bluuebunny/crossref_metadata_2025 huggingface dataset:
Implantable loop recorder follow-up
Authors: Pena Mellado J , Macias R , Tercedor L , Alvarez Lopez M
Published: October 2021

Introduction

Long ambulatory ECG monitoring can be a useful component in the evaluation of the patient with unexplained syncope or syncope with suspected arrhythmic origin, as well as a sensitive tool for detecting asymptomatic spontaneous cardiac arrhythmias or conduction abnormalities in predisposed patients.

Purpose

To determine the diagnostic cost-effectiveness of the implantable loop recorder (ILR) in the origin of unexplained syncope in our center.

Methods

A retrospective observational study was carried out in a tertiary center, those patients with an ILR between August 2014 and March 2021 were included. Baseline characteristics of the population and their previous ECG, arrythmias detected during follow-up and pacemaker implant rate were evaluated.

Results

One hundred twenty-seven patients with a ILR were included (age 67 years, 49.6% males). Most often cause of ILR was unexplained syncope (90.6%) followed by monitoring after TAVI implant (3.9%). Normal LVEF (>50%) was present in 85.6%,and 75.6% had NYHA I functional class. 118 patients (92.9%) presented sinus rhythm at implant time, and 8 (6.3%) presented AF. 12.6% presented first degree atrioventricular (AV) block, 2 patients (1.6%) had presented previously Mobitz Type I AV block and one patient 2:1 block. Left bundle branch block (LBBB) was present in 13.4%,RBBB in 3.1%,LAFB in 9.4%, RBBB+LAFB in 11% and RBBB+LPFB in 2.4%. Median time of follow-up was 21 months. 3rd degree AV block was the most frequent arrhythmia detected (12.1%), followed by >3s pause (8%) and previously unknown AF (2.4%).The patients with syncope who suffered head trauma (33%) presented a higher rate of pacemaker (PCM) implant compared to those without head trauma: 31.6% vs 14.7%. In total,19.8% PCM rate implant during follow-up. No complications ILR related.

Conclusion

In conclusion, long home ECG monitoring with ILR is a powerful and helpful tool to find out or rule out potentially dangerous arrhythmias as cause of syncope, with no complications in our experience.

Funding Acknowledgement

Type of funding sources: None. Baseline characteristicsArrhythmias detected during follow-up
Role of LA strain assessed by speckle tracking echocardiography in predicting patients who develop POAF after a coronary artery bypass surgery
Authors: Rukmani Prabha V , Rajeshwari N , Jenifer J
Published: October 2021

Objectives

To evaluate the correlation between left atrial dysfunction assessed by speckle tracking echocardiography and development of postoperative atrial fibrillation (POAF) in patients undergoing coronary artery bypass grafting. To determine the role of coronary risk factors in development of POAF.

Method

Patients undergoing CABG from January 2019 till June 2020 in Apollo institute, fulfilling the inclusion and exclusion criteria were included.Total of 200 patients were followed.They were subjected to LA strain and strain rate analysis by speckle tracking.

Results

The incidence of POAF in our study was 24% (n=48). The mean age of this study population was 59.13 years. The patients who developed POAF were older (68.5±9.048 vs 58.39±9.74 years, p value=0.05) than those with no POAF. POAF occurred in 2 phases. the highest proportion of POAF occurrence noticed on postoperative day 2. Among the total POAF cases 79.% occurred within the first 48 hours and 20.8% occurred later (p=0.001). Among the 48 patients who developed POAF, 5 of them developed recurrence during their hospital stay. They had reverted to sinus rhythm following anti-arrhythmic medication for a duration of >24 hours, but went on to develop recurrence of AF at a later. 4 among them reverted to sinus rhythm at discharge while 1 continued to remain in AF at discharge.The duration of hospital stay for patients with POAF group was 10.4 days compared with 10.04 days for those without POAF. Similarly the post-operative stay in the hospital was 7.4 days for the POAF group and 7.04 days for the NO POAF.There was no added economic impact secondary to AF.Comparing the values of left atrial volume index of both the groups it was derived that the mean LAVI value of the POAF group was 26.84+3.654 ml/m2 and that for the NO POAF group was 26.6+3.037ml/m2. Though the patients with POAF had larger LA volume, the chi square test analysis did not yield any clinically significant relationship between LAVI and POAF in our study (p=0.3). The mean LA global strain for the patients with POAF was 29.73+3.695%. And for the patients with no POAF was 36.3+4.854%. LA global strain was reduced in patients who developed POAF (P<0.001) which indicated a strong correlation between LA strain and POAF.

Conclusion

There is significant correlation between Global Left Atrial Strain and POAF in patients undergoing CABG (P<0.001).There is no significant correlation between patient factors like age, BMI, and the conventional coronary risk factors with POAFThere is no significant correlation between the conventional echocardiographic parameters like LA diameter, LAVI, LVDD, LVSD, LVEF and transmitral flow velocities with POAF.

To conclude, preoperative speckle tracking assessment of LA has a strong predictive role in determining the occurrence of POAF in patients undergoing Coronary artery bypass grafting surgery.

Funding Acknowledgement

Type of funding sources: None.
Electrograms from the coronary sinus as a predictor for the outcome of a re-do pulmonary vein isolation
Authors: Mohsen Y , Grossmann N , Draheim J , Horlitz M , Stoeckigt F
Published: October 2021

Background

Voltage signals in the coronary sinus (CS) have been associated with the presence of left atrial fibrosis. The aim of the present study was to evaluate the value of CS voltage signals as a predictor for atrial fibrillation (AF)-recurrence-free outcome of pulmonary vein isolationprocedures (PVI) in patients after a first unsuccessful cryo-balloon PVI.

