bluuebunny/crossref_metadata_2025 huggingface dataset:
P538Single- and Multi-Site Pacing Strategies for Optimal Cardiac Resynchronization Therapy: Impact on Device Longevity and Therapy Cost
Authors: D"onofrio A , Bertini M , Infusino T , D Arienzo G , Misiani A , Bianchi V , Licciardello G , Savarese G , Russo G , Ricciardi D , Manzo M , Santini L , Ospizio R , Valsecchi S , Forleo G B
Published: June 2020

Funding Acknowledgements

No funding

Introduction

Multiple left ventricular pacing strategies have been suggested for improving response to cardiac resynchronization therapy (CRT). However, these programming strategies can be obtained by accepting configurations with high pacing threshold and accelerated battery drain. We assessed the feasibility of predefined pacing programming protocols and we evaluated their impact on device longevity and their cost-impact.

Methods

We estimated battery longevity in 167 CRT-D (RESONATE, Boston Scientific) patients based on measured pacing parameters and according to multiple programming strategies: single-site pacing associated with lowest threshold, non-apical location, longest interventricular delay, pacing from two electrodes. To determine the economic impact of each programming strategy, we applied the results of a published model-based cost analysis to a 15-year time-horizon.

Results

Selecting the electrode with the lowest threshold resulted in a median device longevity of 11.5 years. Non-apical pacing and interventricular delay maximization were feasible in most patients (99% non-apical pacing, 65% RV-to-LV interval >80ms), and were obtained at the price of a few months of battery life. Device longevity of >10 years was preserved in 87% of cases of non-apical pacing and in 77% on pacing at the longest interventricular delay. The mean reduction in battery life when the second electrode was activated was 1.5 years. Single-site pacing strategies increased the therapy cost by 4-6%, and multi-site pacing by 12-13%, in comparison with the best-case scenario.

Conclusions

Modern CRT-D systems ensure effective pacing and allow multiple optimization strategies for maximizing service life or for enhancing effectiveness. Single- or multi-site pacing strategies can be implemented without compromising device service life and at an acceptable increase in therapy cost.

Abstract Figure. Image1
P377Zero-fluoroscopy ablation with ultrasound-guided sheath insertion
Authors: Kawakami T , Saitoh N , Asukai Y , Wada S , Sasaki H , Takahashi H , Hatori K , Itou N , Fukunaga H , Toubaru T
Published: June 2020

Background

Radiation exposure during catheter ablation procedures is a risk for both the patient and electrophysiology staff. Recently, the feasibility and effectiveness of zero-fluoroscopy ablation have been shown. However, ensuring a safe sheath insertion through the venous system toward the heart is a concern in catheter ablation using the zero-fluoroscopy technique. 

Purpose

The objective of this study was to confirm feasibility and safety for zero-fluoroscopy ablation using ultrasound-guided sheath insertion.

Methods

Zero-fluoroscopy catheter ablation was performed in 220 patients (185 patients with atrial fibrillation (AF), 26 patients with supraventricular tachycardia (SVT), and nine patients with ventricular arrhythmias (VA)) using a 3-dimensional electro-anatomical mapping system, contact force monitoring, and intracardiac echocardiography (ICE) imaging. In all cases, ultrasound-guided sheath insertion was performed through the femoral vein. In 6 cases of VA, the retrograde approach through the femoral artery was performed with ICE imaging and contact-force monitoring. The endpoint of ablation for AF was pulmonary vein ablation in all cases and addition of left atrial posterior wall isolation in persistent AF cases. The endpoint of ablation for SVT and VA was noninducibility after ablation.

Results

The endpoints of ablation were achieved in all cases. The fluoroscopic time during ablation procedures was 0 seconds. There were two complications (one cardiac tamponade and one acute heart failure). There were no complications related to sheath insertion. 

Conclusions

Zero-fluoroscopy catheter ablation with ultrasound-guided sheath insertion may be feasible and can be performed safely. This method eliminates exposure radiation safely, which is a concern of zero-fluoroscopy endocardial catheter ablation.
P1377Substrate-based ablation in patients with frequent appropriate ICD therapy and dilated cardiomyopathy: long-term experience with high-density mapping
Authors: Oliveira M M O , Cunha P S C , Valente B V , Portugal G , Lousinha A , Pereira M , Braz M , Delgado A S , Ferreira R C
Published: June 2020

