 Italian centers from 2013 to 2019.

Results

CT data were missing in 27 patients. CT was performed in 1300 patients. Successful conversion with ≤65J was obtained in 97.4% of patients. Shock at 80J was not effective in 12 (0.9%) patients. In 10 of these patients the CT was successful after device repositioning, while in 2 patients it was decided to implant a transvenous ICD. Two (0.15%) episodes of electromechanical dissociation (1 fatal) were reported as consequence of CT. CT was not performed in 325 patients (for clinical reasons in 182 patients, for facility preference in 71, ventricular fibrillation not inducible in 72 patients). As compared to the CT group, these patients were older (51 ± 16 vs. 48 ± 15 years; p < 0.01) and had lower ejection fraction (37 ± 16% vs. 46 ± 16%; p < 0.01). 243 non-CT patients had at least 6 months follow-up (median 15 months). In this group, 12 (4.9%) patients had appropriate shocks to treat VT/VF (all successfully terminated with the first shock), and 9 (3.7%) patients had inappropriate shocks.

Conclusions

This analysis showed that CT is frequently omitted in current clinical practice, especially in older patients with worse systolic function. Shocks at CT are very frequently effective and system revision after CT is rarely required. CT is also safe, although serious adverse events cannot be excluded. A strategy that omits CT did not appear to compromise the effectiveness of the S-ICD, but larger populations and longer follow-up are needed to confirm this finding.
P1181Lead dependent tricuspid dysfunction- mechanism and treatment
Authors: Polewczyk A , Nowosielecka D , Tomaszewski A , Brzozowski W , Szczesniak-Stanczyk D , Polewczyk M , Jachec W , Kutarski A
Published: June 2020

Background

Lead dependent tricuspid dysfunction (LDTD) is  a hardly recognizable severe complication of permanent cardiac pacing.

Purpose

Aim of the study was to assess the mechanism of lead dependent tricuspid dysfunction (LDTD) and effect of transvenous leads extraction (TLE) in theese patients.

Methods

We analyzed the clinical data of 3110 patients undergoing TLE from 01/2006 to 09/2019 in a single center. Echocardiographic assessment  was performed in 2559 patients. LDTD mechanism and improvement of valve function after unblocking (by removing the lead) were analyzed.

Results

LDTD was recognized in 98 (7,3%) patients. The most common mechanism of LDTD was pulling up the leaflet of tricuspid valve by the lead. Improvement of tricuspid valve function was observed in all patients with recognized LDTD. 18 patients with slight improvement were directed to cardiosurgery after TLE.

Conclusions

LDTD should be considered in patients with implanted pacing system and severe tricuspid regurgitation. Transvenous leads extraction can improve function of tricuspid valve in theese patients.

Abstract Table
P1147Complications in young ICD patients - a retrospective analysis
Authors: Zweiker D , Puntus T , Egger F , Kriz R , Koch J , Hellebart P , Huber K , Nurnberg M
Published: June 2020

Introduction

In specific situations implantable cardioverter defibrillator (ICD) therapy is recommended for patients under the age of 40 years. Due to the active lifestyle of this patient population, complication rates in devices with conventional transvenous electrodes may be higher than for the remaining population.

Methods

The ICD-YOUNG study is a retrospective analysis of consecutive patients ≤ 40 years undergoing transvenous or subcutaneous ICD (s-ICD) implantation, device change or lead revision at our centre between July 2006 and December 2017. Rehospitalization for lead failure or device battery depletion was documented.

Results

Out of 586 patients undergoing ICD implantation, 35 patients (6.0%) were ≤ 40 years. Mean age was 30.0 ± 7.2 years, 48.6% were female, 37.1% received ICD therapy for primary prevention and 11.4% primarily received s-ICD. Median follow up was 7.3 (interquartile range, 1.8-12.0) years, with a lower follow up duration in s-ICD patients than conventional ICD patients (median, 2.9 vs. 9.0 years). Over the course of follow-up, 37.1% received successful anti-tachycardia therapy. 19.4% of patients in the conventional ICD group had right ventricular lead problems requiring intervention, while none of the s-ICD patients had to be revised. Time to first device change due to battery depletion and/or device upgrade was similar in young and remaining patients (median 5.4 vs 6.0 years, p = 0.23).