Method

We collected recordings from a diagnostic catheter positioned in the CS from 282 consecutive atrial fibrillation patients undergoing a re-dopulmonary vein isolation using a 3D mapping system. The patients were followed-up (Holter ECG and telephone calls) for at least one year (median of 14 months).

Results

Of the 282 patients (male 72%, mean age 63±10.8 years, 61% persistent AF) AF recurrences were documented in 152 pts (54%)with a signal amplitude in the proximal CS position of 2.4 mV ± 1.5 mV. Patients free of AF-recurrence showed significantly higher signal amplitude of 2.9 mV ± 2.1 mV (P<0,05).

A CS voltage <0.53mV could predict recurrences of AF with a sensitivity of 94.7% (95% CI 89.3% – 97.8%) and specificity of 8.6% (95% CI 4.6% – 14.8%; PLR 1.04; AUC 0.55).

Conclusion

Voltage signals in the CS, as a marker for left atrial fibrosis, are associated with the outcome of PVI. A voltage threshold of <0.53mV can predict AF recurrences with a high sensitivity. However, the predictive value for AF recurrences is not high due to the low specificity of this test.

Funding Acknowledgement

Type of funding sources: None.
Novel rhythm conversion approach in unsuccessful electric cardioversion of persistent atrial fibrillation
Authors: Pyataeva O V , Zenin S A , Kononenko O V , Felikov I M , Fedoseenko A V
Published: October 2021

The average effectiveness of electrical cardioversion in persistent atrial fibrillation (AF) is considered about 90%. The success is limited by arrhythmia longevity, essential heart pathology, excessive body mass, concomitant deceases. A novel developed in Russia class III intravenous medication “Refralon” (4-nitro-N-(1RS)-1(4-fluorophenyl)-2-(1-ethylpiperidin-4-ethyl) benzamide hydrochloride) seems to be promising in sinus rhythm restoration in such patients.

The aim of the study was to assess the effectiveness of a novel class III intravenous medication “Refralon” in conversion to sinus rhythm in patients with permanent AF in whom electrical cardioversion was unsuccessful.

Materials and methods

19 patients were included: 16 male and 3 female aged from 45 to 68 years old (59,9±5,84 (M±SD)). Left atrial size was 47±3,2 × 59±2,8 mm, BMI 38,5±7,0 kg/m2, arrhythmia duration from 2 to 21 months (6,7±4,99). Refralon was injected according to the approved manual in ICU; heart rhythm and rate, blood pressure, SpO2 were monitored. Dynamic assessment of QT and QRS duration was performed.

Results

In 17 of 19 patients (89,4%) sinus rhythm was restored. In 7 patients (41%) sinus rhythm was restored before 10 min, in 4 patients (24%) before one hour, in 4 patients (24%) before two hours, in 2 patients (11%) before six hours. In two patients sinus rhythm was not restored. In both target dose was not infused due to non-sustained ventricular tachycardia in one case, and QT prolongation in another.

Conclusion

In a small pilot study Refralon was highly effective in patients with persistent atrial fibrillation when electrical cardioversion was ineffective. All the patients had significantly increased BMI. The results may suggest the indication for Refralon usage in obese patients.

Funding Acknowledgement

Type of funding sources: None.
Long-term outcomes among a cohort of 4296 implantable cardioverter-defibrillator patients: insights from the UMBRELLA study
Authors: Briongos Figuero S , Garcia Alberola A , Rubio J , Segura J M , Rodriguez A , Peinado R , Alzueta J , Martinez Ferrer J B , Vinolas X , Munoz Aguilera R , Perez M L
Published: October 2021

Background

Large observational real-world studies describing modern implantable cardioverter-defibrillator (ICD) populations with long-term follow-up are lacking.

Purpose

To assess the incidence of arrhythmias in a cohort of contemporary patients undergoing ICD implant from 2005 and 2017 and to analyze the arrhythmic risk and mortality according to their clinical profiles.

Methods

UMBRELLA (NTC01561144) is a prospective, multicentre, nationwide study of ICD patients followed by remote monitoring. All device information was automatically stored through the remote monitoring system and a blinded review of all the stored arrhythmic episodes was performed. The study outcomes were first appropriate ICD therapy and all-cause death.

Results

The study population consisted of 4296 patients (61.9±12.9 years, ischaemic cardiomyopathy (ICM): n=2150, dilated cardiomyopathy (DCM): n=1166, valvular heart disease (VHD): n=119, hypertrophic cardiomyopathy (HCM): n=294, arrhythmogenic right ventricular cardiomyopathy (ARVC): n=71, Brugada syndrome (BS): n=143, long QT syndrome (LQTS): n=43, and adult congenital heart disease (ACHD): n=60)). Primary prevention (PP) was the main indication (n=2758).

During a mean follow-up of 46.6±27.3 months, 16,067 episodes of sustained ventricular arrhythmia (SVA) occurred in 1344 patients. Appropriate ICD therapy was delivered to 85.7% (n=13,767) episodes of SVA in 1173 patients (27.3% of population). A higher risk of first appropriate ICD therapy was observed in VHD (HR: 1.94, 95% CI: 1.43–2.62), ARVC (HR: 1.84, 95% CI: 1.28–2.66), ICM (HR: 1.51, 95% CI: 1.29–1.78), and DCM (HR: 1.28, 95% CI: 1.07–1.53) whereas patients with HCM (HR: 0.72, 95% CI: 0.54–0.96) and BS (HR: 0.25, 95% CI: 0.14–0.45) were at significantly lower risk (Figure 1A). In multivariate analysis (Table 1), age, gender, atrial fibrillation (AF), secondary prevention, LVEF ≤35%, and QRS width emerged as clinical predictors of appropriate ICD therapy, whereas CRT-D correlated with lower risk. An independently higher risk was found in DCM, VHD, and ARVC, and a lower risk in BS patients.