Recurrent ventricular tachydisrhythmias (VT) episodes have a negative impact in the outcome of patients (P) already with an implantable cardioverter-defibrillator (ICD). Elimination of arrhythmic reentry circuits represents a difficult challenge, mainly due to the induction of intolerable VTs, with multiple ECG morphologies, requiring rapid interruption. Substrate guided ablation has been used as a promising approach strategy to treat recurrent VTs. Aim: to assess long-term results of a VT substrate-based ablation using high-density mapping in P with an ICD, severe left ventricular (LV)  dysfunction and recurrent appropriate ICD therapy. Methods: 16P (12 men, non-ischemic cardiomyopathy 67%, 55 ± 13 years, LV ejection fraction 32 ± 6%) and recurrent appropriate shocks despite antiarrhythmic drug therapy and optimal heart failure medication. All P underwent a protocol of ventricular programmed stimulation (600 ms/S3) to obtain baseline VT documentation. A sinus rhythm (SR) voltage map was created using a 3D electroanatomic mapping system (CARTO) with a high-density mapping catheter (PentaRay) to delineate areas of scarred myocardium (ventricular bipolar voltage ≤0,5 mV – dense scar; 0,5-1,5 mV – border zone; ≥1,5 mV – healthy tissue) and provide high-resolution electrophysiological mapping. The substrate modification included catheter elimination of local abnormal ventricular activities (LAVA) - fractionated, splited, low-amplitude/long-lasting, late potentials, pre-systolic potentials - and linear ablation to obtain scars homogenization and scar dechanneling. Pace-mapping techniques were used when capture was possible. LV approach was retrograde in 6 cases, transeptal in 4 and endo-epicardial in 2 cases. In 2P the ablation was performed in the right ventricle. Results: VTs were induced and interrupted with bursts or external DC shocks. LAVA were identified and ablated in all P. Eleven P underwent modification of scar areas. The mean duration of the procedure was 153 mn (103-218 mn), with radiofrequency ranging from 18 to 60 mn (mean 33 min), and a mean fluoroscopy time of 16 mn. Non-inducibility was achieved in 75% of the cases. There was 1 pericardial tamponade drained successfully. During a follow-up of 48 ± 18 months, 75% had no VT recurrences, 2P underwent redo ablation, 1P died from stroke. Conclusion: Catheter ablation of VT based on substrate modification guided by high-density mapping is feasible and safe in P with LV dysfunction. This approach may be of clinical relevance, with potential benefits in reducing VT burden.
P1448Ablation of cti-dependent flutter using a novel advanced mini-electrodes technology: preliminary results from Leonardo registry
Authors: Maglia G , Pentimalli F , Solimene F , Infusino T , Calo" L , Perego G B , Stabile G , Matta M , La Greca C , Rago A , Tomasi C , Zingarini G , Bottoni G , Malacrida M , Verlato R
Published: June 2020

Funding Acknowledgements

NO FUNDING

OnBehalf

LEONARDO study group

Background

Ablation of cavotricuspid isthmus (CTI) represents the standard therapeutic approach for the creation of bidirectional conduction block (BDB) across the isthmus and the prevention of recurrences, yet recurrence of arrhythmia is common.

Objective

To evaluate the acute and long-term outcome of CTI ablation through a novel ablation catheter equipped with three radially distributed mini-electrodes (ME) compared with standard ablation catheter technology (ST).

Methods

Atrial Flutter Ablation in a Real World Population (LEONARDO) is a prospective, multicenter cohort study aimed at providing an estimate of acute to long-term outcome in a large population of pts indicated for AFL ablation from 2015 to 2017. The procedural endpoint was the creation of a BDB. Presence of widely split double potentials (DP) along the ablation line and assessment of the atrial activation sequence (AAS) were used as criteria for complete BDB. Recurrence of AFL and complications were assessed at 12-month follow-up.

Results

  205 consecutive pts undergoing typical AFL ablation were included (74% male, 50.6% with history of AF, median of 7[4–11] ablation lesions, median ablation time of 20[10-30] min). Complete BDB was achieved in 175 (85.4%) pts (10 pts had DP only criterion, 19 pts had AAS only criterion whereas in 1 pt we failed to reach a BDB). 15 (7.3%) pts experienced AFL recurrence during follow-up. 102 pts (49.8%) underwent ablation procedure with ME catheters whereas 103 (50.2%) pts were treated by ST catheters. The median number of lesions/pt was significantly lower in the ME group compared to the ST one (4[3-6] vs 8.5[6-12], p < 0.0001), whereas no differences were found in terms of fluoroscopy time (10.5[7-15] min vs 10[5.8 ± 15] min, p = NS) or ablation time (22.5[10-30.5] min vs 18[10-26] min, p = NS). No complications were reported. The acute procedural success was comparable between groups (81.4% vs 89.2%, p = NS) whereas the time to AFL recurrence was significantly longer among pts targeted with ME catheters (HR = 0.343; 0.12 to 0.97; log-rank p = 0.044).

Conclusions

In our preliminary experience, the use of the ME technology seemed safe and effective. It resulted in fewer lesions/pt and a lower AFL recurrence rate at 1-year follow-up compared with ST ablation catheters.
1324Reprocessing of electrophysiology catheters in EHRA countries. An EHRA Young EP survey
Authors: Duncker D , Svetlosak M , Guerra F , Nagy K V , Vanduynhoven P , Mikhaylov E , Kosiuk J
Published: June 2020

Introduction

Reprocessing of electrophysiology (EP) catheters in daily routine varies through countries and may depend on national laws, catheter (cath.) models or supplier. Data on reprocessing of EP materials is sparse and remains a matter of controversy. The aim of this study is to collect data on reprocessing usage through EHRA countries.

Methods and results

A structured online questionnaire comprising 27 questions was distributed among electrophysiologists in EHRA countries. Two-hundred-and-two participants from 34 countries completed the survey (161 males, 36.8 ± 5.8 years old). Overall, 111 (55%) of respondents currently use reprocessed materials and 30 (15%) have used them in the past. Cables, diagnostic cath. with deflectable curve and diagnostic cath. with fixed curve were the most frequently reprocessed materials (87%, 80% and 78% respondents, respectively). Maximum number of times (median) a cath. was usually reprocessed was 6 for diagnostic cath. and 5 for ablation cath. Among potential benefits of reprocessing, cost reduction for the providing hospital (65%), cost reduction for the health provider (42%) and making EP procedure available for more patients (42%) were most frequently reported. Respondents reported a need to change the reprocessed material due to its insufficient functionality in around 15% of cases. They were also concerned about the quality of the reprocessed material (58%), contamination issues (52%) and loss of precision (47%). Nineteen (17%) users of reprocessed EP material reported at least one complication potentially related to the reprocessing during their whole reprocessing experience. Sixty-six (73%) respondents who did not use reprocessed EP material would consider using it in the future.