Discussion

Young patients requiring ICD have a high rate of lead problems. In most young patients, s-ICD therapy is an encouraging alternative to conventional ICD therapy with a lower lead failure rate.
P526Are 40 joules enough for successfully defibrillate with subcutaneous implantable cardioverter-defirbrillator?
Authors: Biffi M , Bianchi V , Ziacchi M , Palmisano P , Pieragnoli P , Manzo M , Ottaviano L , Piro A , Nigro G , Bonfantino M V , Perego G B , Rapacciuolo A , Caroli E , Lovecchio M , Viani S
Published: June 2020

Funding Acknowledgements

NO FUNDING

OnBehalf

Rhythm Detect Registry

Background

The subcutaneous ICD (S-ICD) is an effective alternative to the traditional transvenous option. Due to its extracardiac design the S-ICD requires a higher shock output than the traditional ICD. Nonetheless, preliminary data suggest that acute defibrillation test may be successful even at energies lower than the usually tested value of 65J, and that optimization of implantation technique may increase the defibrillation safety margin among S-ICD recipients.

Purpose

To evaluate the efficacy of conversion test performed at 40J, and to investigate the association between shock efficacy, clinical characteristics and device position.

Methods

VF was induced and subsequently, conversion test was performed by delivering a 40J shock. Success was defined as termination of VF by the first shock. S-ICD system positioning was evaluated with the PRAETORIAN score using bidirectional chest X-rays. Cranial-caudal S-ICD placement was defined as superior if the entire generator was contained in the cardiac silhouette, inferior if partially or completely outside.

Results

233 consecutive patients (83% male, 49 ± 14 years, BMI 26 ± 4kg/m2, ejection fraction 46 ± 17%, 112 (48%) ischemic/non-ischemic dilated cardiomyopathy) were enrolled and underwent S-ICD implantation with conversion test at 40J. The generator was positioned in an intermuscular pocket in 228 patients (98%). The PRAETORIAN score was <90 (low risk of conversion failure) in 218 (94%) patients. Cranial-caudal generator placement was superior in 188 (81%) patients. Overall, VF termination occurred in 191 (82%) patients with 40J. The BMI was similar in patients with successful and unsuccessful termination (26 ± 4kg/m2 versus 27 ± 6kg/m2, p = 0.195). The efficacy was comparable in patients with dilated cardiomyopathy (86%) versus other conditions (79%, p = 0.153). PRAETORIAN score was not associated with shock efficacy at 40J (82% with score <90 versus 87% with score ≥90, p = 1.000), while a trend toward higher efficacy was seen with superior generator placement (84% versus 73%, p = 0.093).

Conclusions

We observed high S-ICD defibrillation success rate at 40J, suggesting that the safety margin is frequently higher than the usually accepted 15J. We found no difference in efficacy according to the cardiac disease and no association between test failure and body habitus. The intermuscular positioning of the generator resulted in low values of the PRAETORIAN score that however did not appear associated with test efficacy.
P1049Influence of body mass index on recurrence in atrial fibrillation patients after radiofrequency catheter ablation
Authors: Calero Nunez S , Hidalgo-Olivares V M , De Leon-Ruiz A , Diaz-Lancha S , Exposito-Calamardo L , Ramos-Martinez R , Garcia-Sacristan J F , Cordoba-Soriano J G , Enero-Navajo J
Published: June 2020

Funding Acknowledgements

No conflicts of interest

INTRODUCTION

 Evidence has shown that obesity, expressed as high body mass index (BMI), is associated with the development of atrial fibrillation(AF). However, the relationship between BMI and recurrence of AF after catheter ablation(CA) remains controversial. Understanding this relationship, may help in regard to patient(p) counseling and management before and after CA.

Purpose

To evaluate single center AF recurrences after pulmonary vein isolation according to BMI status. Secondary endpoints were to compare the influence of other comorbilitys such as pulmonar disease or obstructive sleep apnea(OSA)

METHODS

We included 114p with AF(54,5 ± 9,6 years; male 75,4%; paroxysmal 70,2%; persistent 29,8%) treated with first time radiofrequency ablation between 2013 and 2018. On the basis of the baseline BMI, patients were categorized into 2 groups: normal/overweigth (BMI < 30kg/m2) and obese(BMI≥30kg/m2).

RESULTS

There was no significant difference between the majority of baseline characteristics of the groups (table 1), however patients with BMI≥30 were more likely to sufferd OSA(34% vs 8,2%:p = 0,001), to have larger left atrial (diameter > 40mm: 70,5% vs 46,3%;p = 0,004), and persistent AF (43,4% vs 18%; p 0,004). During 12 months of follow-up AF recurred in 34p (29,8%), the freedom from AF was significantly higher in the BMI < 30 group (48p(80%) vs 31(58,5%), p = 0,015). Multivariate analysis including variables of type of AF, OSA, BMI, left atrial size, ejection fraction, and hypertension demonstrated that BMI was the strongest predictor of being freedom from recurrent AF (OR = 0.35, 95% CI: 0,11–0,81, P = 0.014). A serious complication occurred in 6p(5,3%), with no relationship to BMI.