At follow-up, 590 deaths (13.4% of population) were reported. Patients with ICM (HR 3.90, 95% CI: 2.58–5.90), DCM (HR 3.33, CI 95%: 2.18–5.10), and VHD (HR 3.97, CI 95%: 2.25–6.99) had worse prognoses and it was significantly better in BS patients (HR 0.11, 95% CI: 0.01–0.67, p=0.017) (Figure 1B). In multivariate analysis, age, gender, AF, renal failure, diabetes and reduced LVEF, emerged as independent predictors of all-cause death (Table 1).

Conclusions

Irrespective of the aetiology, contemporary ICD patients with an arrhythmic substrate derived from left ventricular systolic dysfunction had a similar risk of ICD life-saving interventions and death.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1
Defibrillation testing of subcutaneous versus transvenous defibrillators in the clinical practice: a nationwide survey in Italy
Authors: Migliore F , Viani S , Ziacchi M , Ottaviano L , Checchi L , Francia P , D'Onofrio A , Bisignani G , Dello Russo A , De Filippo P , Solimene F , Pisano E , Palmisano P , Manzo M , Botto G L ,   RHYTHM DETECT registry
Published: October 2021

Aims

According to current guidelines, defibrillation testing (DT) for efficacy can be omitted in patients undergoing transvenous implantable cardioverter–defibrillator (T-ICD) implantation. DT is still recommended for patients at risk for a high defibrillation threshold (e.g. hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, right-sided implantations) and for ICD generator changes. Moreover, a class I recommendation remains to perform DT during the implantation of subcutaneous ICD (S-ICD). The aim of the present survey was to analyze the current practice of DT during T-ICD and S-ICD implantations in Italy.

Methods

In March 2021, an ad hoc questionnaire on the current performance of DT and the standard practice adopted during testing was completed by 72 operators at Italian centers implanting S-ICD and T-ICD.

Results

48 (67%) operators reported never performing DT during de-novo T-ICD implantations, while no operators perform it systematically. The remaining respondents perform it in specific cases: right sided implantations (54%), poor signal sensing (46%), secondary prevention patients (42%), arrhythmic syndromes (13%), hypertrophic cardiomyopathy (8%). DT is never performed at T-ICD generator change. At the time of de-novo S-ICD implantation, DT is never performed by 9 (13%) operators and performed systematically by 48 (66%). The remaining operators perform DT in cases of: secondary prevention patients (73%), sub-optimal S-ICD placement (33%), non-compromised ejection fraction (33%) or obese patients (7%). DT is not performed at S-ICD generator change by 92% of operators. DT is conducted by delivering a first shock energy of 65J by 60% of operators, while the remaining 40% test lower energy values. The most frequently reported conditions for revising the system at the end of de- novo implantation procedure is high shock impedance (54%) and sub-optimal S-ICD placement or high PRAETORIAN score (50%). With adequately low shock impedance and optimal system placement, 37% of operators would accept a defibrillation margin <15J.

Conclusion

In current clinical practice, the vast majority of operators omit DT at T-ICD implantation, even when still recommended in the guidelines. DT is also frequently omitted at S-ICD implantation. We also report a wide variability among operators in the procedures followed during DT and in the criteria applied for defining the procedural success.

Funding Acknowledgement

Type of funding sources: None.
Acute change in parasympathetic cardiac innervation after pulmonary vein isolation by pulse-field and radiofrequency energy
Authors: Stojadinovic P , Wichterle D , Peichl P , Cihak R , Haskova J , Jansova H , Nejedlo V , Kautzner J
Published: October 2021

Background

In patients with atrial fibrillation (AF), pulmonary vein isolation (PVI) by radiofrequency (RF) energy is associated with a significant change of cardiac autonomic regulations due to collateral ganglionic plexi ablation. Pulse-field (PF) ablation energy presumably spares neural tissue.

Purpose

We compared the effect of PVI by PF and RF energy on cardiac autonomic function.

Methods

A study enrolled 23 patients who underwent PVI in general anaesthesia. In 12 patients, a novel lattice-tip catheter and PF energy were used for ablation while 11 patients were ablated using a conventional irrigated-tip catheter and RF energy. The response of the sinus node (SAN) and atrioventricular node (AVN) to extracardiac high-frequency vagal stimulation (ECVS) was tested before and after PVI (via right internal jugular vein; stimulation frequency of 50 Hz; pulse width of 0.05 ms; output of 1 V/kg (<70V); train duration of 5 s).

Results

At baseline, physiological massive response to ECVS (sinus arrest and/or AV block) was demonstrated in the majority of patients. After PVI, complete loss of autonomic response of the SAN in 11/11 (100%) and 3/12 (25%) patients (p=0.003), and the AVN in 9/11 (82%) and 3/12 (25%) patients (p=0.01) was observed in RF and PF groups, respectively. The figure shows the maximum duration of the pause in sinus rhythm (maximum P-P interval) and AVN block (maximum R-R interval during atrial pacing) induced by ECVS after PVI.