Conclusions

Reprocessing of EP material is heterogeneously managed among the EHRA countries, as wide differences are present in terms of national and local regulations, clinical practice and technical aspects. Nonetheless, the current data show that European electrophysiologists consider the use of reprocessed EP material as generally safe and cost-effective.
P1101Is there any link between vitamin D deficiency and vasovagal syncope?
Authors: Usalp S , Kemal H , Yuksek U , Yaman B , Gunsel A , Edebal O , Akpinar O , Cerit L , Duygu H
Published: June 2020

Background

This study aimed to investigate serum 25[OH]D levels between patients with vasovagal syncope(VVS) diagnosed by head-up tilt table test (HUTT) and patients who do not develop syncope during the test.

Methods

Sixty-eight consecutive patients [mean age 33.2 ± 14.5 years, 49 females (72.1%)] were categorized based on their HUTT results (positive vs. negative, n = 40 vs. 28).25[OH]D levels were measured by chemiluminescent microparticle immunoassay method in all patients.

Results

There was no difference between the two groups in terms of blood tests, Body Mass Index, gender, echocardiographic findings(p > 0.05).Mean 25[OH]D level was lower in HUTT positive patients when compared to the HUTT negative group(p < 0.05).25[OH]D levels were significantly lower between patients over the age 25 in two groups (mean level 17.9 ± 7.3 vs 26.3 ± 8.5, respectively,p < 0.005).(Table 1) 

Conclusion

We found that patients diagnosed VVS by HUTT test had lower 25[OH]D levels.Measurement of vitamin D level may be an important factor in VVS patients.

Table 1 Head-up Tilt Testing positive (n = 40) negative (n = 28) p value Age (years) 33.2 ± 13.7 33.3 ± 15.9 0.973 Female gender (%) 31 (77.5) 18(64.3) 0.232 BMI (kg/m2) 23.4 ± 3.1 23.0 ± 2.6 0,596 EF (%) 59.2 ± 1.6 59.1 ± 1.3 0.357 LA (mm) 34 ± 2.4 33 ± 2.7 0.715 RA (mm) 32 ± 2.5 31 ± 2.7 0.141 Vitamin D (ng/mL) 16.5 ± 6.6 23.9 ± 9.5 0.001 Vitamin B12 (pg/mL) 355.1 ± 124.6 378 ± 87.0 0.367 TSH (mIU/L) 1.8 ± 0.8 1.7 ± 0.9 0.367 Glucose (mg/dL) 87.0 ± 7.4 90.5 ± 8.1 0.076 Creatinine (mg/dL) 0.6 ± 0.1 0.7 ± 0.1 0..55 Sodium (mmol/L) 139.8 ± 2.0 139.7 ± 2.5 0.931 Potassium (mmol/L) 4.1 ± 0.3 4.1 ± 0.2 0.674 Calcium (mg/dL) 8.9 ± 0.9 8.9 ± 1.1 0.476 Wbc (x103/uL) 7.3 ± 1.6 6.9 ± 1.6 0.339 Hb (g/dL) 13.3 ± 1.3 13.5 ± 1.8 0.664 Age (years) Vitamin D level Vitamin D level 0.132 ≤ 25 (n = 31) 14.8 ± 5.5 21.2 ± 10.2 0.057 > 25 (n = 37) 17.9 ± 7.3 26.3 ± 8.5 0.005 Patients characteristics of Head-up Tilt Testing positive and negative group
P1496Impact of electrical reverse remodeling by cardiac resynchronization therapy on adverse cardiac events in patients of heart failure with reduced ejection fraction
Authors: Kobayashi H , Okada A , Tabata H , Shoin W , Okano T , Yoshie K , Shoda M , Kuwahara K
Published: June 2020

Background

Recently, structural reverse remodeling (SRR) and electrical reverse remodeling (ERR) after cardiac resynchronization therapy (CRT) have been reported in patients of heart failure with reduced ejection fraction (HFrEF). However the relationship between ERR and subsequent adverse cardiac events is still unknown. We aimed to elucidate the impact of ERR after CRT on the occurrence of heart failure events and ventricular arrhythmias.

Methods

A total of 36 HFrEF patients who underwent newly CRT implantation were investigated retrospectively. The intrinsic QRS duration (iQRSd) had been recorded before and more than 6 months after CRT implantation. Biventricular pacing was temporarily turned off during measurement of iQRSd. ERR was defined as positive shortening of iQRSd and SRR was defined as reduction of left ventricular end systolic volume by more than 15% after CRT implantation. The primary endpoint was a composite of all cause death, heart failure hospitalizations and ventricular tachyarrhythmia events.

Results

ERR was observed in 17 patients (47.2%) and SRR in 22 patients (61.1%). The group with ERR included more patients with lower NYHA class prior to CRT and patients with SRR. The primary endpoint was observed in 15 patients (51.4 %) for a median of 181 [63, 367] days during follow-up. Kaplan-Meier analysis revealed that the group without ERR was poor prognosis compared with the group with ERR (p = 0.022, Log-rank test).

Conclusion

Patients of HFrEF with ERR after CRT may have fewer adverse cardiac events such as worsening heart failure or ventricular arrhythmia events from this short-term study.

Abstract Figure. Adverse cardiac events and ERR
P1453Feasibility and safety of a minimal fluoroscopy approach, aiming to ALARA strategy, compared to conventional approach in a population of adult patients with high risk accessory pathways
Authors: Buia V , Bastian D , Walascheck J , Rordorf R , Petracci B , Vicentini A , Muca M , Savastano S , Sanzo A , Rittger H , Vitali Serdoz L
Published: June 2020

Funding Acknowledgements

None

Introduction

Catheter ablation is the treatment of choice for accessory pathways (AP) in high risk patients.Traditionally fluoroscopy has been the primary tool for visualizing catheter position and stability, however it has been shown that 3D electro-anatomic mapping systems (3D EAMS) can significantly reduce and even eliminate fluoroscopy exposure during catheter ablation, thus reducing the stochastic risk of malignancies.