CONCLUSION

This study suggest that tight association between obesity and AF recurrence after ablation may be partly due to other concomitant conditions which in turn are more frequent in obese patients like OSA, left atrial size and presence of persistent AF.

Abstract Table 1
855Performance of a multisensor icd algorithm in heart failure patient management
Authors: Santini L , Bianchi V , Dello Russo A , Calo L , Pecora D , Mahfouz K , Favale S , Petracci B , Costa A , Cipolletta L , De Ruvo E , La Greca C , Mangone G , Campari M , D Onofrio A
Published: June 2020

Funding Acknowledgements

No funding

Background

The HeartLogic index combines data from multiple implantable cardioverter-defibrillator (ICD)-based sensors and has proved to be a sensitive and timely predictor of impending heart failure (HF) decompensation.

Purpose

To describe a multicenter experience of remote HF management of patients who received a HeartLogic-enabled ICD or cardiac resynchronization therapy ICD (CRT-D).

Methods

The HeartLogic feature was activated in 104 patients (76 male, 71 ± 10 years, left ventricular ejection fraction 29 ± 7%). In accordance with a standardized follow-up protocol, remote data reviews and patient phone contacts were performed monthly and at the time of HeartLogic alerts (when the index crossed the nominal threshold value of 16), to assess the patient decompensation status. In-office visits were performed every 6 months or when deemed necessary.

Results

During a median follow-up of 13[11-18] months, 100 HeartLogic alerts were reported (0.82 alerts/pt-year) in 53 patients. 60 HeartLogic alerts were judged clinically meaningful (i.e. associated with worsening of HF or resulted in active clinical actions). Specifically, multiple associated conditions were reported: 45 (75%) symptoms or signs of clinical deterioration of HF, 13 (22%) discontinuations or reductions of prescribed HF therapy, 11 (18%) declines in CRT percentage (with or without new onset atrial fibrillation), 8 (13%) recurrences of previous HF events. For 48 out of 60 alerts the clinician was not previously aware of the condition. Of these, 43 alerts triggered multiple clinical actions. Alert-triggered actions were: 30 (70%) diuretic dosage increases, 15 (35%) other drug adjustments, 6 (14%) HF hospitalizations, 3 (7%) device reprogramming/revisions, 1 (2%) cardioversion, 1 (2%) patient education on therapy adherence. Out of 40 non-clinically meaningful alerts (0.33 alerts/pt-year), 8 (20%) were associated with non-HF therapy changes or interventions, 3 (8%) with pulmonary events, 29 (72%) remained unexplained. The overall number of HF hospitalizations was 16 (rate 0.13 hospitalizations/pt-year). Five HF hospitalizations were not preceded by HeartLogic alert (0.04 hospitalizations/pt-year).

Conclusions

The HeartLogic index provided clinically meaningful information and allowed to remotely identify relevant HF related clinical conditions, with a low rate of unexplained detections and undetected HF events. In this experience, remote monitoring using HeartLogic alerts allowed to drive HF care and take effective clinical actions.
P1492Comparison of the long-term performance of the quadripolar IS-4 and the bipolar IS-1 left ventricular lead for cardiac resynchronization therapy
Authors: Maurhofer J , Tanner H , Haeberlin A , Noti F , Seiler J , Baldinger S H , Roten L , Lam A , Asatryan B , Nozica N , Franzeck F , Kueffer T , Reichlin T , Servatius H
Published: June 2020

BACKGROUND

The implantation of left ventricular (LV) leads for cardiac resynchronization therapy (CRT) and the management of lead-related complications can be challenging. The introduction of the quadripolar IS-4 LV lead may have facilitated the implantation procedure and may have reduced lead-related complications. Data of long-term follow-up (FU) comparing the IS-4 lead with the IS-1 LV lead are rare and conflicting.

PURPOSE

Comparison of lead-related complications and all-cause mortality between CRT patients who received an IS-4 or an IS-1 LV lead in the long-term FU.

METHODS

Adults with an indication for a CRT-Defibrillator or CRT-Pacemaker, a successful endovascular IS-4 or IS-1 LV lead implantation, and a minimal FU of three years were included in this retrospective study. The combined primary endpoint was freedom from lead-related complications defined as (i) occurrence of persisting high pacing threshold (>2.75V/0.4ms), (ii) unresolved phrenic nerve stimulation, (iii) LV lead dislodgement/disruption, (iv) the necessity of re-interventions affecting the LV lead, and (v) LV lead deactivation/explantation. Secondary endpoints were all singular complications and all-cause mortality.