Conclusion

Cardiac vagal response is preserved in a considerable proportion of AF patients after PF ablation which is in contrast with a significantly stronger effect of RF energy. This may influence the clinical outcome of AF ablation procedures.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Institute for Clinical and Experimental Medicine, Prague
Earliest pulmonary vein potential guided cryoballoon ablation is associated with better clinical outcomes than conventional cryoballoon ablation: a result from two randomized clinical studies
Authors: Yonekawa J , Mizutani Y , Yamashita D , Makino Y , Hiramatsu T , Ichimiya H , Uchida Y , Watanabe J , Kanashiro M
Published: October 2021

Background

With regards to short-term outcome in atrial fibrillation (AF), the benefit of cryoballoon ablation (CBA) by pressing a balloon against the earliest pulmonary vein (PV) potential site during pulmonary vein isolation, (earliest potential [EP]-guided CBA) has been previously demonstrated.

Objective

The present study aimed to evaluate the long-term outcome of the EP-guided CBA.

Methods

This study included 136 patients from two randomized studies, who underwent CBA for paroxysmal AF for the first time. Patients were randomly assigned to the EP-guided and conventional CBA groups in each study. In the EP-guided CBA group, we pressed a balloon against the EP site when the time to isolation (TTI) after cryoapplication exceeded 60 s and 45 s in the first and second studies, respectively. The patients were followed up for 1 year after procedure. We compared the clinical outcomes between the EP-guided CBA group (68 patients) and the conventional CBA group (68 patients).

Results

No significant differences in baseline characteristics were observed between the two groups. Compared with the conventional CBA group, the EP-guided CBA group had a significantly higher success rate at TTI ≤90 s (98.5% vs. 90.0%, P<0.001); lower touch-up rate and total cryoapplication; and shorter procedure time, and fluoroscopy time. The recurrence at 1-year after ablation was significantly lower in the EP-guided CBA group than in the conventional CBA group (6.0% vs. 19.4%; P=0.019).

Conclusions

The EP-guided CBA approach can facilitate the ablation procedure and achieve low recurrence at 1-year after ablation.

Funding Acknowledgement

Type of funding sources: None. Earliest potential [EP]-guided CBAThe recurrence at 1-year after ablation
Long-term outcome of endocardial-only versus combined endocardial-epicardial homogenization of the scar for treatment of ventricular tachycardia in patients with ischemic cardiomyopathy
Authors: Mohanty S , Trivedi C , Della Rocca D G , Gianni C , MacDonald B , Mayedo A , Bassiouny M , Gallinghouse G J , Horton R , Al-Ahmad A , Di Biase L , Burkhardt J D , Natale A.N.D.R.E.A
Published: October 2021

Introduction

We investigated the ablation success of scar homogenization with combined (epicardial + endocardial) versus endocardial-only approach for ventricular tachycardia (VT) in patients with ischemic cardiomyopathy (ICM) at 5 years of follow-up.

Method

Consecutive ICM patients undergoing VT ablation at our center were classified into group 1: endocardial scar homogenization and group 2: endocardial +epicardial scar homogenization. Patients with previous open heart surgery were excluded.

All patients underwent bipolar substrate mapping with standard scar settings defined as normal tissue >1.5 mV and severe scar <0.5 mV. Non-inducibility of monomorphic VT was the procedural endpoint in both groups. Patients were followed up twice a year for 5 years with implantable device interrogations.

Results

A total of 361 (Group 1: 291 and group 2: 70) patients were included in the study (mean age: 67 years, male: 88.4%).

At 5 years, significantly higher number of patients from group 2 remained arrhythmia-free (figure 1). Of those patients, 87 (45%) and 51 (89%) from group 1 and 2 respectively were off-anti-arrhythmic drugs (AAD) (p<0.001). After adjusting for age, gender, hypertension, diabetes, and obstructive sleep apnea, scar homogenization using endo-epicardial approach was associated with 51% less recurrence compared to the endocardial ablation strategy (Hazard Ratio: 0.49, 95% CI: 0.27–0.89, p: 0.02).

Conclusion

In this series of patients with ischemic cardiomyopathy and VT, endo-epicardial scar homogenization was associated with a lower need for AAD and a significantly lower recurrence rate at 5-years of follow-up compared to the endocardial ablation alone.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Initial experience and follow up on the PolarX cryoablation system compared to the established Arctic Front cryoablation system in PVI ablations
Authors: Riesinger L , Popal S R , Bohnen J E , Siebermair J , Pesch E , Rassaf T , Kochhaeuser S , Wakili R
Published: October 2021

Introduction

Pulmonary vein isolation (PVI) with cryoablation was shown to be comparable to radiofrequency ablation (RF) in terms of safety and outcome for patients with atrial fibrillation (AF), so that both techniques are recommended equally by the current guidelines. A new cryoablation system PolarX® was introduced in 2020. We analysed the first patients, who underwent ablation with the new system with respect to procedural and safety outcome and evaluated the freedom from arrhythmia occurrence in the first 6 months compared to patients treated with the established Arctic Front Advance® cryoablation system.

Methods

We included the consecutive 44 patients who underwent cryoablation with the new PolarX® cryoablation system (28mm) and 24 patients who underwent cryoablation with the established Arctic Front Advance® cryoablation system (28mm) for paroxysmal AF. We retrospectively analysed baseline characteristics, procedural- and safety data. In 5 patients of each group an additional high-density 3D-mapping was performed, evaluating the scar-area after cryoablation in both groups (figure 1A+B). After 6 months the freedom of AF (by 7d-Holter-ECG) was evaluated in both groups.