Purpose

aim of our study is to assess that an ablation strategy using 3D EAMS with limited or no fluoroscopy, rigorous set-up of the X-ray equipment and intracardiac or transesofageal (TEE)echo to guide the transeptal puncture has the same degree of safety and effectiveness in ablating APs as the conventional fluoroscopic approach (CFA), and can be adopted for both right and left sided APs in the adult population,reducing the effective doses.

Methods

our retrospective analysis included 60 consecutive-prospective enrolled adult patients with high-risk APs treated either with a CFA in IRCCS Policlinico San Matteo (Pavia) or with a 3 EAMS guided minimally fluoroscopic approach (MFA) in Klinikum Fuerth (Fuerth) between 01/2016 and 09/2019. 

Results

the 2 groups were homogeneous and comparable for age,sex and numbers of right/left-sided SP. In the MFA group we demonstrated the safety and feasibility of a principally 3D EAMS guided ablation approach, having the same rate of acute ablation success,while obtaining a statistically different fluoroscopy exposure time (P <0.000), dosis-area product (P< 0.000) and effective dosis (P < 0.000) compared to the CFA group. (Table)

Conclusions

the radiation exposure risk is cumulative and lifelong. We demonstrated that to adopt a MFA increasing the use of 3D EAMS, fluoro optminization and  of TEE guided transeptal is feasible and safe forAPs ablation in adults, which will benefit of a lower or even absent fluoroscopic exposure while having the same degree of safety and efficacy of a CFA.

Results Conventional Fluoroscopic Approach Minimal fluoroscopic approach P Patient (N) 31 29 n.s. Right AP 10 6 n.s. Left AP 21 23 n.s. Acute Efficacy 27 (87%) 28 (96.6%) n.s. Complication 1 (3%) 0 n.s. Fluoroscopy Time (min) 43+/-32 1.8+/-3.8 0.000 DAP (microGray*m2) 15252+/-11132 56.8+/-135.6 0.000 Effective Dosis (mSv) 30.35+/-27.7 0.09+/-0.28 0.000 AP, accessory pathway; min, minutes.
P992Socio-demographic inequalities in the uptake of screening for atrial fibrillation within the STROKESTOP II study: support for decentralised screening
Authors: Kemp Gudmundsdottir K , Holmen A , Fredriksson T , Svennberg E , Al-Khalili F , Engdahl J , Stromberg U
Published: June 2020

Funding Acknowledgements

Roche Diagnostics, The Swedish Heart and Lung Foundation, Carl Bennett AB

Background

To prevent stroke as a first clinical manifestation of atrial fibrillation (AF), screening for AF has been suggested. In the STROKESTOP I (SSI) study, participation was significantly influenced by socio-demographic and geographic factors.

Purpose

The main aim was to improve participation in the STROKESTOP II (SSII) study, especially aiming at socioeconomically weaker groups.

Methods

As in the SSI study, in the SSII study all 75/76-year-olds were randomised 1:1 to either a screening arm or a control arm. The individuals in the screening arm were invited to an AF-screening-program. Two screening sites were added in the SSII study, located closer to low-income neighbourhoods with very low participation rates in the SSI study. Information on each invitee’s residential parish was used for a geo-mapping analysis of the geographical disparities in participation. Individual data for the participants and non-participants were obtained with respect to the following socioeconomic variables: educational level, disposable income, immigrant and marital status. Geographic and socio-demographic disparities in the uptake of the SS2 study were analysed and the results compared between the STROKESTOP trials.

Results

Overall, higher participation was observed in those with higher education, high income as well as among non-immigrants and married individuals. Participation between the SSI and SSII improved significantly in the two areas where additional screening sites were introduced. These improvements were generally significant, in each population group according to the socio-demographic characteristics.

Conclusion

Decentralisation of the screening sites in an AF-screening-program had significant impact on the screening uptake. Addition of local screening sites in areas with a very low uptake may have a beneficial impact on the uptake across the full spectrum of socio-demographic groups

Abstract Figure. Participation map
1268A family with a novel variant in the SLC4A3 gene leading to short QT phenotype - the importance of whole-exome-sequencing and cascade screening
Authors: Kovacs B , Graf U , Magyar I , Baehr L , Maspoli A , Firat D , Berger W , Saguner A M
Published: June 2020

Funding Acknowledgements

none

Introduction

 Short QT syndrome (SQTS) is a rare, autosomal dominant disease causing ventricular fibrillation and sudden cardiac death. Genetic testing is recommended according to current guidelines. Mutations in KCNQ1, KCNH2, KCNJ2 and more recently SLC4A3 genes have been implicated in SQTS. These genes encode potassium channel subunits and a bicarbonate transporter regulating intracellular pH. A dominant mutation in this transporter can lead to increased intracellular pH and shortened action potential.

Purpose

 We present a family with a short QT phenotype and recurrent syncope in whom a novel genetic variant was detected by whole-exome sequencing (WES), confirmed by cascade screening.

Methods

 We performed a thorough work-up of the index patient including medical history, physical examination, 12-lead ECG, echocardiography, stress testing, coronary angiography, flecainide challenge, and genetic testing with NGS. QTc was determined using Bazett’s formula. CS of all 1° and two 2° relatives was performed.