RESULTS

Eligible for the study were 133 patients (IS-4 n = 66; IS-1 n = 67) with a mean FU of 4.03 ± 1.93 years. Baseline characteristics of both patient groups did not differ significantly. Freedom from lead-related complications was higher in patients with an IS-4 lead as compared to an IS-1 lead (Figure 1; 87.9% vs. 65.7%; p = 0.002). The secondary outcomes showed a higher rate of LV lead dislodgement/disruption (4.5% vs. 17.9%; p = 0.015) in the IS-1 patient group and more patients suffered from unresolved phrenic nerve stimulation with an IS-1 lead (3.0% vs. 13.4%; p = 0.029). LV lead deactivation/explantation during FU and LV lead-related re-interventions were fewer in case of an IS-4 lead (4.5% vs 22.4%; p = 0.003; 6.1% vs. 17.9%; p = 0.036, respectively). The rate of persisting high pacing thresholds and all-cause mortality did not differ (4.5% vs. 9.0%; p = 0.492; 22.7% vs 25.4%; p = 0.721, respectively).

CONCLUSION

The quadripolar IS-4 LV lead showed in this retrospective study a better long-term performance than the bipolar IS-1 lead.

Abstract Figure 1
P311Hypertrophic cardiomyopathy and other forms of left ventricular hypertrophy. The P wave can make the difference
Authors: Raab S , Roten L , Branca M , Nozica N , Wilhelm M , De Marchi S , Brugger N , Elchinova E , Seiler J , Asatryan B , Tanner H , Baldinger S H , Lam A , Reichlin T , Servatius H
Published: June 2020

Background

Structural disarray of hypertrophied myocytes and interstitial fibrosis characterize hypertrophic cardiomyopathy (HCM). These morphological changes also affect atrial myocytes and, together with hemodynamic alterations because of HCM, may lead to atrial cardiomyopathy. 

Purpose

To investigate the incremental value of P-wave parameters to differentiate left ventricular hypertrophy (LVH) because of HCM from LVH in hypertensive heart disease (HHD) and athletes heart. 

Methods

In a prospective study, we compared electrocardiographic (including signal-averaged ECG of the P wave) and echocardiographic data of patients with HCM, HHD and athletes heart. We developed a predictive model with a simple scoring system to identify HCM.

Results

We compared data of 27 patients with HCM (70% males, 49.8 ± 14.5 years), 324 patients with HHD (52% males, 74.8 ± 5.5 years), and 215 subjects with athletes heart (72% males, 42.3 ± 7.5). The table shows the significant differences among the 3 groups. We included the following parameters into a predictive score to differentiate HCM from other forms of LVH: QRS width (>88ms = 1 point), P-wave integral (>688µVs = 1 point) and septum thickness (>12mm = 2 points). A score >2 (Youden index 0.626) correctly classified HCM in 81% of the cases with a sensitivity and specificity of 82% an 81%, respectively. 

Conclusion Differentiation of HCM from other forms of LVH is improved by including atrial parameters. A simple scoring system including septum thickness, QRS width and P wave integral allowed identification of patients with HCM with a sensitivity and specificity of >80%. This score needs to be validated prospectively.

Table 1 HCM HHD Athletes P-value HCM vs HHD* HCM vs Athletes* 95%-CI P-value 95%-CI P-value P-wave duration [ms] 152.7 ± 25.8 143.9 ± 16.5 133.5 ± 14.2 <0.001 -16.9 -24.6 to -9.1 <0.001 -16.3 -22.7 to -9.9 <0.001 P-wave integral [µVs] 850.4 ± 272.4 672.0 ± 235.4 773.1 ± 260.1 <0.001 -198.6 -320.8 to -76.3 0.002 -68.2 -169.7 to 33.2 0.187 QRS [ms] 110.3 ± 27.3 96.9 ± 20.3 95.1 ± 9.8 <0.001 -16.4 -24.7 to -8.1 <0.001 -13.8 -20.8 to -6.9 <0.001 QTc [ms] 447.9 ± 27.2 438.6 ± 24.5 414.0 ± 22.9 <0.001 -21.1 -32.7 to -9.5 <0.001 -30.8 -40.5 to -21.2 <0.001 LVMMI [g/m2] 153.6 ± 55.5 133.5 ± 30.3 98.6 ± 19.7 <0.001 -15.3 -29.7 to -0.9 0.038 -56.1 -67.7 to -44.6 <0.001 IVS [ms] 16.8 ± 4.2 11.8 ± 2.2 10.3 ± 1.5 <0.001 -5.2 -6.3 to -4.1 <0.001 -6.4 -7.3 to -5.6 <0.001 LAVI [ml/m2] 43.2 ± 13.9 30.5 ± 9.7 30.8 ± 9.5 <0.001 -14.6 -20.0 to -9.3 <0.001 -12.2 -16.6 to -7.9 <0.001 The table shows the study result after univariate and multivariate (*; adjusting for age and sex) analysis.

Abstract Figure 1