Results

Baseline, procedural characteristics and results are listed in table 1. Mean total procedure duration (“door-to-door-time”) was significantly shorter in the PolarX group compared to the Arctic-Front group (136±34min vs. 163±43min; p<0.05). Number of freezes required to achieve isolation of all pulmonary veins (PVs) and cumulative freezing time was comparable in both groups. Minimal achieved temperatures were significantly lower in the PolarX group vs. ArcticFront group. The scar-area analyzed by 3D-mapping post ablation did not differ in the two groups. Complication rates as well as clinical outcome (freedom from AF) were low and did not differ in the Kaplan-Meier analysis (table 1; figure 1C).

Conclusion

Based on these initial results, cryoablation with the PolarX cryoballoon seems to be comparably effective and safe, with a significantly shorter procedure time and significantly lower achieved temperatures. Nevertheless, future controlled trials with a longer follow-up period will be necessary to evaluate long-term effectiveness.

Funding Acknowledgement

Type of funding sources: None.
Cardiac implantable electronic devices: a marker for poor outcome in patients with COVID-19 infection
Authors: Wizman B , Haim M , Yasoor N , Peles I , Novack V , Konstantino Y ,   Soroka University Medical Center
Published: October 2021

Background

A high percentage of SARS-CoV-2 patients suffer from comorbidities and there is increasing evidence that previous cardiac disease contributes to poor outcome in these patients (1,2). There is a paucity of information regarding the implications of the disease in patients with cardiac implantable electronic devices (CIEDs). Due to the increasing use of CIEDs in the management of arrhythmias and heart failure, determining the association between CIEDs and the severity of this disease is essential.

Aim

To obtain an adequate understanding regarding the association between cardiac devices and severity of COVID-19 infection in order to achieve optimum management of these patients.

Methods

All clinical and demographic parameters were collected retrospectively from a cohort of patients who underwent implantation of CIED in our Medical Center, Israel. We included 42 patients who tested positive for SARS-CoV-2, between January and December of 2020. Propensity score matching based on age and gender and adjusted Kaplan Meier curve of mortality were performed in order to evaluate the clinical outcome of patients with CIEDs and SARS- CoV-2 infection in comparison to the control group.

Results

The mean age of patients was 72.9 years, compose of 50% male and 50% female in both groups. In the group of patients with CIEDs, 11 (26.1%) patients had implantable defibrillator, and 31 (73.8%) had pacemaker. Univariate analysis revealed that patients with CIEDs suffered more from heart failure, coronary artery disease and atrial fibrillation, as well as hypertension, diabetes, and chronic kidney disease. Four patients (9.5%) with cardiac devices were hospitalized in the ICU due to critical illness, as compared to 1 (0.6%) patient in the control group (p=0.005). Moreover, 10 patients in the cardiac devices group (23.8%) died of SARS-CoV-2 infection, versus 25 (14.9%) in the control group.

Conclusions

CIEDs are a marker of poor outcome in patients with SARS-CoV-2 infection. Patients with CIEDs suffer from increased comorbidities in comparison with age and gender matched population and therefore should be managed with the utmost caution.

Funding Acknowledgement

Type of funding sources: None. KM curve of all-cause mortality
Unearthing the evidence: post-mortem interrogation of cardiac implantable electronic devices
Authors: Block T , Paratz E , La Gerche A , Stub D , Strathmore N , Mond H , Kistler P , Kalman J , Burke M , Voskoboinik A
Published: October 2021

Background

The diagnostic yield of post-mortem interrogation of cardiac implantable electronic devices (CIEDs) including pacemakers, defibrillators and implantable loop recorders has not been well described.

Methods

We reviewed all post-mortem CIED interrogations performed by our statewide Institute of Forensic Medicine between 2005–2020 for investigation of sudden or unexplained death.

Results

260 patients (68.8% male, median age 72.8 years [IQR 62.7–82.2]) underwent post-mortem CIED interrogation (202 pacemakers, 56 defibrillators and 2 loop recorders). CIEDs were implanted for a median of 2.0 [IQR 0.75–5] years, with 19 devices requiring replacement (and 5 end of life). Post-mortem interrogation was successful in 256 (98.5%) cases. Potential CIED malfunction was identified in 21 (8.1%) cases: untreated ventricular arrhythmias (n=13), lead failures (n=3) and battery depletion (n=5). CIED interrogation directly informed cause of death in 130 (50.0%) cases, with fatal ventricular arrhythmias identified in 121 patients (46.5%). In retrospect, 72 (27.7%) patients had abnormalities recorded by their device in the 30 days preceding death: non-sustained ventricular tachycardia (n=26), rapid atrial fibrillation (n=17), longevity concerns (n=22), intrathoracic impedance alarms (n=3), lead issues (n=3) or therapy delivered (n=1). In 6 cases where the patient was found deceased after a prolonged time, CIED interrogation accurately determined time of death. In one case, CIED interrogation was the primary method of patient identification.

Conclusion

Post-mortem CIED interrogation frequently contributes important information regarding critical device malfunction, pre-mortem abnormalities, cause and time of death or patient identity. Device interrogation should be considered for select patients with CIEDs undergoing autopsy.

Funding Acknowledgement

Type of funding sources: None.
Relation of biomarkers of inflammation, oxidative stress and fibrosis in patient with atrial fibrillation
Authors: Pauklin P , Eha J , Zilmer M , Tootsi K , Kals M , Kampus P
Published: October 2021

Background

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in clinical practice. The patogenesis of AF is linked to an inflammatory reaction and oxidative stress that leads to fibrosis of the atria and progression of the disease. However, the role of different biomarkers in patients with AF is poorly defined. The purpose of this study is to define the role of several biomarkers of inflammation, oxidative stress and fibrosis (myeloperoxidase (MPO), high-sensitivity C-reactive protein (hsCRP), galectin-3 (Gal-3), oxidized low-density lipoprotein (oxLDL)) in patients with AF.