Results

 The ECG of the index patient showed a QTc of 340ms and characteristics compatible with a SQTS (figure). Clinical work-up was unremarkable. A first genetic search with next generation sequencing focusing on genes that have been previously involved in the pathogenesis of channelopathies detected a rare known heterozygous missense variant in the KCNH2 gene (Arg328Cys, frequency 0.053%), which was predicted to be pathogenic according to various prediction algorithms (Polyphen, SIFT, Align GVGD, mutation taster). ECG screening of all asymptomatic first-degree family members identified a SQT phenotype in the mother (QTc 355ms), but not in the father (QTc 380ms) and sister (410ms). The KCNH2 variant was found in the father and sister but not the affected mother, which excludes this variant as the causative mutation in this family. Therefore, reanalysis of WES data was performed and revealed a novel heterozygous missense variant p.(Arg370Cys) in the SLC4A3 gene, recently associated with SQTS. A mutation in this gene at the same position has been previously reported in SQTS. The p.(Arg370Cys) mutation was found in the mother but not in the unaffected father or sister. Furthermore the mutation was present in two affected maternal uncles (QTc 319ms and 342ms) supporting the assumption that this was the causative mutation in this family.

Conclusions

 A novel genetic variant in the SLC4A3 gene leading to sQT phenotype could be detected using WES and cascade screening. Predictive bioinformatic algorithms to assess the pathogenicity of missense variants are of limited relevance, but genetic analysis of additional unaffected and affected family members may be instrumental to identify pathogenic DNA sequence variations.

Abstract Figure. Pedigree and ECGs of the family
P1096Cardioneuroablation changes the type of vaso-vagal response in patients with asystolic reflex syncope
Authors: Piotrowski R , Zuk A , Baran J , Sikorska A , Krynski T , Kulakowski P
Published: June 2020

Funding Acknowledgements

Centre of Postgraduate Medical Education No. 501-1-10-14-19

Background. Cardioneuroablation (CNA) - ablation of ganglionated plexi (GP) to eliminate or reduce parasympathetic overactivity, has been recently proposed as a new therapeutic method in patients with vaso-vagal syncope (VVS) due to cardioinhibitory or mixed mechanism.

Purpose. To assess the impact of CNA on the type of VV response during tilt testing (TT).

Methods. The study group consisted of the first 20 patients (7 males, mean age 38 ± 9 – year – old) enrolled in the ongoing prospective Roman study (NCT 03903744). All patients had a history of ECG documented syncope due to asystole and confirmed asystolic form of VVS at baseline TT. CNA was performed using electroanatomical system Carto 3 and radiofrequency applications delivered in the right and left atrium at the right anterior GP and right inferior GP sites. The second TT was performed three months later. Resting heart rate (HR) and heart rate variability parameter (SDDN) were also assessed.

Results. At baseline TT, nineteen patients had cardioinhibitory syncope (asystole ranging from 3 to 60 s)  (sinus node arrest – 17 patients, A-V block – 2 patients) and 1 had mixed form of VVS (asystole lasting 3 s preceded by hypotension). During three-month follow-up no syncopal episodes were noted. At the 3-month TT, 6 (30 %) patients had no syncope whereas the remaining 13 (65 %)  had syncope – twelve (60 %) due to vasodepressor mechanism and only one (5 %) due to asystole - as before CNA. One patient did not have TT because of pregnancy. Mean resting HR after CNA was significantly faster and SDNN significantly lower than before the procedure (82 ± 9 vs 69 ± 11 beats/min, p = 0.0004 and 74 ± 22 vs 143 ± 40 ms, p = 0.00003, respectively) and these changes were was similar in those who fainted during second TT and those who did not (82 ± 11 vs 81 ± 4 beats/min, p = NS and (75 ± 2 vs 77 ± 18 ms, p = NS, respectively).

Conclusions. CNA profoundly affects the type of VV reaction causing normalization of the response to tilting or changing cardiodepression to vasodepression. These effects are also depicted by changes in HR and heart rate variability. Elimination of TT-induced reflex asystole may prevent clinical recurrences of syncope during short-term follow-up. These findings encourage to conduct further studies involving CNA since this method appears to be effective and obviates the need for pacemaker implantation in young people with reflex asystolic syncope.
P1025Incidence and characteristics of pulmonary vein reconduction after second-generation cryoballoon-based pulmonary vein isolation: Impact of different ablation strategies
Authors: Heeger C H , Rexha E R , Maack S M , Rottner L , Fink T , Mathew S M , Maurer T M , Lemes C L , Rillig A R , Wohlmuth P W , Reissmann B R , Tilz R R , Ouyang F O , Kuck K H K , Metzner A M
Published: June 2020

Funding Acknowledgements

none

Introduction

The second-generation CB (CB2, Arctic Front Advance, Medtronic Inc., Minneapolis, USA) has demonstrated high procedural success rates, relatively short procedure times, high durability of PVI and convincing long-term clinical success rates. Nevertheless, data on the impact of different ablations protocols on durability after CB2 based PVI is limited.

Purpose

We aimed at comparing durability of pulmonary vein isolation (PVI) following three different ablation strategies utilizing the second-generation cryoballoon (CB2) in patients with recurrence of atrial fibrillation (AF) or atrial tachycardia (AT) undergoing repeat procedures.

Methods

In 192 patients a total of 751 PVs were identified. All PVs (751/751, 100%) were successfully isolated during index PVI. Thirty-one out of 192 (16%) patients were treated with a bonus-freeze protocol (group 1), 67/192 (35%) patients with a no bonus-freeze protocol (group 2), and 94/192 (49%) patients with a "time-to-effect"-guided ablation protocol without bonus freezes (group 3).