Methods

We included 75 patients with paroxysmal/persistent AF, who were admitted for electrical cardioversion or pulmonary vein isolation. MPO, hsCRP, Gal-3 and oxLDL were measured before the procedures. We compared the results with 75 healthy age-, sex- and blood pressure-matched individuals.

Results

Patients with AF had higher MPO (77.1 vs 41.7 ng/ml, p<0.001) compared the healthy subjects. There was also significantly higher hsCRP (3.7 vs 1.6 mg/L, p<0.001) and Gal-3 (12.3 vs 10.4 mg/L, p=0.003). No difference in oxLDL levels (78.8 vs 75.3 U/L, p=0.414) were seen (Table 1). MPO (β=0.012, p=0.014), hsCRP (β=0.213, p=0.046), and weight (β=0.037, p=0.006), were independently associated with AF in a logistic regression analysis (Table 2).

Conclusions

Patients with AF have increased markers of inflammation and fibrosis, whereas no increase in oxidative stress markers was detected. MPO, hsCRP and age weight were independently predictive of AF. These findings support the role of inflammatory and fibrotic mechanisms as important factors in the electrical and structural remodelling progress in the atria of patients with AF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Estonian Research Council
Cerebral microbleeds and risk of adverse outcomes in patients with atrial fibrillation: a systematic review and meta-analysis
Authors: Corica B , Romiti G.F , Raparelli V , Cangemi R , Basili S , Proietti M
Published: October 2021

Background

Long-term anticoagulation in patients with atrial fibrillation (AF) imposes a careful balance between the thromboembolic and hemorrhagic risks. An association between cerebral microbleeds (CMBs) and an increased risk of intracranial hemorrhage (ICH) has already been described; however, conflicting evidence exist on the association with ischemic stroke (IS). Although CMBs are often observed in AF patients, the actual prevalence and the magnitude of the risk of adverse events in patients with CMBs is unclear.

Purpose

We aimed to estimate the pooled prevalence of CMBs in patients with AF through a systematic review and meta-analysis of the literature. Additionally, we evaluated the risk of ICH and IS according to the presence and burden of CMBs.

Methods

We perform a systematic search on PubMed and EMBASE from inception to 6th March 2021. We included all studies reporting the prevalence of CMBs, the incidence of ICH and/or IS in AF by presence of CMBs. Pooled prevalence and odds ratios (OR), along with their 95% Confidence Intervals (CI), were computed using random-effect models; we also calculated 95% Prediction Intervals (PI) for each outcome investigated. Additionally, we performed subgroup analyses according to the number and localization of CMBs.

Results

We retrieved 562 records from the literature search, and 17 studies were finally included. Pooled prevalence of CMBs in AF population was 28.3% (95% CI: 23.8%-33.4%; 95% PI: 12.2%-52.9%, Figure 1). Individuals with CMBs showed a higher risk of both ICH (OR: 3.04, 95% CI: 1.83–5.06) and IS (OR: 1.78, 95% CI: 1.26–2.49). Moreover, patients with more than 5 CMBs, as well as patients with both lobar and mixed CMBs, showed a higher risk of ICH.

Conclusions

CMBs were found in 28.3% of AF patients, with 95% PIs indicating a potentially higher prevalence. Moreover, CMBs were associated with an increased risk of both ICH and IS, with the effect potentially modulated by their number and localization. CMBs may represent an important and often overlooked risk factor for adverse outcomes in patients with AF.

Funding Acknowledgement

Type of funding sources: None. Prevalence of CMBs in patients with AF
Impact of haemodialysis in the development of atrial fibrillation: a retrospective cross-sectional study
Authors: De Almeida Fernandes D , Santos Mira F , Pimenta C , Escada L , Antonio N , Goncalves L , Alves R
Published: October 2021

Background

Chronic kidney disease (CKD) is a very common co-morbidity in patients with cardiovascular disease, particularly in those with atrial fibrillation (AF). There is an increasing number of patients on haemodialysis who have AF and its impact is not fully understood.

Purpose

To assess the prevalence of AF in patients on haemodialysis, trying to identify predictors of AF development.

Methods

Unicentric, retrospective study including all patients admitted to the Nephrology ward from October 2020 to December 2020 who had CKD. Cardiovascular risk factors, known cardiac disease, time on haemodialysis, type of vascular access and demographic data were analysed. The control group was comprised of hospitalized CKD patients who were not on renal replacement therapies.

Results

A total of 126 patients were included, 57 on dialysis. Mean age for the renal replacement therapy group was 71.07±15.68 years and for the control group was 72.59±14.74 years old (p=0.575). There was an increased proportion of patients with type 2 diabetes mellitus in the control group (39 vs 20, p=0.021). No statistically significant differences were found regarding hypertension, heart failure, coronary disease or sleep apnoea between groups.

The prevalence of AF was similar in both the haemodialysis and the control group (26.3% vs 24.6%, p=0.829). Age, heart failure and coronary disease were significant risk factors for AF, irrespective of the studied group (p<0.05). There was also a significant correlation between time on dialysis and a greater likelihood of presenting AF (p<0.05). There was no correlation with type of vascular access.

Using the Youden index, an age of 80.5 years was determined as the cut-off for an increased prevalence of AF, irrespective of the study group (sensitivity of 66.7%; Specificity of 78.8%). Using ROC curves, an area under the curve (AUC) of 0.74 was obtained for age and the likelihood of AF (figure 1). Regarding time on dialysis, a cut-off point of 4.5 years was obtained with an AUC of 0.67 (sensitivity of 73% and specificity of 68.7%) (figure 2).