Results

Persistent PVI was documented in 419/751 (55.8%) PVs, and in 41/192 (21%) patients all PVs were persistently isolated. The number of patients with all PVs being persistently isolated was not significant between the groups (p = 0.594). The total rate of PV reconnection was not significantly different between the three groups (p = 0.134) and the comparison of individual PVs revealed also no differences for different ablation protocols (p-values for RSPV: 0.424, RIPV: 0.541, LSPV: 0.788, LIPV: 0.346, LCPV: 0.865). The procedure times were significantly reduced in non-bonus freeze ablation protocols and/or when applying individualized application times (group 1: 123.4 ± 31.5min, group 2: 112.9 ± 39.8 min, group 3:  86.67 ± 28.4 min, p <0.001).

Conclusions

A considerably high rate of persistent PVI was demonstrated in patients after index CB2-based PVI. No differences for durable PVI were detected for different ablation protocols. Therefore, individualized ablation protocols might be a beneficial ablation strategy during CB2-based PVI.
P1488Autonomic nervous system optimized cardiac resynchronization therapy
Authors: Thong T , Tran-Tat D , Nguyen-Duy T
Published: June 2020

Introduction. Traditional Cardiac Resynchronization Therapy, CRT, relies on bi-ventricular, bi-V, pacing. For left bundle branch block, LBBB, patients with good atrial-right ventricular conduction, A-RVc, alternatives have been proposed that use left-ventricular only pacing, LVoP, with adaptive atrio-ventricular delay, AVD, that is updated every minute from A-RVc measurements. The key advantage is extended device longevity since the RV pacing pulse is not emitted.

Purpose. In this paper we present a CRT alternative using fixed AVD LVoP + RV sense trigger (an LV pulse is triggered when an RV depolarization is sensed), RVsT, that can be used with LBBB patients with good A-RVc. Intrinsic RV depolarization is used. The longevity of the device is expected to approach that of a dual chamber device since AVD adaption is not needed.

Method. 5 CRT patients with LBBB and good A-RVc, previously programmed to bi-V pacing, were reprogrammed to fixed AVD LVoP + RVsT. The devices are standard CRT pacemakers, CRT-P, with RVsT. They are normally operated in LVoP mode. In response to atrial tachycardia, mode switching to bi-V will be required. So, 3 chamber devices are still required.

Results. Nightly at about 02:00 the CRT-P collects Ax-Vs (Ax = As & Ap) statistics for 35 consecutive heart cycles with AVD of 300 ms, while the patient is asleep. A typical plot of  these timing statistics at the time of reprogramming to LVoP is shown in Fig. 1. After a self-training period of 2 weeks to 9 months, these statistics coalesce in a narrow range of values, 20 ms wide, as illustrated in Fig. 2 for our super responder (2 weeks). This 20 ms wide pattern persisted for the next 9 months. In the case of the index patient this lasted 3+ years. This persistent A-RVc pattern across all 5 patient can only be explained by a tight dromotropic control by the Autonomic Nervous System, ANS.

Fig. 3 illustrates RVsT. As the RVs arrives earlier than the LVp, there is no longer synchronicity improvement since the LVp now follows the RVs immediately. In Fig. 4, we see long periods with high %RVs associated with high heart rates. Increased hemodynamic demand can only be met by increased contractility. Thus inotropic modulation by the ANS is now active and effective.

The patients were put on remote monitoring with nightly follow-ups. Over a period of 6.5 months RVs (pre LVp) statistics were collected. A daily median of 11% was reported for this patient. On a particular day, it can be as high as 50%. Dromotropic action to pull in the RVs cannot be explained without concurrent inotropic modulation.

Conclusions. Traditional CRT leads to ineffective ANS modulation due to bi-V pacing for >95-98% of the cycles. In our 5 patients the fixed AVD LVoP + RVsT program has allowed nervous system remodeling and the ANS is back in control of hemodynamics. Thus we have ANS optimized CRT! It is an attractive CRT alternative for LBBB patients with good A-RVc since device longevity is also improved.

Abstract Figure. Fixed delay LV-only + RVs trigger
P1463Regional variation in survival rates among primary prevention implantable cardioverter-defibrillator recipients in Eastern and Northern Europe POLKARD Polish ICD Registry perspective
Authors: Warchol I , Lubinski A , Sterlinski M , Kowalski O , Goscinska-Bis K , Pytkowski M , Mitkowski P , Kazmierczak J , Szwed H , Przybylski A , Trusz-Gluza M , Kempa M , Zienciuk-Krajka A , Sielski S , Pazdyga A
Published: June 2020

Funding Acknowledgements

None.

OnBehalf

POLKARD Polish ICD Registry

Objective

The findings of Danish Study to assess the efficiency of ICD in patients with non ischemic heart failure has recently raised questions about the current strategy of ICD implantation for the primary prevention of sudden cardiac death. POLKARD - Polish ICD Registry is a prospective, non-randomised, central registry of patients who are referred for an implantation of an ICD in Poland. The Registry contains prospectively collected follow-up data including mortality.

Purpose

To compare survival rates between Polish and Danish ‘real-world’ non-ischemic primary prevention cohorts.

Methods

Retrospective analysis of clinical characteristics and long-term follow-up of patients referred for primary prophylactic implantable cardioverter defibrillator (ICD) implantation in Poland between April 2008 and November 2014 was performed. The primary outcome of the trial was all-cause mortality. Results: The polish study cohort was large (964) as compared to Danish population randomized to receive ICD therapy (556). The median follow-up time in DANISH Study and Polish ICD Registry was 67,6 and 77 months, respectively. Compared with patients enrolled in the DANISH Study, patients in the Polish ICD Registry were age-similar. However, the polish study population was male-dominated. What is more, male gender was identified as a risk factor for long-term mortality in polish study population (p = 0.005). In the matched cohorts, there was difference in survival between DANISH Study and Polish ICD Registry patients (all-cause mortality rates: 21,6% - 44 events per 1000 person-years and 39,3% - 72 events per 1000 person-years, respectively).

Conclusions

Our findings imply that survival among patients who receive a primary prevention ICD for non-ischemic cardiomyopathy in clinical practice in Central Europe is different from Northern Europe.
P931Assosiation of the levels of galectin-3 and MMP-1 with the type of myocardial dyssynchrony in patients with heart failure and concomitant type 2 diabetes mellitus
Authors: Rudenko T , Bilchenko O V , Khvysiuk M O , Karami Saliba D Y
Published: June 2020

Background

Myocardial dyssynchrony  leads to heart remodeling and the progression of heart failure (HF) in patients with type 2 diabetes mellitus. Studying the mechanisms of the development of myocardial dyssynchrony can help in timely diagnosis and treatment.

Aims

To study the association of the level of galectin-3 and matrix metalloproteinase 1 (MMP-1) and the type of myocardial dyssynchrony in patients with heart failure and concomitant type 2 diabetes mellitus.

Methods

98 patients with heart failure and concomitant type 2 diabetes mellitus were examined, average age (67.45 + 10.32) years. Patients were divided into two groups due to the presence or absence of myocardial dyssynchrony: the first group: with myocardial dyssynchrony (n = 56), the second group: patients without myocardial dyssynchrony ( n = 42). All patients were examined for electrical (enhanced QRS ≥ 120 ms) and mechanical myocardial dyssynchrony using echocardiographic and electrocardiographic methods for assessing intraventricular, interventricular, atrioventricular and combined myocardial dyssynchrony, as well as serum concentration of fibrosis markers - galectin-3 and MMP-1. The determination of percentage of interstitial collagen volume fraction (CVF) was performed in both groups.

Results

To determine the levels of fibrosis markers depending on the presence of diabetes, the results of patients with myocardial dyssynchrony (n = 56) were compared with the results of the control group without myocardial dyssynchrony (n = 42). In patients with myocardial dyssynchrony, there was an increase in the levels of galectin-3 (7.49 + 0.6 ng / ml) and CVF (7.6 ± 4.03%), a decrease in MMP-1 (0.46 + 0.2 ng / ml ) compared with the group without myocardial dyssynchrony (p <0.05). An increase in galectin-3 levels was observed in the presence of combined forms of myocardial dyssynchrony. In patients with a combination of intraventricular, interventricular, or atrioventricular myocardial dyssynchrony (n = 28), the levels of galectin-3 (9.03 + 0.3 ng / ml) and CVF (8.04 + 1.6%) were the highest; in patients with isolated forms of myocardial dyssynchrony, the levels of galectin-3 (6.67 + 0.2 ng / ml) and CVF (6,93 + 1,4%) were significantly lower. MMP-1 was greater in patients with isolated forms of myocardial dyssynchrony (0.78 + 0.2 ng / ml), compared with patients with combined forms of myocardial dyssynchrony (0.2 + 0.01 ng / ml) (p <0.05 ).

Conclusions

An association is observed between myocardial dyssynchrony and the levels of galectin-3 and MMP-1 in the blood. These findings are important for prognostic implications and require further research.
P1428The outcome of atrial fibrillation ablation in patients undergoing radiofrequency ablation, guided by novel indices incorporating force, time and power
Authors: Rattanakosit T , Franke K , Marshall H , Agbaedeng T , Sanders P , Lau D , Mahajan R
Published: June 2020

Background

Ablation index (AI) and Lesion Size Index (LSI) are novel parameters that incorporates contact force, time, and power in a weighted formula. Recent studies have shown that such indices predict lesion size and durability of pulmonary vein isolation (PVI). However, the outcomes of ablation guided by indices of force-time-power, such as PV reconnections and atrial fibrillation recurrence, have not been well characterised.

Objectives

To determine the association between indices of force-time-power and acute PV reconnections, procedure and fluoroscopy time and AF recurrence in patients undergoing radiofrequency PVI.

Methods

PUBMED and EMBASE were searched using the terms "catheter ablation" AND "Ablation index" OR "Contact force" OR "Force time integral" OR "lesion size" from inception through 22 May 2019. Studies reporting the procedure time, ablation time, fluoroscopy time, and incidence of AI acute and late reconnection and AF recurrence were included.

Result

 Six studies were included in this study with 530 patients, which n = 416 were paroxysmal AF and 114 non-paroxysmal AF. All procedural characteristics (procedure, radiofrequency, and fluoroscopy times) were similar between AI guided and non-AI guided ablation (p > 0.05). Two studies comparing mean PV reconnections in AI guided vs. AI Blinded. Two studies compared minimum AI in reconnected vs. non-reconnected PV segments. Acute PV segment reconnection was associated with a lower minimum AI vs. non-reconnection. In 3 studies reporting AI guided vs. AI blinded ablations, AI was associated with an increased freedom from AF after average follow-up of 12 months.

Conclusions

Radiofrequency ablation guided by AI/LSI was associated with lower acute PV reconnection rates and improved AF freedom after PVI. There was no difference in fluoroscopy, ablation or procedure time with the use of these novel parameters.