Conclusion

AF is very common in patients with end-stage renal disease, with a prevalence estimated to be 4 times greater than the general population. Our results suggested that, while haemodialysis may not be a risk factor for AF by itself, a longer time on haemodialysis may contribute to its onset. Age was also a contributing factor. Further prospective studies with more homogeneous groups are needed to clarify its role as an independent risk factor for AF.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Age as predictor of AFFigure 2. Time on dyalisis as predictor of AF
Impact of rate control medications on one-year outcomes with atrial fibrillation and heart failure
Authors: Mo R , Yang Y , Yu L
Published: October 2021

Purpose

Atrial fibrillation (AF) and heart failure (HF) often coexist. The impact of rate-control regimens in AF and HF patients has not been well understood.

Methods

In this multicenter, prospective registry with one-year follow-up, 1359 persistent or permanent AF patients got enrolled. A 1:1 HF to non-HF propensity score matching was applied to adjust for confounding variables. The primary endpoint was all-cause mortality while the secondary endpoint was defined as cardiovascular death and stroke. Multivariate Cox analysis was performed to evaluate the association between different rate-control treatment and incidence of adverse events.

Results

Before matching, HF patients were much younger and more likely to be female. They had a much higher prevalence of previous myocardial infarction, chronic obstructive pulmonary disease and valvular heart disease. Among 1359 participants, we identified 1016 matched patients. The number of drugs did not affect the risk of all-cause mortality in both cohorts. For non-HF patients, using calcium channel blockers (CCBs) plus digoxin had a significant higher risk of all-cause death (HR=5.703, 95% CI 1.334–24.604, p=0.019) and cardiovascular death (HR=9.558, 95% CI 2.127–42.935, p=0.003) compared with patients not receiving rate-control treatment. The use of beta-blockers, CCBs, digoxin alone, other dual or triple combinations was not related to risk of adverse events in both groups.

Conclusions

The combined use of CCBs and digoxin was related to increase all-cause and cardiovascular mortality in AF patients without HF but not for those with HF. However, the ideal rate-control regimen for AF and HF patients has not been established and well-designed clinical trials are needed.

Funding Acknowledgement

Type of funding sources: None. Results of multivariate Cox analysisKaplan-Meier curves by drug numbers
Thromboembolic risk of movable type left atrial appendage thrombi in patients with atrial fibrillation under widespread use of anticoagulants
Authors: Mine T , Sugitami M , Fukuhara E , Kitagaki R , Ishihara M
Published: October 2021

Background

Left atrial appendage thrombi (LAAT), especially movable type LAAT, have been reported to be high-risk for thromboembolic events in patients with atrial fibrillation (AF). However, thromboembolic risk of the movable-type LAAT under widespread use of anticoagulant therapy remains unclear.

Methods

We retrospectively studied 65 LAAT patients taking anticoagulants out of 1381 consecutive patients who underwent transthoracic echocardiography prior to cardioversion or catheter ablation for AF. Patients with significant valvular disease and coagulation disorder were excluded. Clinical data were evaluated at the time of TEE. The LAAT were classified into movable and fixed type LAAT by three independent observers.

Results

Sixteen of 65 LAAT patients showed movable type LAAT. During follow-up (42±34 months), one patient underwent emergency thrombectomy, 5 patients developed thromboembolic event, and 12 patients died. There were no differences in clinical data, parameters, thrombectomy/thromboembolic event, and survival rate between patients with movable and fixed type LAAT.

Conclusion

Thromboembolic risk of the movable-type LAAT is the same as fixed type LAAT, under widespread use of anticoagulant therapy.

Funding Acknowledgement

Type of funding sources: None.
The prognostic value of hypoxia biomarkers in older patients with chronic heart failure
Authors: Efremova E , Shutov A.M
Published: October 2021

Chronic kidney disease (CKD) worsens the prognosis of chronic heart failure (CHF). Hypoxia is the leading link in pathogenesis, especially in older patients with comorbidity. The aim of this study was to investigate the prognostic value of biomarkers of myocardial, renal dysfunction and hypoxia in older patients with CHF.

Materials and methods

80 older hypertensive patients with CHF (48 females, mean age 70.7±8.7 years) were examined. CHF was defined according to ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2016. CKD was diagnosed and classified according to the KDIGO guidelines (2012). Serum levels of hypoxia-inducible factor 1-alpha (HIF-1α), endogenous erythropoietin (eEPO), N-terminal propeptide of type B natriuretic hormone (NT-proBNP), cystatin C were assessed. The follow-up period was 12 months; the primary endpoint was total mortality.

Results

CKD was diagnosed in 49 (61.3%) older patients with CHF. The HIF-1α level was significantly higher in the group of deceased patients than in the survivors (0.08 (IQR 0.06; 0.11) and 0.05 (IQR 0.04; 0.07) ng/ml, p=0.02), as well as the level of NT-proBNP (1126.3 (IQR 551.8; 2750.0) and 164.4 (IQR 135.5; 1100.9) pg/ml, p<0.0001), eEPO (16.92 (ICR 5.43; 64.57) and 5.36 (IQR 1.65; 8.85) mIU/ml, p<0.0001), cystatin C (1.49 (ICR 0.86; 2.13) and 0.99 (IQR 0.82; 1.32) Mg/l, p=0.0005). Cox regression analysis adjusted for sex, age and comorbidity (χ2=36.8, p<0.0001) showed that endogenous erythropoietin, independently of other factors and biomarkers, determined the prognosis of annual mortality in patients with chronic heart failure (HR 3.27 (95% CI 1.08–9.91, p=0.03); χ2=30.7, p=0.0002). When constructing classification trees, in older patients with CHF in the presence of eEPO less than 16.19 mIU/ml NT-proBNP more than 232.5 pg/ml is an unfavorable factor (in patients with NT-proBNP <232.5 pg/ml the risk decreased to 0) (for model: sensitivity – 57.1%; specificity – 92.3% (AUC=0.87); p=0.0015).