Abstract Figure.
P1444Empirical Slow Pathway Ablation in Documented but Noninducible PSVT
Authors: Vasheghanifarahani A , Tabrizi MARYAM , Sadeghian SAEID , Bozorgi A L I , Kazemisaeid A L I , Davoodi GHOLAM , Jalali ARASH , Yamini Sharif AHMAD
Published: June 2020

Funding Acknowledgements

This study was not funded

Background

The empirical slow pathway ablation /modification (ESPA/M) is often applied to a documented but noninducible supraventricular tachycardia (SVT) in the electrophysiology study (EPS). A clinical paroxysmal supraventricular tachycardia (PSVT) cannot be induced renders the therapeutic end point of radiofrequency catheter ablation difficult. The data supporting the ESPA/M in adult patients are limited. The aim of this study was to assess the clinical efficacy and safety of the ESPA/M in adults.

Methods

A retrospective study of symptomatic patients with ECG- or Holter-documented PSVTs who underwent the ESPA/M in our department between May 2011 and March 2018 was performed. A telephone questionnaire was conducted for follow-up. Recurrence was based on preprocedural symptoms and/or ECG documentation.

Results

152 (5%) out of 3018 Slow pathway ablation /modification (SPA/M) procedures were identified as the ESPA/M. The mean age of the study population was 51 (range = 16–82) years, and 62% of the subjects were female. Thirty-eight (25%) patients had a atrium-His (AH) jumps only, 90 (59.2%) had AH jumps plus a single or 2 atrioventricular nodal echo beats (AVNEBs), 17 (11.2%) had a single or 2 AVNEBs without AH jumps, and 7 (4.6%) had no AH jumps or AVNEBs by programmed electrical stimulation at baseline. During a mean follow-up period of 43 months (6–81 mon), 92% of the patients benefited from the procedure (full elimination of symptoms in 80.3% and an improvement in clinical symptoms in 11.7%). The symptomatic recurrence rate, defined as preprocedural symptoms and any documented arrhythmia due to an SVT, was 8.1% (11 patients).

Conclusions

The ESPA/M can be performed safely and effectively in patients with documented but noninducible AVNRTs with good long-term results.
P577Effect of adding an implantable cardioverter defibrillator on long-term survival in non-ischemic CRT patients stratified by Goldenberg risk score
Authors: Kosztin A , Schwertner W R , Behon A , Merkel E , Zima E , Geller L , Becker D , Merkely B
Published: June 2020

Background

There are limited and incomprehensive long-term data on the effects of adding an implantable cardioverter defibrillator (ICD) to cardiac resynchronization therapy (CRT) in patients with non-ischemic heart failure. 

Purpose

We compared the long-term all-cause mortality and relative risk reduction in mortality of non-ischemic patients after CRT-P vs. CRT-D implantation stratified by their Goldenberg risk score.

Methods

In our retrospective registry, data of 1196 non-ischemic patients who underwent CRT implantation between 2000 to 2018 were collected. Goldenberg sudden cardiac risk score was calculated by the presence of atrial fibrillation, NYHA class > 2, age > 70 years, blood urea nitrogen > 26mg/dl and QRS width. 

Results

In our registry from 1196 CRT implanted patients with non-ischemic heart failure, 716 patients had all the required data to calculate the Goldenberg score. From this cohort 379 (53%) had CRT-P and 337 (47%) CRT-D implantation. The mean value of the Goldenberg score was 2.7 in the total cohort, while a significantly higher score was found in the CRT-P group (CRT-P 2.9 ± 1.1 vs. CRT-D 2.5 ± 1.1 p < 0.001). During the median follow-up time of 4.9 years, 345 (48%) patients reached the primary endpoint, 220 patients (64%) with CRT-P and 125 patients (36%) with CRT-D. After comparing patients by low (≤3) and high (>3) Goldenberg score, we found that CRT-D patients with lower risk score showed mortality benefit compared to CRT-P (HR 0.69; 95%, CI 0.53-0.89; p = 0.001). In the contrary there was no apparent mortality benefit in CRT-D patients compared to CRT-P when high Goldenberg score subgroup was analyzed (HR 0.99; 95%, CI 0.67-1.45; p = 0.95).

Conclusions

In non-ischemic heart failure patients, Goldenberg sudden cardiac risk score can be also applied. In CRT-D patients those with less co-morbidities and lower (≤3) Goldenberg risk score showed mortality benefit compared to CRT-P patients, while among patients with higher score (>3) adding an ICD had no additional effect on all-cause mortality.
P1179Transvenous extraction of partially controlled leads
Authors: Benak A , Bencsik G , Makai A , Pap R , Klausz G , Kohari M , Miklos M , Saghy L
Published: June 2020

Background

Lead control has an essential role in successful transvenous lead extraction (TLE), however, there is limited data about leads without adequate control

Objective

The aim of the study was to assess the success rate, complexity, and safety of partially controlled lead extraction.

Methods

A single-center retrospective analysis of consecutive patients underwent TLE procedures was performed.

Results

From May 2012 to Aug 2019, 137 consecutive patients (76% male, mean age: 65 ± 15 years) underwent TLE procedures (273 leads, 93% infective indication, 37% with high voltage leads). Locking stylet was used in 83% (n = 224) of the leads. Advancement of the locking stylet all the way to the tip was not possible in 30.4% (n = 68) of the leads, resulting in partial control (LC- group). The mean age of the lead was significantly higher (11.06 +/- vs 7.76 +/- 6.3, p = 0.001) and the success rate was lower (76.1 % vs 93.2%, p = 0.001) in LC-. The need for femoral approach was more frequently in LC- leads (36.9% vs 16.2%, P= 0.001). Inadequate lead control was an independent predictor of lead extraction failure (OR: 5.27, 95% CI: 1.71-5.27, p= 0.004) and femoral approach (OR: 2.1, 95% CI: 1.054-4.08, p= 0.035). Three out of five major complications occurred in LC- group.

Conclusions

Partial lead control results in lower success rate and more complex TLE procedures.