Conclusions

The level of eEPO in older patients with CHF has an independent and closer relationship with the annual mortality of patients than the NT-proBNP – currently accepted biomarker of the severity and prognosis of CHF.

Funding Acknowledgement

Type of funding sources: None.
IV sodium ferric gluconate complex in patients admitted due to acute decompansated heart failure and iron deficiency
Authors: Borreda I , Zukermann R , Epstein D , Marcusohn E
Published: October 2021

Introduction

Patients suffering from heart failure (HF) and iron deficiency (ID) have worse outcomes. Intra-venous (IV) ferric carboxymaltose has been shown to reduce HF readmissions and improve symptoms in patients with HF with reduced ejection fraction. However, IV ferric carboxymaltose is significantly more expensive than IV Sodium Ferric Gluconate Complex limiting its availability to most HF failure patients around the globe.

Methods

This is a retrospective analysis comparing patients admitted due to acute decompensated HF (ADHF) and treated with or without IV sodium ferric gluconate complex on top of standard medical therapy. The study included all patients admitted due to ADHF, with either reduced or preserved EF between January 2013 to December 2018.

Results

During the study period, a total of 1856 patients were admitted due to ADHF. Among them 840 patients had an indication for IV iron therapy. Among them 122 (14.5%) patients were treated with IV Sodium Ferric Gluconate during hospitalisation. When comparing the group that was treated with IV iron compared to standard HF treatment no difference was found at one year after the hospitalization regarding reduction in readmissions due to ADHF (27.9% vs 24.8% respectively P=0.54), nor in all-cause mortality (25.4% vs. 25.6% respectively, P=0.99).

Conclusion

Treatment with IV Sodium ferric gluconate complex during hospitalization due to ADHF did not show any advantage in reduction of readmission due to heart failure after 1 year follow up.

Funding Acknowledgement

Type of funding sources: None.
The role of iron supplementation in reducing all-cause mortality of heart failure patients with iron deficiency: a systematic review and meta-analysis
Authors: Dewangga R , Winston K
Published: October 2021

Background

Many heart failure patients also suffer from anemia suggesting potential therapeutic targets. However, the role of iron supplementation in patients with heart failure with iron deficiency in reducing all-cause mortality remains unclear.

Purpose

We aim to compare the risk of all-cause mortality in iron deficient heart failure patients who were given iron therapy versus placebo.

Methods

We systematically searched for RCTs comparing Fe supplementation with placebo in heart failure patients with iron deficiency from PubMed, Scopus, Science Direct, and ProQuest up to March 2021. The inclusion criteria was Randomized Controlled Trial Study with outcome of all-cause mortality. The exclusion criteria were observational studies, animal studies, and studies without English language. Odds ratio (OR) was calculated with 95% confidence interval (CI), while heterogeneity was assessed using the I2 statistics. The primary outcome was all-cause mortality. Data from eligible studies were pooled for effect estimates. Statistical analysis was performed using Review Manager software.

Results

From literature search, 7 RCTs were obtained. The total patients used for pooled analysis were 1192 patients receiving iron therapy and 973 patients receiving placebo. Pooled analysis using a random-effect model showed that iron therapy use was not associated with better all-cause mortality in heart failure patients with iron deficiency (OR: 0.91; 95% CI: 0.68–1.23; p: 0.56; I2: 0%). The funnel plot was asymmetric, suggesting presence of publication bias.

Conclusion

No benefit of Fe supplementation in reducing all-cause mortality of heart failure patients with iron deficiency.

Funding Acknowledgement

Type of funding sources: None. Pooled analysis for all-cause mortality
Association between malnutrition status and incident heart failure in community population
Authors: Zhuang Z X D , Zhang S Z , Liao X X
Published: October 2021

Background

Malnutrition is commonly prevalent in patients with heart failure (HF) and associated with poor prognosis. However, few studies have explored the association between malnutrition status and incident HF in community population.

Method

379,759 participants (46.3% women) without HF at baseline from the UK Biobank were included. Nutritional status was evaluated using the Controlling Nutritional Status (CONUT) score, with higher scores reflecting worse nutritional status. Association between CONUT score and incident HF were investigated using Cox proportional hazard regression models, with adjustment for traditional risk factors.

Results

During a median follow-up of 8.1 years, 5,520 cases (1.5%) of HF occurred. The hazard ratio for incident HF with 1-point increase of CONUT scores was 1.16 (95% CI, 1.12–1.20, P<0.001), after adjustment for traditional HF risk factors. Compared with good nutritional status, malnutrition was associated with significantly increased risk for incident HF [adjust hazard ratio were 1.25 (95% CI 1.17–1.34, P<0.001) for mild malnutrition and 2.06 (95% CI 1.36–3.12, P=0.001) for moderate or severe malnutrition]. Conclusion Malnutrition status were associated with increased risk of incident HF. Further studies are needed to confirm these findings and evaluate the use of CONUT in community monitoring.

Funding Acknowledgement

Type of funding sources: None.